AUTISTIC BARRIERS

IN NEUROTIC PATIENTS

toilet training, 50, 87, 122,
206,247
psychological, 223
Tony (autistic youth), 130-
131, 137, 147
Topiquc, 141
touch, 63, 65, 120, 145
transference relationship, 242,
243,246,251
transitional objects, 116-1 18
transitional states, 221, 228
Trevarthen, C., 42
triangles, 159, 161, 163
Tustin, F., xiv-xix, 5, 36, 104,
144, 166,215,224
unreality, 185
Waller, J. V., 238
weaning, 49,55,97,265
weight changes, 238-267
Weiszaecker, B. von, 262
Whan, M., 199
Winnicott, D. W., xiv, xvi,
xix, 6, 31,51,55,268
INDEX 327
on autistic objects, 1lO-
112, 116-1 18, 128, 168
on autistic shapes, 139-
140, 154
on 'black hole', 36, 58, 144
on depression, 27, 36,39,
67, 87
on 'false self', 44
on 'holding situation', 70,
76, 88, 90
on illusion, 224
on 'maternal
preoccupation', 63,95,
284
on separation from mother,
23
on terrors, 99, 104
on tr'msitional states, 221,
304
womb, 63,210
words, 105, 174,243
as autistic objects, 113
Yeats, W. B., xiv, 296
Youderian, P., 128
 326 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
'self-object', 39
self-representation, 216, 232
sensations, 54, 190,223-226
separation, 20,23, 27,42-43,
62, 85-86
in early infancy, 298
AUTISTIC BARRIERS primal, 101
psychological, 64, 155, 299
sexuality, 260-262, 284
IN NEUROTIC PATIENTS 'shell-type' children, 22, 57,
205
sight, 120, 142, 145, 150
Simon, P., 237
skin, 228, 301, 304
sleeping problems, 70, 80,260
Frances Tustin smell, 120
Child Psychotherapist sociability, 56
and Honorary Affiliate sound, 120, 150
of the British Psycho-Annlyticnl Society space, 55
speech, 49,54,76, 87, 162
lack of, 68, 125
Spensley, S., 41
Foreword b y spilling, 99, 127, 197-214,
220
James S. Grotstein fear of, 197,208,212, 301
spitting, 73
Spitz, R., 27,40, 63, 223
'startle response', 62
Stephen (autistic boy), 21-22,
154
Stem, D., 23
Steve (autistic boy), 142-143,
147.205-214.303
sticking, 144
Stroh, G., 113, 134
Structure of Scierttific
Revolutions [Kuhn], 37
Subirana, V.. vi
'subjective-object', 39
London sucking, 43, 58,60,97,99,
KARNAC BOOKS 111
cheeks, 281, 293
difficulty in, 49, 55, 56, 69
thumb, 165, 208
suckling, 29-30. 164
suicide, 294, 299
survival, 55,213
psychic, 291
Sylvester, E., 263,266
symbiotic children, 80
symbol formation, 59, 117,
192
syrlibolic equations, 74, 139,
27 8
tactile reactions, 65
tantlums, 73, 128, 131, 147-
148, 195,266,277
'held', 89
of rage, 56
screaming, 78
of terror, 56, 111
'unheld', 87
taste, 120
Tavistock Clinic, London, 34,
38
'teat-tongue' combination, 82,
295
teething, 95, 97, 206,211
Tennyson, A., Lord, vi, xiv
terrors, 171, 187-188, 191,
198,293
atavistic, 284
infantile, 74,75, 90,98, 99,
108, 115
of non-existence, 217, 218,
220
of spilling, 212, 224
thought^, 175-179
time, 56, 162
Tischler, S., 61, 132
togethen~ess,207,247, 303
 INDEX 325
emergence from, 157-169, reality principle, 164-166,
187,294,305,307 260,266
nature of, 19-32,44 'refrigerator mothers', 61
origins, 22-24.59 regression, 50-5 1, 254
precipitation, 59, 94-101 religious experiences, 284
psychopathology, 53,268 representational activities, 74 Drawing by J.F. Batellier, reproduced from Is Anybotiv Ozrl There:)
psychotherapy, 92-93, 101, Resnik, S., 172 courtesy of Free Association Books.
286-287,308 retreat into autism, 289-290
treatment, 33, 115,287-308 reverie, 89, 95, 135, 139, 236,
psychogenic damage, 22 Ted Hughes' poem 'Wodwo' is reprinted from Wo&-o by perlnission of
2 84
psychological tests, 54 Faber and Faber Ltd. Verses from ' I an1 a Rock' are reproduced by kind permission
Richardson, H. B., 238
psychomorphology, 125 of Mr Paul Simon. O Paul Simon, 1965.
Ricks, D., 111
psychoses, 45,51, 66, 68,298 Riley, C., 10, 11
psychosomatic illness, 216, Ripley, H. F., 238
305,307 rivalry, 219, 257 First published in 1986 by
psychotllerapy, 31, 68, 84,98 rocking, 131-132, 206 H. Karnac (Books) Ltd.
in anorexia, 239 Rosenfeld, D., 100,228 6 Pelnbroke Buildings
difficulties, 309 Rosenfeld, H., 34,45,298 London N W I0 6RE
effectiveness, 30 'rubber stamping', 222
possibilities, 309 Rubinfine, D. L., 98 Second impression 1994
psychoanalytic, 41, 133-
140,286 Sade, Marquis de, 299 Reprinted 2003
in psychogenic autism, 92- safety, 95
93, 101, 117, 126, 191, rhythm of. 268-285, 296 O 1986 by Frances Tustin
286-308 Sam (autistic boy), 158, 165
scientific art, 3 10 Sandler, J., 272 All rights reserved. No part of this publication may be reproduced, stored in a
Putnarn, M., 67 Sutre, J. P., 208 retrieval system, or transmitted, in any form or by any means. electronic, mechanical,
Putnm Children's Center, Schilder, P., 234 photocopying, recording, or otherwise, without the prior written permission of the
Boston, MA, 34 schizophrenic-type disorders, publisher.
20,36,40,45, 50, 53
Rallman, L., 238 in adults, 142
Rank, B., 67 Scott, C., 238 British Library Cataloguing in Publication Data
'raw beta elements', 139 screaming fits, 70, 74,76-79, A C.I.P. for this book is available frorn the British L,ibraly
reality: 159, 163
baniers to, 111 scribbling, 143, 158, 160, 206 ISBN: 0 946439 25 7
bridges to, 111 Segal, H., 54, 105,291 www.karnacbooks.com
detachment from, 185 on symbol fot-mntion. 59,
as disillusionment, 194 74, 139,278 Printed & bound by Antony Rowe Ltd, Eastbourne
evasion of, 283 self, 44
inner, 230 false, 44,45
outer, 230 'felt', 216, 221-223, 225
representation of, 100 sense of, 44, 60, 146
 324 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
ACKNOWLEDGEMENTS neurotic patients, 100-101,
106, 166
adult, 150-151, 190,268,
287-289,299-301,307
with capsule of autism, 151,
168, 195, 197,204,215-
216,287-289,298-300
Newman, A., vi
Newm,m, M., vi
nightmares, 74
nipple-seeking, 84
see also breast, breast-
feeding
non-autistic shapes, 160-161
nose-picking, 73
'not-me', 128, 132, 138, 277
'blacked-out', 304
hard, 305
and 'me', 55, 57, 162,276
11but three of the papers that compose this book have terror of, 58
been written since the publication of my last book, threats, 22
Autistic States in Children. An invitation to speak to numbers, 130, 148
a receptive audience inevitably engenders new thoughts, so
Ogden, T. H., 298
my gratitude goes out to the various organizations who have O'Gormon, G., 305
welcomed me into their midst. The book also owes a great Olin, R., 96
deal to those psychoanalysts mid psychotherapists from Eng- omnipotence, 249, 250,265,
land and abroad who have consulted me about their work and 307
have generously allowed me to use their observations. When organic autism, 19-20, 91
they presented their work to me, they were often not aware of 'out-of-the-body' experiences,
the new thoughts that were stirring in my mind; their work 25, 189
and the discussions I had with them either confirmed or modi- over-concretized thinking, 25
fied what I was thinking. I am grateful to these people for panic states, 307
their carefully recorded material and for the discussio~~s I had paralysis, 187
with them. They are too numerous to nlention individually, parental neglect, 20
but they will know who they are, and I take this opportunity to Park, D., 128
thank them. Paul (autistic boy), 48,49
As always, gratitude is felt towards my husband for raising penis, 79, 83, 85,262
uncomfortable question-marks in niy mind about the conclu- envy of, 260,264
handling of, 70,7 1, 73, 77
perception, 161, 190, 192, 292
beginnings, 84, 92
primitive modes, 148
peripheral vision, 154
Persori arid Psychosis
[Resnik], 172
personal pronoun, 73,2 15,
225
perversion. 299
Peter (autistic boy), 103, 104,
135-139, 147, 149
phantasies, 53, 261
phobias, 26
physical development, 21
Piaget, J., 84
Piell'e (autistic boy), 221-223,
225
Piggott, L. R., 22, 187
Plath, S., xiv, 202-204,210
'polar chill', 203, 204
Popper, K., 38
predators, fear of, 63-64
pregnalcy, 98,248, 250,261,
262,266
phantasy, 249, 254,258,
26 1
'primal sulk', 194
'primal unity', 224
primeval terrors, 63-66
primordial shapes, 144, 148-
150
projective identification, 53,
168,303
psychic functioning, 28
psychic work, 298
psycho~~alysis, 52, 133-140,
225,262,286-308
psychodynamic treatment of
autism, 20
psychogenic autism, 40, 42,
192-193
development, 67-93
effects, 298-301

MacNeice, L., xiv, 197,200,
202,212
Mdller, M., xiii, xiv, xvi, 37,
39,53,104, 141
on autistic shapes, 148
on 'black hole', 36
on emergence from autism,
168,303
on grief, 58, 67,90
on 'psychological birth',
233
on separation, 20
Maiello, S., 225-232,301,
305
manic defence, 26
Margaret (anorexic girl), 237-
267
Mary (autistic woman), 150-
153, 159
masturbation, 125, 25 1
'maternal preoccupation', 63,
95,284
Maufras de Chuellier, A., vi,
221-222,227
McDougall, J.. 2, 306
Medawar, P., 33,37-38,40
Meltzer, D., xiii, xiv, xv, xvi,
34.61, 127,229,306
Meltzoff, A., 62, 145, 148
'me-ness', 55, 224,277
menstruation, 198,240,249,
254,260,261
metaphors, 139, 145, 167,
282
Mexican earthquake (1985),
28,291
mid-life crisis, 307
Miller, J., 138,216,222, 230,
234-235
Milner, M., 88, 139-140, 200,
280
mirrors, 23 1
INDEX 323
modification of autism, 3 1-32
Mollon, P., 296
Morrison, J., 3
Morton, R., 238
mother 'alpha function', 139
as autistic shape, 173
'blacked-out', 65
body of, 56
as 'container', 88
depressed, 60, 94-98, 163,
171, 179
hostility towards, 241, 251,
254-255,263
r n o u ~ ~ ~ i308
ng,
non-responsive, 61
obsessional, 277
over-dependence on, 270
relationship with child, 64,
113, 164, 173,264-266
separation from, 23, 25,26,
43,51,298
suckling, 23, 27, 29, 108,
250, 292,
ultraresponsive, 63
underconfident, 108, 132
undermining situations, 94-
96,295
unresponsive, 167, 253
mourning, 28, 58-59, 90-91,
296-297.308
mouth, 54, 69,70,75,77-79,
144
differentiated from breast,
58, 61, 83,284
Munrow, D., 183-196
musical shapes, 162-164
mutative understmdi~~gs, 37-
42
narcissism, 45, 59, 60
Nwh, D.. 154-156,282
neuromentnl system, 44
vi AUTISTIC BARRIERS IN NEUROTIC PATIENTS
sions I was drawing from my observations. These have
opened doors to increased insight. The effort to think about
such questions lights a lamp in the mind which helps in facing
the inevitable areas of darkness imposed by one's own human
limitations.
Warm thanks are also due to Miriam and Alex'mder
Newman of the Squiggle Foundation, wlno have always been
on hand to help me in situations of crisis. I also want to thank
my friend Victoria Hamilton for giving me a complete copy of
Tennyson's In Memoriant. and for all tlne helpful discussions I
have had with her.
These acknowledgements would not be complete without
mentioning Professor Adri'ulo Giannotti, wlno now has the
Chair of Child Neuropsychiatry in the Institute of Childhood
Neuropsyclniatry of Rotnle University, and his co-workers,
who have welcomed me every year for the past ten years
to give papers to well-attended conferences. Work with this
well-endowed institute, in which autistic children are investi-
gated from tlne metabolic, organic, psychotherapeutic, and
educational points of view, has extended my knowledge of
autistic children. I am grateful to Dr Decobert of the
Clapar&de Clinic in Paris, and to Dr Genevieve Haag, Leni
Iselin, and Dr Anik Maufras de Chatellier for their support
and invitations over many years. Dr Viky Subirana, Medical
Director of Carrilet Unit for Autistic Children in Barcelona, is
remembered for her warm welco~nneto me and to my ideas. I
am also grateful to the California Institute of the Arts and tlne
Continuing Education S e m i n m of Los Angeles for their en-
couragement and the videos they have made of my presenta-
tions to them.
I must also acknowledge with thanks the per~nnissionfro111
the editors of the Inter-national Review cf Psycho-Analysis,
Journal of Child Psychology and Psychiatry. BI-itishJournal
of Medical Psychology, Journal of Child Psychottrer'apy,
Patio, and Topique to reprint papers originally published in
their journals.
 ACKNOWLEDGEMENTS vii 322 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
I should also like to thank Ann Scott for her careful and illusion, 111, 112, 218, 224
facilitating editing of this book. Image and Appearance of the
Finally, I am grateful to Harry K'u~lacand Cesare Sacerdoti Human Body [Schilder],
234
for giving me the privilege of preparing a book which I knew
imagination, 31, 149, 192, 282
had a publisher enthusiastic to receive it, and who would development of, 226, 305
expedite its publication. lack of, 21, 125
Last but not least, I want to thank Audrey Franklin and imaging, 216-217
Mrs. G. Soloman, who have typed these papers so accurately 'imitative fusion', 128
and-expeditiously. immobilization, autistic, 24-
27
Frances Tustin impulsivity, 88, 235
March 1986 individuation, 20
'I-ness', development of, 215-
236
infantile transference, 64,75,
165, 166,194,273, 300
as healing medium, 3 1, 38,
177
innate forms, 85-86, 166-167
Institute of Childhood
Neuropsychiatry, Rome,
35,52,133,206
intangibles, 278
integration, 100
Internatiortal Review of
Psycho-Analysis, 30,
102, 119
in utero disturbances, 98
investigative methods, 23
Isaacs, S., 53
Iselin, L., vi
Jackson, M., 298
James, M., 234
jealousy, 212,277
Jean (anorexic girl), 197-202,
217-220,225
John (autistic boy), 30,36,39,
58-59, 68-93.209, 292
Journal of Cltild Psyclrology
and Psycltiatry, 67
Journal of Child
Psychotherapy, 48
Jung, C. G., 166
Kafka, F., 221
Kanner, L., xiii, 19-20.22, 36,
48-50,52,61, 187
-type autism, 50
Kaufman, M. R., 238
Khan, M., 95
Klein, J., 97
Klein, M., xiv, xvi, 242, 260
on projective identification,
168,303
on psychogenic autism, 36,
148-157,59, 63,66, 146,
268
on unconscious ph~ltasies,
166,305
Kleininn psychoanalytic
technique, 36, 38
Klein, S., xviii, 7, 14, 15, 25,
242
on encapsulation, 45, 306
on neurotic patients, 100,
168, 181, 196,215, 301
on psycl~oa~alysis, 278
on psycl~oso~natic illness,
305-306
Kohut, H., 60
Kuhn, T., 37
language, 57, 111, 166
Lasegue, C., 238
learning difficulties, 269, 282
Levis, E., 170-179
locotnotor development, 69
loneliness, 99, 130
Lorand, S., 262
loss feelings, 59, 104
Louise (autistic girl), 227-
228
 INDEX 321
threat of, 193-196 Gault, S., 97
fantasies, 226.26 1,282 geometrical shapes, 161-163,
of child, 103-104, 110- 167
112, 117, 192,226,261, Gero, G., 263
281 Giannotti, A., vi, 35
of mother, 96.98 on caesura of birth, 43, 99,
father, 99, 113, 132-133,206, 224,283
209,270 on onset of autism, 96, 133,
absence, 94, 132,265 206
authority, 295-296 'going-on-being', 23, 24, 99,
hatred for, 241 176, 189,276
hostility towards, 266 Great Ormond Street
influence, 308 Children's Hospital,
fetishism, 118 London, 35,68
fidgeting, 143 Greeks, 156
floating state, 223-224, 226 grief, 58-59,67, 80, 179
'flowing-over-at-oneness', Greenacre, P., 118
224 Greene, J., 208, 212
foetus, 98 Grotstein, J. S., xiii-xx, 27,
food, 49.55, 69,250,261; 98,272,305
see also eating problems growth, 279
Fordham, M., 39 Gull, W. W., 238
forgetting, 199, 202, 218
'fragile chrotnosome', 20 Haag, G., vi, 146, 157,225
Freud, S., 8,38, 143,205 hallucinations, 112
on autism, 27,306 audito~y,142
on 'backward pull to the scl~izophre~~ic,39
inanimate', 294, 306 tactile, 39, 142
on birth, 210 visual, 125, 142
on narcissism, 59 Hnmilton, V., vi
on play, 234 healing, 279, 283, 302-305
on reality principle, 260 hearing, 142
Fritll, U., 21, 192 Hobson, P., 3, 20, 133, 192
frustration, 112, 130, 133, 'holding situation', 70, 76,
212,226, 228 88-90
avoidance, 87 hotnosexual tendencies, 84
toleration, 111 hospitalization, 50
fusion, 203, 208 Hoxter, S., 126
Hughes, T., xiv, 200-202, 301
Gaddini, E., 118, 122, 128, hyperactivity, 171, 174, 175
146, 157,219
Gaddini, R., 117, 122 identity, 20.44.215, 217

This book is dedicated
to the sad and terrified children
from whom I have learned so much,
and also to their parents
who have supported me so valiantly
320 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
dangers, 81-82, 155,224
unconceptualized, 193
David (autistic boy), 102-106
Daws, D., 159-161
De Astis, G., 35
on caesura of birth, 43, 99,
224,283
on onset of autism, 96, 133,
206
death, 25, 179-1 80,254, 271,
282,308
death wish, 92
Decobert, vi
dementia praecox, 50
Denis (autistic boy), 6-10
depression, 87, 198,217, 262-
263,265
anaclitic, 27
elemental, 67
maternal, 60-62,94-97,
163
post-natal, 163, 171
primal, 27.67, 88,237
psychotic, 27,36,67, 88
despair, 165,242, 266, 280,
290
Deutsch, F., 238
Dick (autistic boy), 36, 48-59
disillusionment, 26, 31, 169,
194,224,300
dissolution, 199-205, 208,
212
dissolving, 99, 197-214, 301
D'Ostimi, E. Fe, 35
drawing, 122, 146, 158, 172,
173
dreams, 24-25,78, 112,269,
272,281
dying, fear of, 90
'early infantile autism', 19.22,
36.37.48.187
eating problems, 238-240,
245,249.252.26 1,263-
2 64
echolalia, 20, 57, 113, 125
echopraxia, 113
ecstasy, 128, 129, 131, 147-
148, 179,277
ego, 44,45
elation, 187, 189
Eliot, T. S., xiv
Elly (autistic girl), 128-13 1,
137, 147, 190
emotional defect, acquired,
27-29
emotional development, 5 1,
100, 102, 178,278,279
empathy, 20, 31, 133, 149
encapsulated children, 22.40,
57,80,205
encapsulation, 24-25.44-46,
201,204,216,233,287
emergence from, 163, 166
exten~al,221
entangled children, 40, 53, 80
see also confusio~lal
children
e~lvironinentalchanges, 95
Erikson, E., xiv, 110, 149.21 1
Essertfiol Tension [Kuhn], 37
ethology, 38
Ettlinger, N., 288
evil, 275-278
extreme attitudes, 36
eye-to-eye contact, 54, 99
avoidance, 21, 56, 82, 293
Fairbairn, W. R. D., xvi
Fall, 25,26,224-225
falling, 23, 25, 183-196
fascination of, 183. 190
fear of, 99, 127, 183, 190,217,
30 1

'with nasty prick', 36, 58,
59.79.80
Biven, B. M., 203-205
bladder control, 69
bleeding, 198, 218, 255
Bleuler, E., 37
bodily separateness, 96-99,
109, 176,178,180,208
awareness of, 23.4243,
53.88, 193-194,270
as catastrophe, 26
in context of togetherness,
207
realization of, 106, 107, 230
shock of, 63,66, 151,203,
282
toleration of, 56
body image, 220-236
autistic, 301-302
misconceptions, 234
subjective, 23 1
as system of pipes, 227-228
Bollea, C., 35
bowel control, 69
Bower, T. G. R., 42,62, 145,
148
Bowlby, J., xvi, 3.4, 34, 38,
63,298
Bradley, N., 306
brain damage, 20, 22,41, 50,
91
Brazelton, T. B., 42, 60-61,
273
breast, 55, 80, 81, 88, 108,
292,295
as auto-sensuous object, 58
desire for, 74-77
differentiation from mouth
of infrmt, 61, 83,284
inf'mt's early experience of,
29, 146
loss of, 105
INDEX 319
use of, 111, 112
breast-feeding, 69, 80, 84, 86,
240.273
Britislz Jor~rnalof Medical
Psycltology, 237
Bronte, A., 190, 302
bulimia, 239
'button' phenomenon, 84.86
case material: see Antonio,
Ariadne, Daisy, David,
Denis, Dick, Elly, Jean,
John, Louise, Marg'uet,
Mary, Paul, Peter, Pierre,
Sam, Stephen, Steve,
Tony
castration anxiety, 107
Cattelml, C., 180
Cauquil, C., 142-144,205-
207,209-214,303
Chasseguet-Smirgel, J., 299
Chomsky, N., 166
Cre,&, M., 35,68
Crick, V., 202,274
circles, 157-164
classification, 84
cognitive defect, 20
acquired, 27-29
innate, 27
cognitive development, 100,
216
early west, 21, 5 1
cognitive functioning, 26, 37
communication, 99, 284
confusional children, 40, 53
see also entangled children
continuity of existence, 226-
227,233
cruelty, 299
Daisy (post-autistic girl), 162,
170-180
 318 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
CONTENTS autistic objects (continued)
origins, 108-1 10, 115, 127-
128
parts of body used as, 28 1
pathology, 39-40
self-generated, 292
as sensation. 108
two-dimensional, 302
use of, 64-65,104, 110-
115,291
autistic protections, 290-294,
303,305
autistic shapes, 30, 37, 39,40,
44, 101, 178
in action, 126
in adult psychopathology,
141-156
autistic encapsulation of,
288-290
ACKNOWLEDGEMENTS v in childhood
psychopathology, 119-
FOREWORD by James S. Grotstein xiii 140
manipulation of, 124, 130
nature of. 141-142
in neurotic adults. 150-151
Preface (1 994) self-generated, 292
Introduction shape-making, 121-124,
292
slippery, 151-153
PART ONE softness, 63, 128, 146, 147,
Psychogenic autism 150,299
two-dimensional, 302
1 The nature of psychogenic autism: an overview 19 use of, 64-65.29 1
2 The growth of understanding: Autistic Stntes in Chilclreri
a personal statement 33 [Tustinl, 35,42, 126, 135
autochthonous sensation, 3 1
3 Thoughts on psychogenic autism
auto-erotism, 59-60, 84, 173
with special reference to a paper by Melanie Klein 48 auto-sadism, 59
4 A significant element auto-sensuous objects, 58
in the development of psychogenic autism 67 auto-sensuous states, 37,42,
44,59
avoidance ~~eactions, 23, 25
'axis wrench' [Plath], 203,
204,210
Balint, E., 189,287-289
Balint, M., 27, 36,44
'basic fault' [Balint, M.], 27,
36
Barrows, K., 146, 157,160
Barton, R., 62, 145, 148
bereavement, 307
Rettelheim, B., 5, 65
Beyond the Pleasure Principle
[Freud], 234
Bibring, E., 27, 67,265
Bick, E., xvi, 34, 38, 110, 127,
205,228
Bion, W. R., xiv, xvi, 34, 229,
260,268,284,290
on autistic shapes, 135
on emergence from autism,
168
on function of analyst, 290
notion of maternal reverie,
95, 139
on origin of psychogenic
autism, 27, 87-89
on role of mother, 116
on terrors, 99
on thinking, 177, 207, 303
birth:
caesura of, 43, 99,210, 224,
283
'psychological', 233
biting, 55, 97, 206, 251-252,
259,264
cheeks, 281, 293,294
sadistic, 60
'black hole', 39.40, 62, 65,
82, 86-88, 144
depression, 43
in mouth, 77, 78
remedying, 30

INDEX
'acting out', 81
'adhesive equation', 127
Advice to a Young Scientist
[Medawar], 37
aetiology, 28, 5 1
affective development. 21,
216
affective functioning, 26
ageing, 306,307
alann states, 62
alexythymia, 27
allegory, 139
Alvarez, Al, 203
Alvarez, Anne, 222
ancient Celts, 155-156, 282
anorexia nervosa, 88, 168,
198,217,237-267
and autism, 237
clinical material, 239
literature, 238-239
relapses, 238
xii AUTISTIC BARRIERS IN NEUROTIC PATIENTS
5 Situations which may precipitate
psychogenic autism 94
6 Autistic objects 102
7 Autistic shapes exemplified
in childhood psychopathology 119
8 Autistic shapes exemplified
in adult psychopathology 141
9 Shapes associated with emergence
from psychogenic autism 157
10 A glimpse into the world of an autistic child 170
PART TWO
Psychogenic autism in neurotic patients
11 Falling
12 Spilling and dissolving
13 The development of 'I-ness'
Anthony, J., 36-37
Antonio (autistic boy), 224- 14 Anorexia nervosa in an adolescent girl
234 15 The rhythm of safety
Anzieu, D., 142,205,228 16 Psychotherapy with psychogenic autistic states
Ariadne (autistic girl), 269-
285,290,293-298,300
'atmospheric' children, 72 Concluding remarks
attachment, 193
Aul,angier, P., 39, 142
authority, 295-296 BIBLIOGRAPHY
Alitism and Cl~ildhood
INDEX
Psychosis [Tustin], 35,
85, 126
autistic objects, 30, 37.44, 57,
101-1 18.178
autistic encapsulation of,
288-290
hardness, 63, 107, 127-128,
146-147, 150,299
manipulation of, 278
nature of, 103-108, 115

FOREWORD
b y James S . Grotstein
nfantile autism, once located in the obscure outback
of the mental health field, has recei~tlycome into well-
deserved prominence because of the pioneering contribu-
tions of several distinguished investigators who have spent a
great portion of their lives in the clinical investigation of this
disorder. Leo Kanner (1949) did yeoman's service in separat-
ing infantile autism from mental retardation. Following this,
Margaret Mahler (1958) recognized the differences between
infantile autism and infantile symbiosis and then postulated
that these disturbances represented pathological extensions of
what she proposed to be normal, successive stages of infant
development, each of which paved the way for the separation
and individuation of the child. Then Donald Meltzer and his
colleagues published a significant monograpl~(1975) which
detailed the phenomenology of infantile autistic psychosis and
helped us to understand it from an intrapsychic point of view.
They postulated that the infant who is to become autistic
recognizes the presence of depression in his or her mother and,
316 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S
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 BIBLIOGRAPHY 315
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xiv AUTISTIC BARRIERS IN NEUROTIC PATIENTS
as a consequence, dismantles his or her own ego, particularly
those capacities that knowingly depend upon mother for their
welfare. The autistic children dismantle their dependency-
aware egos allegedly so as not to jeopardize their depressed
mothers further. Illusory autistic autonomy is the result.
Frances Tustin has more recently joined this distinguished
group of investigators of autism and has already made con-
tributions that have not only greatly increased our knowledge
about the nature of this disorder and how to treat it but,
perhaps even more significantly, have brought the concept
of autistic enclaves into the very centre of our concept of
neuroses as well as other more common psychopathological
disorders. Moreover, she has nude formulations which, if
accepted, may help to alter some of our fundamental con-
ceptions about infant development itself. The present work
comprises a series of papers, most of which were published
subsequent to her latest book, Autistic States In Children
(1981). They continue the thrust of this earlier work 'and also
constitute clarifications and modification of her rich ideas. In
addition, they offer some significant newer ideas about
autism, not only in infants and children, but also ill adults,
particularly in such entities as neuroses, phobias, anorexia
nervosa and other eating disorders, substance abuse, and
perversions.
Frances Tustin's wellspring is that of Melanie Klein and
Wilfred Bion, but the range of writers she draws on is note-
worthy-Winnicott, Bowlby, Meltzer, Erikson, Mdller, and
also, poignantly, such poets as Tennyson, MacNeice, Plath,
Eliot. Hughes, and Yeats. The reader is therefore presented
with a patchwork quilt of many colours but one which never-
theless achieves har~nony,texture, and quality.
In her earlier works, particularly Autistic Stares in Children.
Frances Tustin emphasized two childhood psychotic entities,
the encapsulated or shell-type child and the confusional or
entangled child. The former constitutes infaantileautistic illness
proper, and the latter, symbiotic or schizophrenic psychosis of
childhood. She described the encapsulated child as a being
 FOREWORD xv
characterized by the use of hard autistic objects, which differ
from transitional objects both in their aim and in the technique
of using them. Autistic objects are employed by the encapsu-
lated autistic infant in an idiosyncratic and surreptitious
manner to soothe himself in his isolation; they are not
meant to maintain the illusion of bondedness to the mother
in her absence. Thus, according to Tustin, transitional objects
are object-related, and autistic objects are purposely non-
object-related. The confusional child, on the other hand, is
characterized as employing soft objects in order to 'mop up'
the experience of woundedness. Both types of autistic child
have in common the experience of a process of 'premature
mental birth', which propels them into a world of precocious
sep'uateness from their mothers without the requisite individu-
ation that this cataclysmic separation would ordinarily entail.
The encapsulated children protect themselves from this cata-
clysm by developing an imaginary hard shell to shield their
hypersensitive surfaces from the hostile, dangerous impinge-
ments of all 'not-me' experiences, primary among which is
that of the 'stranger/mother'. The confusional child, on the
other hand, seems to t'ke the opposite course, becoming inex-
tricably bound in the substance of mother, confused with her,
so as not to be separate.
In this present work, Frances Tustin concentrates more on
encapsulated children, reiterating her belief that they have
experienced 'premature mental birth', that they are probably
born with a hypersensitivity to life, and that they frequently
have experienced impingement by mothers who suffered from
depressive illness, a fhding that Meltzer and his colleagues
had also noted (1975). Confusional children, Tustin now
believes, may have developed a maternal bond and then
regressed from it. Further, she now states that the autistic
encapsulated child is not psychotic by virtue of his or her
encapsulation; in fact, this seenls to protect this type of child
against the psychosis that charncterizes the confusional child.
What I find to be of particul'u significance in Frances
Tustin's present work is her elaboration of aurosensuousness,
314 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
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xvi AUTISTIC BARRIERS IN NEUROTIC PATIENTS
a phase of development which she now suggests occurs
normally prior to autoeroticism and autosadism and is
followed in turn by narcissism. The emphasis in classical psy-
choanalysis has clearly shifted lately from neuroses to more
primitive stages of development, and narcissism seems to have
emerged as the commonly designated term to embrace them.
Melanie Klein had been there all along with her psycho-
analytic conception of internalized objects and the infant's
identifications with them, which constituted her version of
narcissism. Klein, however, as Tusti~lpoints out, dealt with
infants who were thought to have been already bonded with
their motliers and, consequently, to have developed psycliopa-
thology in proportion as they attacked (or believed ~ J phantasy
I
that they attacked) those bonds, metaphorically represented
principally as the breast. Tustin suggests that Klein's psy-
chology applies to symbiotic or schizophrenic-type children,
not to autistic ones. Here, she is explaining a stage that is
more primitive th'm bonding, a state already alluded to by
Fairbairn's description of the schizoid position (1952). by
Bion's theory of infantile catastrophe (1970). by Mahler's idea
of infantile depression (1966), and by Winnicott's of 'failure
to go-on-being' (1958). In my own writings, I have referred to
this stage as that of inchoate randomness or meaninglessness
awaiting the mother's loving signification to give the i11fa11t its
tneaningfuh~essand thus to rescue him or her from the 'abyss
of the deep and formless infinite'. Two other followers of
Klein, Esther Bick and Donald Meltzer (1968), had already
made forays into this earlier era of mental life when tliey
posited that some of their autistic children showed develop-
mental arrests which occurred even earlier than Klein's
paranoid-schizoid position. They termed this adhesive identifi-
cation and postulated tliat these children suffer consequently
from adhesive identity, by which they tneai tliey have no sense
of identity of their own mid achieve a tentative 'as if' identity
by adhering to solid surfaces, including the surfaces of their
mother's body, at first concretely and later metaphorically.
 FOREWORD xvii
Frances Tustin's conceptualization of autosensuousness
seems to give important perspective to this newly discovered
phase of infant development and is undoubtedly being con-
f m e d at this time by empirical itlfiult observation. Of particu-
lar importance for clinical psychoanalysis and psychotherapy,
however, is her postulation of critical deficits in this primitive
stage, an area that she has explored extensively over decades.
I understand her to suggest that encapsulated autistic children
in particular demonstrate a pathological, abrupt rupture of
autosensuousness so that, whereas normal autosensuousness
and subsequent development into sensual differentiation and
integration ultimately link to bonding with objects through the
senses separately and together, pathological autosensuousness
has cut the cord, so to speak. Herein lies the brilliance of
Tustin's contribution, I believe. She states that, in effect, the
encapsulated autistic child seems never to have developed a
viable, sanguine sensuous colltact with its motlier because of
its experience of premature mental birth. It felt too existen-
tially alone too early and therefore became sealed off by
this very aberrant, involuted autosensuousness. Thereafter, tlie
objects of the senses are no longer tlie desired and needed
mother; instead, they are tlie sensuous pllantoms of the sense
organs themselves; the autoclitl~onous'objects' that auto-
sensations now patllologically create on their own become the
new-found 'objects' of the encapsulated child.
Frances Tustin's first discovery in the area of deviant
autosensuality was in relation to autistic objects, hard objects
barred from the outside or objects from the self (the tongue,
faeces, extensions of the inner tilucosa of the mouth, etc.)
which would, by their reassuring hardness, seemingly, 'plug
up the holes above their inner emptiness'. Her later discovery,
elaborated in the present work, is that of autistic shapes. Thus,
clutchblg an object tightly produces hard object-like sensa-
tions, whereas stroking or holding an object loosely produces
evanescent shapes soothing to the encapsulated child. Thus,
such a child seems trapped in an empty fortress surrounded by
312 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
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xviii AUTISTIC BARRIERS IN NEUROTIC PATIENTS
a wall of pathological autosensuousness which conjures up
hard object-like sensations 'and soft idiosyncratic shapes to
reassure the child, wlio is now cut off from humui contact.
Mention should also be made of Tustin's emphasis on
the importance of dentition as a catastrophic landmark in the
development of autistic children. Apparently, the transfornia-
tion from the sucking inf'ant to the biting infant is a critical one
and seems to inspire the emergence of atavistic phantasies
belonging to the preylpredator category. According to Tustin,
predator anxiety beconies intimately linked 'and confused with
all 'not-me' experiences and associated with the experience of
infantile depression. To that, I would add infantile panic dis-
order. It therefore becomes more understmidable that these
children should hide behind their shells, involute develop-
mentally back into tlien~selves,mid compulsively manipulate
their objects, both autistic objects mid hum'an 'not-me' objects,
into being their servants-so that they do not have to leave the
capsule and experience disaster while servicing their needs. In
this regard, Tustin's observations display tlie origins of per-
versions, both physical a i d cyclical, froni tlie ~iiostunique arid
credible perspective.
These ideas might seen1 to be recondite and confined to the
limited area of infantile autistic illness, were not Tusthi's
ideas so credible when linked to more comn~onlydiscussed
adult psychopathology. Dr Sydney Klein, a fellow traveller of
Frances Tusthi's, had already made a contribution along these
lines, and she greatly elaborates on his contribution in the
present work. Pathological autosensuousness can clearly be
seen, for instance, in patients with anorexia nervosa who can
be thought of as having erected mi imaginary autosensuous
shell around them to keep out 'not-me' food from the outside
world. Again, it can be seen in the behaviour of a patient of
mine, a dutiful housewife wlio shunned sex mid obsessively
engaged in meaningless crossword puzzles till late in the night
while by day she distracted herself with meaningless book-
keeping-all to keep her emotions at bay as well as her
awarenesses of need for her husband and her analyst. Another
 FOREWORD xix 310 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
patient of mine, a man in his late fifties who had been mamed throw light on those adult neurotic patients whose mental and
five times, revealed a dream in which one of the features was emotional life has been impeded by autistic barriers erected in
a concrete bathroom. His associations led to the need for early infancy.
privacy aid insulation, from which developed a history of Psychotherapy is a scientific art. Science is the study of the
pseudocontact with people but with a sense of detachn~ent regularities of the network of sequence and associations which
from them. Where he really lived was in his concrete bath- we call causation. In working with our patients this is what we
room of isolation. The sub-clinical encapsulated child prob- are studying. We are scientific in our attempts to understand
ably continues on in tlie wide variety of alexithyniic disorders the nature of the disorder we are dealing with (although not
and the whole gamut of those suffering from schizoid detach- exactly in the manner of the natural sciences), and we are
ment, whereas the sub-clinical confusional child s e e m to artistic in resonating with our patients so that we can help them
live on as borderline with narcissistic personality disorders to change. In doing this, we are challenging as well as tactful.
and, in particular, in the new category known as hysteroid The format of this book has tried to convey this marriage of
dysphoria, an entity known for its particular hypersensitivity both science and art.
to object loss and its compensatory use of objects in an en- There is a saying that 'It is better to light one small candle
tangled, addictive manner. While there is some similruity to than to go on cursing the darkness.' It has been my privilege to
Winnicott's concept of the 'true selflfalse self', Tustin has light 'one small candle' to shed its light on the dark scene of
amended her views about this correlation in her present work, psychogenic autism. With my advantages and opportunities,
She now finds that the phenomenon she designates is even it would have been a professional dereliction not to attempt
deeper than 'true self/false self' insofar as autistic children to do so.
have never even developed a sense of self; they have only
a neuronientd ego looking for a self, but never finding it
because of tlie barricade erected by their autistic auto-
sensuousness.
Even more profoundly, Frances Tustin's research allows us
to penetrate to a level of meaning beyond cognition, beyond
instincts, beyond emotions, even beyond phantasy; she has
given us a glimpse into the very roots of perception and has
thereby elevated (auto)sensuousness to its deserved signifi-
c~mce.
This is an important work and also a most enjoyable one to
read. I am sure that many readers will feel, as I did, 'That
applies to a patient of mine; this applies to another patient.
Hey, wait a minute, that applies to tne !'
 xx AUTISTIC BARRIERS IN NEUROTIC PATIENTS
CONCLUDING REMARKS REFERENCES
Bick, E. (1968). 'The experience of the skin in early object reln-
tions'. International Journal of Psycho-Analysis, 49: 484-486.
Bion, W. R. (1970). Attention and Interpretation. London, Sydney,
Toronto, and Wellington: Tnvistock Publications. meprinted Lon-
don: Kmnac Books, 1984.1
Fairbairn. W. R. D. (1952). Psyckoanalytic Studies of the Personal-
ity. London, Henley and Boston: Routledge & Kegan Paul.
Kanner, L. (1949). 'Problems of nosology and psychodynamics of
enrly infantile autism'. American Journal of Orthopsycltiutry, 19:
41-26.
Klein, M. (1950). Contributions to Psycho-Analysis 1921-1945.
London: The Hogarth Press and the Institute of Psycho-Analysis.
Klein, M. (1959). The Psycho-Analysis of Children. London: The
Hogarth Press and the Institute of Psycho-Analysis.
Mnhler. M. (1959). 'Autism and sy~i~biosis-two extreme distur-
bances of identity'. International Jorrrnal of Psycho-Analysis, 39:
77-83.
Mahler, M. (1966). 'Notes on the developnient of basic moods: the
depressive affect'. In R. M. Lowenstein. L. M. Newman, M.
Schur, and A. J. Solnit (Eds.), Psyckoanalysis: Essays in Honor of
Heinz Hartmann @p. 152-168). New York: Internntional Univer-
sities Press.
Meltzer, D. (1975). 'Adhesive identification'. Contenrporary Psyclzo-
analysis, 11: 289-3 10.

T
his book has sought to add to the psychoanalytic under-
Meltzer, D., Bremner, J., Hoxter, S., Weddell, H.. & Wittenberg. I.
standing of the psychopathology and development of (1975). Explorations in Atttisni. Strnth Tny, Perthshire: Clunie
autistic states. A simple, almost colloquial style has Press.
been used as seeming most appropriate for the crude, basic Tustin. F. (1981). Atttistic States in Clzilclrcn. London, Henley, and
elements which have been discussed. Technical terms have Boston: Routledge & Kegan Paul.
been kept to a minimum. Winnicott, D. W. (1958). Collected Pupers: Throligh PaeJiutrics to
Psychoanalysis. London: Tnvistock Publications.
I have learned a great deal from working directly with autistic
children. It has become clear to me that autistic patients have
become trapped in a chain of psychophysical reactions from
which they feel that they cannot escape. T o help them to get
free from these is an arduous and painful process for all
concerned. When working with autistic children we must not
raise false hopes in parents who have already suffered so much.
This. book has highlighted some of the difficulties, and also
some of the possibilities of psychotherapy with carefully se-
lected, usually young, autistic children. It has also sought to
 308 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
sometimes find that when the analysis is over, they have to work
over residues of autism which have been undetected. These are
often people who, as infants, had to take care of a bewildered
and confused mother, or a mother who was mourning the loss
of a former child. Usually the father's influence has not been
sufficiently felt. These patients were not able to mourn as
infants, and this unworked-over mourning can often only be
worked over when the analysis has finished. Also, such patients
have tended to try to do the analysis for themselves in order to
spare the analyst. Thus, the wounds of separation have not
been healed as much as they could have been. In this situation,
they have to use what they have learned from their experiences
of vacations and weekends in the analysis, to help them to come
to terms with the mourning that assails them when they lose the
bodily presence of their analyst for good.
Perhaps this damaged wayward part is never completely
healed but, by facing and giving up our autistic bluffs, and by
becoming more capable of robust creative interactions with the
possibilities of life, we prepare ourselves for the caesura of
death, and muster the necessary courage to face it.

An infant crying in the night:

An infant crying for the light:
And with no language but a cry.

Tennyson, In Memoriant. LIII

 THERAPY IN PSYCHOGENIC AUTISTIC STATES 307
ly the process of oscillation which repeatedly occurs, for
example, between states of omnipotence and helplessness ... .
In connection with this, he describes a manic patient who
'talked incessantly as a defence against feelings of emptiness'. It
occurs to me that such talking could also have been an attempt
on the part of the patient to 'talk herself through' panic states
such as have been described in other chapters in this book.
The so-called 'panic states' in otherwise normal individuals
are very like those experienced by psychogenic autistic children
as they emerge from their autistic encapsulation. This
encapsulation has been a protection against such panic.
Neurotic patients in panic states complain about not being able
to breathe, of feeling that the ground will open beneath their
feet, of a sense of impending catastrophe, of a terrible feeling of
lassitude. They often find it helpful to 'talk themselves through'
such panic states, or to have someone to talk to. Certainly, the
'talking cure', as one of Freud's patients called psychoanalysis,
seems relevant to the alleviation of the panic states. of psy-
chogenic autism, both in autistic children and in neurotic adults
with a capsule of psychogenic autism. Findings from
psychotherapy with psychogenic autistic children promise to
add to our understanding of such panic states. As has been
indicated at various places in this chapter, they also promise to
deepen our understanding of psychosomatic illnesses, psy-
chopathic personalities, addictions, hysteria, certain phobias
and cyclothymic states.
In my clinical experience, psychogenic autism is liable to
crack in situations of biological change such as puberty, after
the honeymoon period of marriage, the midlife crisis, and
ageing or bereavement. The unmodified vulnerability against
which the autism has been a protection is laid bare. This can
also sometimes occur after an analysis is terminated. In working
with adult neurotic patients with a hidden capsule of autism, it
is difficult to ensure that all the autism is being brought within
the reflective care of the psychoanalyst's attention. Patients

PREFACE
am grateful to Cesare Sacerdoti of Kamac Books for
giving me the opportunity to write a new preface to
this second impression of Autistic Barriers in Neurotic
Patients. for since this book was first published certain experi-
ences have caused me to think more deeply about the nature
of Childhood Autism. Of necessity, what I have to say will be
somewhat anecdotal because I shall be instancing recent
experiences that have influenced my thinking along certain
lines.
Revised views on normal printnry auzism
After I had given up the hypothesis of autistic illness being a
regression to an early infantile stage of normal primary autism
('Revised understandings of psychogenic autism', 1991, and
'The perpetuation of an error', 1994), I made a careful survey
of the early histories of my own treatment cases of autistic
disorder. As a result of this, I developed the alternative
hypothesis that early-childhood autism is a two-stage illness:
306 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
cysts as encysted autistic parts of the self which had been dealt
with in a somatic way. Dr Joyce McDougall, a French
psychoanalyst who 'has studied psychosomatic illness very
intensively, speaks of a 'robot' part of the personality as being at
the root of such illnesses (1980). She does not use the word
autism, but is obviously aware of the 'backward pull to the
inanimate', as Freud called it (Freud, 1920).
It is interesting that at many points in studying autism we are
led back to Freud. As well as the 'backward pull to the
inanimate', we also become aware of the disastrous effect of
buried traumas to which Freud alerted us, although the in-
fantile illusory traumas which have been significant in the
development of psychogenic autism take place earlier than
those that Freud wrote aboyt. Also, in his 'Fragment of an
analysis of a case of hysteria' (1905), Freud recognized the
importance of the nipple, after which time it was virtually
ignored in psychoanalytic literature for about sixty years, until
Meltzer (1963) and Bradley (1973) revived interest in its
significance.
The value of a study of psychogenic autism Apart from
enabling us to be more closely in touch with psychogenic
autistic children so that some of them may be helped to more
normal functioning, the findings from the study of psychogenic
autism promise to deepen our understanding of certain neurotic
disorders. Dr Sydney Klein (1980) writes as follows:
It is my impression that recognition of the existence of the
encapsulated part of the personality reduces the length of the
analysis considerably, and moreover may prevent further
breakdowns in later life. This was borne in on me when I
treated several patients who had been analysed at earlier
periods in their lives and who became very disturbed in the
course of the process of ageing.
There is one other important feature which repays ob-
servation in these patients, and indeed in all patients, name-
 THERAPY IN PSYCHOGENIC AUTISTIC STATES 305
'not-me' which could not be moulded to be what he wanted and
expected it to be. The therapist has to be firm in encouraging
such patients to find the courage to 'stomach' the hard 'not-me'
bit.
When they start to 'kick up a fuss' about the hard 'not-me'
which will not be controlled by them, but instead does
unexpected things and so brings shocks, they are well on the
road to recovery. All the unconscious phantasies described by
Melanie Klein become operative in this phase. In unconscious
phantasy, the inside of the mother's body is attacked and re-
paired. Also, the imagination is stirred by these unseeable in-
side places; as witness Dr Maiello's patient Antonio, in Chap-
ter 13, who fantasied about the wonderful Maiello things he
imagined were hidden away in the rooms with locked doors.
Because Dr Maiello helped him to bear his frustration about
this, imagination could develop. Imagination is a healing
psychic process. It helps to heal the wounds caused by
frustration and disappointment.
Psychosomatic illnesses When patients are encased in their
autistic protection, they are rarely, if ever, physically ill. As
they emerge from autism, and their vulnerability is exposed,
autistic children begin to have the usual infectious illnesses of
childhood, and adult neurotic patients begin to have bodily
illnesses. As they lose their autistic protections, they seem to
need medical healing as well as psychotherapy. This may
indicate, as Dr Grotstein (1983) has suggested, that psy-
chogenic autism is a psychosomatic illness in statu nascendi.
O'Gormon (1967) has suggested that hormonal factors may be
involved. However, as a psychotherapist, I have only studied
psychological factors. Dr Sydney Klein also concentrates on
these, when he describes one patient who had a dermoid cyst
which had to be cut out. Both the patient and Dr Klein saw this
as being a bodily dramatization of an encysted autistic part of
her personality from which she needed to be cut off. Another
patient developed an inflamed ovarian cyst. Dr Klein saw these
2 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
the first stage being an unduly close association with the
mother, the father often being virtually absent or excluded.
Such a child has been described as a 'cork child' to plug the
hole of the mother's depression and loneliness (Joyce
McDougall, 1986 and 1989). The second stage is when this
over-vulnerable, 'hot-housed' child inevitably becomes aware
of bodily separateness. This is in such a sudden and painful
way for it to seem to be a life-threatening disaster. It is trau-
matic.
Trauma as a precipitant
The undue closeness of mother a11d child me'ans that
from birth the infant has had the illusion that (s)he was still
part of the mother's body. This prevented normal attachment
processes from developing. Sudden awareness of their
separatedness from each other had felt like being violently
wrenched apart. It was experienced as a death-dealing catas-
trophe of poignant loss.
It had been a traumatic 'psychological birth' (1981), fol-
lowing which the mother had not been able to provide the
'mental uterus' the baby needed. Lacking the focus of a
secure attachment to a breast that was the source of sensuous
satisfaction, post-umbilical susten'mce, and safety has tainted
the whole of these children's psychological development.
Autistic processes have developed as a reaction to this un-
bearable elemental trauma of separatedness: the deadening of
responsiveness being a reaction which is specific to any kind
of trauma.
Murderousness as a consequence of trauma
and non-attachment
My conviction about the appositeness of this hypothesis re-
lating the precipitation of autism to a traumatic experience
was strengthened by two broadcasts about serial killers.
The milkers of one of these (ITV Chulnel 4, Sunday, 12
December 1993) talked to the parents of a mass killer and
were given unique access to audio-taped interviews between
hirn and a forensic psychologist.
 PREFACE
They found that research into more than 200 cases of serial
murders had enabled forensic psychologists to create a model
of a typical mass-murderer's personality. This had sliown that
the behaviour of some serial killers could be traced back to
childhood traumas. The traumas of being subjected to physi-
cal or sexual abuse, or of experiencing a painful break-up of
their parents' mamage, were cited. Tlie elemental trauma of
awareness of wounding bodily separatedness such as I had
found to have happened to autistic children was not instanced,
although Dr John Bowlby's work comes close to this. In his
early paper concerning 'Forty-four juvenile thieves: tlieir
characters and home-life' (1944), Bowlby traced their delin-
quency back to early traumas of geographical separation from
the mother, such as going into hospital. He described actual
experiences of separation fro111 the mother, but these were at
an age older than that of the autistic children I have studied.
In the second programme about 'Serial Killers' (Radio 4, 3
December 1993), a psychiatrist called Janice Morrison, who
had spent hundreds of hours with some of America's most
notorious murderers, described her interviews with them. I
was particularly struck by her description of these killers as
not making tlie distinction between animate and inanimate
objects. This is the distinguishing feature of autistic children.
For example, Peter Hobson, in his recent book Autism and the
Development of Mind (1 993), writes about autistic children as
follows:
They are relatively successful hi following the I-It develop-
.
mental pathway. . . It is specifically in 1-Thou interper-
sonal relatedness that we find the abnormalities
characteristic of 'autism'. (p. 197)
When Momson investigated tlie early personal history of the
murderers, she found that, as infants, many of them had been
relatively undifferentiated from their mothers with whom they
had been unduly close.
3 304 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
this service for the patient when he is well able to do it for
himself. All our work has to be directed towards his becoming
able to do this for himself by the development of healing
psychic images, aesthetic images being very important in this.
The fact that the damage is often illusory makes it very
potent and difficult to deal with. In patients who have actual
bodily damage, either at birth or later on, feelings about this
actual damage can become confused with feelings about illusory
damage. This makes it difficult for them to come to terms with
either of these situations. Patience is needed on the part of both
therapist and patient in working through and disentangling
these threads.
In Phase 2, although the patient is developing a sense of
identity, this is by no means securely established. It is de-
pendent on seeming to live inside the therapist's skin (as if it is
a mother's skin). The aim is to help such patients to develop the
sense of having an intact skin of their own. As we have seen
from both Steve and Jean in Chapter 12, interruptions to the
treatment can make them feel that there are gaps in the
envelopment by the skin of the therapist-mother, and that they
are leaking out of it. This can either stimulate them to develop
a skin of their own, or it can drive them back into psychogenic
autism which seems to callus them over with an artificial skin.
Phase 2 is a confusing period because there is constant
slipping back from a state of feeling human and alive into the
inanimate empty fake of autism. In the interactive coexistence
of Phase 2 in which healing becomes possible, there is dawning
awareness of 'me' and 'not-me', but the 'not-me' can sometimes
be so unbearable that it is'blacked out'. However, this 'blacking
out' gradually comes to be countered by the use of the
transitional object and transitional activities (Winnicott, 1958).
This buffers the child against too painful experiences of the
hard 'not-me'. We saw this in Sam's use of the piece of shawl in
Chapter 9 which, when sucked, gave him the sensation of a
beneficent circle. However, his thumb gave him the 'nasty'
sensation of a triangle with sharp corners. This was the hard
 THERAPY IN PSYCHOGENIC AUTISTIC STATES 303
Healing pmcesses The autistic protections having cracked,
the reaction is to feel wrapped up inside the body of the
therapist (the mother in the infantile transference). This
enfolding has been termed symbiosis by Margaret Mahler. It is
a state in which projective identification, as described by
Melanie Klein, is active. It was exemplified by Steve in Chapter
12 who, after one-and-a-half years of psychotherapy, drew a red
oval containing two shapes, a smaller oval and a circle. Madame
Cauquil, his psychotherapist, felt that these two containers
within a large one indicated that Steve felt that he and his
therapist were held within a shared ambience. Within this
context of 'togetherness', Steve could begin to have a sense of
identity, and could begin to think. In this state, each other's
existence is felt to depend upon the actual physical presence of
the other. Thus, partings are excessively painful and terrifying.
Dr Bion has amplified Melanie Klein's concept of projective
identification, and has shown us that it facilitates the
development of thinking. The child projects a scream, a tan-
trum or some other piece of impulsive activity; the mother em-
pathically identifies with it and understands it. She responds
appropriately. Gradually, instead of using explosive pro-
jection, the child begins to be able to sustain tension and to
delay action, which is the basis for thinking. But for this to
become possible, the child's protests must not seem to go into
an unattentive void, nor to rebound back at him from a seeming
brick wall. The mother does not necessarily 'give in' to him, but
she responds in some appropriate way.
It has seemed to me that the processes of empathic in-
teraction (projective identification) are important in the heal-
ing that takes place in Phase 2. The therapist is now felt to have
an inside, and damaged patients feel that the damaged parts can
be reposed within the therapist's 'stomach-mind', so that the
attendant terrors can be 'stomached' for them until they can
begin to 'stomach' them for themselves. In Phase 2, this
empathic 'stomaching' is the psychotherapist's most important
healing role. But it is important that we do not go on performing
4 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
Conzparison of autistic children
and serial killers
In spite of the differences in the traumas that have precipitated
their disorder, both autistic children and delinquents (includ-
ing mass murderers) have important features in common.
They have both experienced difficulties in what Bowlby, in-
fluenced by ethology, called 'Bonding'. This notion of 'bond-
ing' is now used in popular speech and was used by the
makers of the television programme about serial killers. This
early lack of a primal attachment affects the development of
relationships to people-the 'I-Thou' approach. As will be-
come clear from this book, clinical work has caused me to see
primal attachment as a time when sensuous contraries, such as
llard and soft, male 'and female elements, come together as the
infant's attention becomes focused upon the suckling mother
in a working relationship. The apathy of a depressed mother
and possibly a depressed child prevents this resilient contact.
Both autistic children and mass murderers are out of touch
with people. The makers of the television programme I have
cited said:
The future killer fends off unhappiness by suppressing a11
feelings towards family and friends and becomes increas-
ingly isolated. Refuge is found in f'antasies which provide
situations which can be controlled. (Article in the Radio
Times. 11-17 December 1993, p. 5)
Autistic children have no fantasies, iuld their trauma has oc-
curred earlier. However, there are other features that autistic
children and mass murderers have in common. They both
have trouble in managing their violent feelings. In addition,
because they both feel so weak and helpless, they need to feel
powerful and in control. Interesth~gly,the forensic psycholo-
gists found that killers conlmitted murders when some person
had threatened to separate from them.
An autistic cltild wlto becantc?nzurderous
The mass murderers were usually glad to be arrested and
imprisoned. The programme-makers suggested that this could
 PREFACE
be due to the fact that, after this took place, they received a
great deal of attention. It could also be due to the fact that they
felt that their violence was being contained. Unlike the autistic
children, they have not had the 'prison of autism' to hold it in
check.
Several years ago, I saw a BBC television film about Bruno
Bettelheim's Orthogenic School, in which former pupils of
the school talked about their experiences there. One of them
(now a professor!) told about an autistic boy in the school. He
described, with great sadness, how this boy had given up his
autistic controls only to become schizophrenic and murder-
ously violent. [The fact that, as I have previously noted (e.g.
Tustin, 1990), a schizophrenic illness can develop when the
controls of autism break down makes me think that there is
something to be said for seeing autism as part of a psychotic
continuum.] From being suicidal-as most autistics a r e - h e
had become tnurderous. Bettelheim could no longer keep him
in the school. He was sent to a state institution, where he was
given a loboton~y.This account brought home to me that it is
a serious matter to disturb the barrier of autism until, it1 psy-
choanalytic therapy, an 'infimtile transference' has begun to
develop. This sets in train sociable ru~d friendly feelings
towards people in the outside world. Even the murderous feel-
ings are attached to real people and begin to lose their larger-
than-life quality. Until these attachn~entsrein in the violence,
the children are instinctively afraid that the violent feelings
that are entrapped by the autism will be let loose. Work with
autistic children highlights the importance of social relation-
ships in human development. These provide constraints on
violence and give protection. The stripping away of autistic
processes by lnetllods that do not take account of the impor-
tance of early relationships must be a cause for concern.
A ysycko-analytic trcatnzcnt
A further relevant experience has been a weekly discussion
with a very experienced child psychotherapist about a three-
times-a-week psycho-analytic treatment of a non-speaking
5 302 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
is a place where things can be stored and digested, and which
would join the upper and lower parts of the body together, and
make it three-dimensional. As we saw, autistic objects and
autistic shapes are two-dimensional. It was the impression that
they made on body surfaces which was attended to. They had
no significance in terms of actual, three-dimensional objects in
the outside world. T h e emergence of the geometrical shapes of
the circle and the triangle ushered in three-dimensional
awareness. These had both insides and outsides. They could
contain something, and were different in this important respect
from zigzags or rounded scribbles. When elemental sensation
shapes become associated with shareable geometrical shapes
which are 'containers', as also when they become associated
with actual, three-dimensional objects in the outside world,
percepts and concepts can begin to develop. This ushers in
Phase 2 of the psychotherapeutic process.
Phase 2 Healing the damaged psyche
The body image associated with this state As the autistic shell
is cracked open by dawning awareness which shatters the au-
tism, a helpless damaged creature is revealed who feels that a
vital part is missing. U p to this point, this vulnerable creature
has been protected by feeling wrapped up in his own bodily
sensations. These have been a protection against the disorder
and confusion of madness. As they emerge from autism we see
such patients' fear of madness. Emergence into this second
phase of increased perception brings an agonizing state of
hothouse hypersensitivity in which they feel skinless. They also
experience states of icy clarity. Associated with these, there
is the sense of thawing out. Anne Bronte expressed this
poignantly when she wrote:
Oh dreadful is the check - intense the agony -
When the ear begins to hear, and the eye begins to see;
When the pulse begins to throb, the brain to think again;
T h e soul to feel the flesh, the flesh to feel the chain.
'On Becoming', Poents
 THERAPY IN PSYCHOGENIC A U T I S T I C S T A T E S 301
psychotherapy. Let us now return specifically to the first phase,
during which we are trying to modify the autism. An awareness
of the type of body image which such patients have in an autistic
state is a help in doing this.
The autistic body image In this first phase of treatment we
meet a patient who has 'jumped out of his skin' with fright, and
who feels skinless and disembodied. T h e skin has been replaced
by the 'armour' of his autistic practices which help him to feel
protected from the terrors of falling, of dissolving, of spilling,
of losing a sensuous object as a part of his body which ensures
everlasting continuity. In Chapter 12 we met the neurotic adGlt
patient who felt that this skinless part of her lived inside a
walnut shell. At the beginning of his psychotherapy with Dr
Maiello, Antonio, in Chapter 13, was floating around in a
disembodied state. At first, these patients have to be enfolded
with firm, confident, understanding care, so that they begin to
feel that it is safe to give up their empty, armoured or disem-
bodied state.
In their autistic state such patients feel 'paper thin'. They do
not differentiate between insides and outsides, and live in terms
of surfaces and superficial appearances. They have no
awareness of their own insides. As we saw with Peter, in
Chapter 6, there was a gap where his stomach should have been.
D r Sydney Klein, in writing about neurotic adult patients who
manifest autistic phenomena, says that they have a 'thinness
and flatness of feeling' (1980). Work with autistic children
reveals that they live in a flat, two-dimensional world. For
example, one autistic boy, very fascinated by a picture which
hung on the consulting-room wall, would go up to it and turn it
over to see what was behind the hills on the picture. Another
child would draw the back of a house on the reverse side of the
paper on which he had drawn the front elevation of the house.
As Ted Hughes said in the verses from Crow which in-
troduced Chapter 6, such patients feel that their 'body' is
'intermittent'. They do not feel that it has a middle part which
6 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
autistic boy, who, since the age of thirteen, has been in psy-
chotherapy for one year.
The parents are co-operative and intelligent. They had
sought psycho-analytic help for Denis (as I will call hirn),
when he was much younger, but it was not available. He is not
a classic Kanner-type autistic child. His early history was
quite complicated. Just before he was born, his head was
thought to be too small, with the possibility of tleurological
disturbance. He screamed constatltly for the first three months
of life and could not be comforted. He was a difficult baby to
rear. He developed a considerable amount of l'mguage be-
tween the ages of one-and-a-half and three but stopped speak-
ing following several traunlatic hospitalizations. He has been
diagnosed as 'autistic' by several psychologists, with a score
of 49 on the CARS scale. This corresponds to 'severe autism'.
He hums persistently and displays characteristic stereotyped
hand movements. About a year before he started treatment, he
began to have fits (which were unsatisfactorily controlled by
medication), but as treattilent has proceeded, these have be-
come much less frequent. He seeins to use psycho-physical
ways of dealing with his developmental difficulties.
In trying to understand this boy, it has become clear to us
that we are in the thick of his moral problem. In working with
him, we seem to be studying the mainsprings of morality-that
which Winnicott (1958) called 'the innate morality' of the
child. This seems to stem from the fact that human beings are
social herd animals. An i~nportantp,m of our understanding
has been to realize the value of his autistic processes to this
boy. We have come to see that Denis is desperately afraid of
his vulnerability and his murderously violent impulses. The
autism seems to provide a tough outer skil, bolh to protect his
vulnerability and also to cage in his murderous violence. It is a
defence against the 'black-hole' type of depression that is
exemplified by John in Chapter 4. This means that it is a
bllrrier against the disintegration 'md chaos threatened by the
'black hole', but it makes him resistant to our attempts to help
him.
 PREFACE 7 300 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
Denis expresses his violence in a 'low-key' way. For ex-
ample, he pinches his therapist as he comes down the corridor
to the therapy room. However, the terrible devil-grimaces he
makes leave no doubt as to the intensity of his violence. As he
enters the room, he bites and snaps at what he conceives to be
the threats that have left traces behind them, such as smells, or
at sensuous vestiges left on chairs, which he removes with
scooping hand movements. He rubs his teeth with a tooth-
brushing motion as if to sharpen his fangs for an attack.
Sometimes he is impelled to pace the room in a11 effort to
master his feelings. However, he is never violent in a 'smash-
ing-up' kind of way, although he will batter his own head very
cruelly if not stopped.
Ordinarily, he does not play with the toys that are put out
for him to use, but recently, on one exciting day, he picked up
the toy crocodile. He felt its hard skin and open mouth, which
he put inside his own n~outli.He then tunled it over so that its
soft vulnerable under-belly was exposed. After this, he sat on
the couch, clutching a pillow. Then he wrapped himself in the
blanket, so that only his head 'and a bit of the pillow were
exposed.
From experiences with other patients, I intuited that he
could be feeling that the hard back protected the soft front. Dr
Sydney Klein (1984), in describing 'an adult patient, gives us
words for the feelings we have had about Denis when he
writes:
He gave me the impression of being covered by a leathery
skin in which little flaps opened to take in interpretations
which then disappeared without a trace 'and without any
recognisable response. (p. 307)
The 'crocodile session' was an occasion when one of the
'little flaps' opened in his tough autistic skin. We felt that,
temporarily at least, Denis was less at the mercy of his violent
feelings. By his use of a plaything, he had been able to clothe
them in imagery, which enabled him to depict and communi-
cate about them. Synlbolic play was beconling a possibility.
their 'cover-up' of this part of their personality. It is vital that
we should be aware of the unmitigated, atavistic savagery
which has never been modified by loving interactions with the
suckling mother. Autistic children have almost completely re-
jected the 'breast-mother', and neurotic patients with a capsule
of autism have a part that has violently turned away from her.
All possible healing overtures from her, tentative though these
may have been, have been rebuffed, just as, in their early
painful awareness of separation from her, they felt that they had
been.
There is a wayward, callous part of the personality. It is
dangerous because it is often associated with great charm. An
important part of the first phase of psychotherapy is to
encourage such patients to relinquish their sidelong autis-
tic practices so that they can have a straightforward relation-
ship with 'life' and its vicissitudes (the 'breast' in infancy), and
develop beliefs and a sense of purpose. In psychoanalytic
therapy this occurs through the infantile transference.
Through this medium, the patients respond to the therapist as
the 'breast' of infancy, and are enabled to work over their
feelings of sulky umbrage about its inadequacies in terms of
their exacting expectations. These perfectionist expectations
have become more exacting as the years have gone by, and the
patients have brooded upon their disappointments. No
therapist, however good, could possibly fulfil them, so they
have ample opportunities to meet their disillusionment about
human inadequacies and to come to terms with it.
As we saw in Ariadne's reactions, the outside world, in terms
of their perfectionist, purist expectations, seems polluted.
They have shrunk away from this seeming contamination. T o
help them to have a more robust approach to life and living is
part of the psychotherapy. It is no good treating such patients
as if they are precious bits of Dresden china. They often try to
get us to do this, but we must not collude with it. They have
many strengths which they have never discovered, and we must
help them to discover them. This goes on in every phase of
 THERAPY IN PSYCHOGENIC AUTISTIC S T A T E S 299
psychological separation from their mother. Their resulting
psychopathic tendency was brought home to me very forcibly
on reading a paper by the French psychoanalyst Dr Janine
Chasseguet-Smirgel, who was writing about perversion.
In the paper she used perversion in the ordinary, everyday
sense and did not restrict it to sexual deviation, as is the case in
most psychoanalytic writings. As an example par excellence of
perversion in this more general sense, Smirgel analyses the
character and writings of the Marquis de Sade (Chasseguet-
Smirgel, 1983). Although she does not use the word autism, all
that she says about perversion applies to the spurious and
devious behaviour characteristic of autism. For example, she
describes the anal preoccupations, the avoidance
of feelings of tenderness, vulnerability and helplessness, the
pseudo-independence, the undifferentiation and merging, the
avoidance of differences and opposites, the non-recognition of
the mother and of family ties. There is also reference to
unmitigated savagery, for in Justine de Sade makes one of his
characters say, 'The creature I am destroying is my mother.'
Later he speaks of 'tearing apart the breast that suckled him'
(1967, pp.209-10).
As the autism is modified, such primitive savagery will be
expressed by the patients we are discussing. In autistic children
it has been hidden by their use of hard autistic objects and soft
autistic shapes. The soft autistic shapes have replaced the
maternal functions, and the hard autistic objects have replaced
the paternal ones. In neurotic adults with a capsule of autism,
psychopathic tendencies are often covered over by obsessional
reaction formations which result in priggish behaviour and
judgemental attitudes. With such patients - both autistic
children and neurotic adults - this potentiality for cruelty is
often turned against themselves in that they will cut and hurt
themselves, bring their creative endeavours to an abortive halt,
or, at worst, kill themselves.
Such patients' potentiality for cruelty is often overlooked. In
psychotherapy with them it is important not to collude with
8 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
However, our joy was short-lived. hi succeeding sessions he
was closed up again. Perhaps he was afraid of having shown
us his vulnerability?
Most of the time, violent sensations seemed to rampage
through muscle and vein to impel him to crude actions. His
body was taut and tense as if to feel that in this way he could
control these violent sensations. Feelings of weakness and
helplessness make autistic children feel that they must be in
control. As one sucli child said to me, 'I am the m'anager'. The
autistic processes of 'autistic sensation objects' and 'autistic
sensation shapes' (such as are described in this book) help
them to feel that poign'ant violent sensations are blocked out.
Realizing this function of the autistic processes has helped us
to see it in a more positive light. We do not wait to batter it
down. Rather, we want to niodify it and to help Denis to
develop less crude ways of coping with the vulnerability and
murderous violence that threaten him with sucli disintegration
and chaos.
Work with these children has made tile realize that sensa-
tions are the beginnings of psychic life. To paraphrase Freud,
the 'body ego' is 'first mid foreniost' a 'sensation ego'.
We have all used 'sensation objects' 'and 'sensation
shapes'. It is when these beconie compulsive atid addictive,
and are used inappropriately to tlie exclusion of more social-
ized ways of dealing with sensation-driven impulses, that they
can be called 'autistic sensation objects' and 'autistic sensa-
tion shapes'. As a result, such children's sensation life has
gone awry. It has become perverse.
From time to time, Denis feels that lie spills, spits out,
throws, or stares the violent sensations out of him to a corner
of the room, where they form a shadow on tlie wall, of which
he is then frightened (the beginnings of projection). At this
stage tlie Jungian image of 'the shadow' seems a potent and
pertinent one. It is formed from the stormy serisatioiis of his
violent impulsions. In psycho~~nlytic psycliotlierapy, tlie 'in-
fantile transference' focuses tliese teliipestuous feelings. Until
 PREFACE 9 298 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
now, he had felt that there was no one to focus them and
contain them adequately, nor to be aware of the content of his
alarms. He had established no framework of relationships to
help him to feel safe. Instead he made use of his autistic strait-
jacket.
The beginnings of fantasy
An import'ant difference between the violence of autistic
children and that of mass murderers is that-as I mentioned
earlier-autistic children do not have proper fantasies. It is a
progress when they begin to do so. This has brought home to
me that the time when autistic children begin to develop fanta-
sies is a critical one. This progress needs to be dealt with by an
experienced and insightful psychotherapist, who well under-
stands the use of the 'infantile tr'ansference'. This mecans that
the infantile trauma of awareness of separatedness can be re-
experienced, and the powerful feelings associated with it can
be felt in the presence of sonleone who u~lderstandsthem
and who can help the child to come to tertns with them. All
this is exemplified in Chapter 4. The working-over of this
early situation towards the suckling mother is critical. It will
affect the development of relationships and also the type of
fantasies developed by the child. What I am trying to say is
that the primary relationship ('bonding') needs to have
become established before it is safe for the strict controls of
autism to be modified. Otherwise the autistic child may
become a murderer, like the child in the Orthogenic School,
instead of confining himself to the murder of his own mind.
An indication that basic infantile feelings associated with rela-
tionships are developing is that the child begins to miss the
therapist when a separation occurs. The violence associated
with this needs to be handled with p'uticularly insightful
understanding. (It is pleasing that on two occasiol~sbefore a
recent holiday separation, Denis put his arnls around his thera-
pist's neck in an affectionate hug rather thul giving her the
strangleholds he had inflicted on her previously.)
Psychic work Work with psychogenic autistic children and
neurotic patients with a capsule of psychogenic autism has
made me echo Murray Jackson's (1985) conviction that 'Some
psychoses ... demonstrate that the ego does not always simply
fall apart as a result of biological deficiency and psychosocial
stress, but is destroyed and fragmented by forces within the
personality that prefer oblivion to pain, or confusion to
depression ...' (see also Ogden, 1980; Rosenfeld, H., 1971). It
is the study of the psyche which informs the type of
psychotherapy being described here.
These patients need time and freedom from undue pressure.
We need to be able to wait so that they can learn to wait. Yet, at
the appropriate time, we need to be able to sense that they are
ready to bear the pressure of active intervention to help them to
leave their aberrant ways, and to bravely take the main highway
which they share with other ordinary earth-based human
beings. T o do this, they have to work over their mourning for
a sensuously beautiful object which cannot be grappled to
them as a physical part of their body. As they do this their
lives become irradiated by an aesthetic vision such as Dave
experienced at the crags. This is not a rarefied, esoteric,
aesthetic vision which is as fragile as is the autistic child's
fascination with his self-engendered iridescent bubble of spit.
It is a robust, interactive enjoyment of the beauty of life which
does not ignore the reality of evil and ugliness. For this to be
possible terrors have to be faced; and illusory ones are harder to
face than actual ones. Through such courage, psychic life
becomes freed from an incubus which can virtually destroy it.
The devastating effects of psychogenic autism As well as
arresting the development of emotional and intellectual life,
psychogenic autism has prevented the development of a moral
sense. This is to be expected, since Dr John Bowlby's study of
delinquency has shown us that geographical separation from
the mother in early infancy is liable to result in an 'affectionless
character' (B.owlby, 1973). Autistic children have experienced
 THERAPY I N PSYCHOGENIC AUTISTIC STATES 297
sensuously exciting object which was felt to be a part of their
body and which had been lost. This mourning established it as
a creative mental conception which held them together, and
connected them with others. For this to occur, they have to bear
the disillusionment that things come to an end, and that they
are ordinary human beings who can come to an end also.
The capacity to mourn John's material demonstrated
convincingly that it was only when primitive processes of
mourning were worked over that the 'button' became a psychic
conception which set creative cognitive and emotional
processes in train. The clinical material of Ariadne showed us
that, in adults, this can be a long and protracted process. Ample
time is needed if the mourning is to be satisfactorily integrated
into the personality. It is hard for such patients to give up the
unrealistic notion of living forever through the illusion of
continuous, fleshly connection with an eternal 'being' who
is for them alone. It was only when Ariadne could give up
this autistic notion that. the 'rhythm of safety' began to be
established. Prior to this, her secret autistic practices had
prevented this development. She herself said that she had
experienced my stern injunction to give' them up as a sign that
I really cared about her. It cleared the way for the dreams which
enabled her toface her terrors instead of avoiding them, and to
begin to be ready to finish coming to see me. T o be able to do
this, she had to become able to do without my physical presence
so that I became a psychic resource in her mind.
That she is getting ready to finish was shown by a recent
dialogue with me when there seemed likely to be a seven-week
gap in what had now become her monthly visits to see me. I
offered her a three-week or a seven-week gap, since the day of
her monthly visit was not available. After some thought, she
looked up with an amused smile and said, 'Shall we be daring
and try seven weeks?' For such a cautious and timid person, this
was a great achievement. But a great deal of psychic work had
had to take place before this was possible for her.
10 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
Brain damage and generic predisposition
The forensic psychologists stated that predisposing factors
for the personalities of tlie serial murderers included brain-
damage and a genetic tendency to violence. Some autistic
children do have brahi damage, but in lily experience not all
of them had been found to be brain-damaged by tlie methods
of investigation available at the time. (I have only treated tlie
ones where no brain damage had been detected). Altliougli
organic factors were clearly important bi Denis's develop-
ment, they cmnot by themselves account for his autism. Thus
lie was able to produce a complete sentence at the age of six,
tliough this was not repeated. Wliile in therapy, he showed
himself to be capable of considerable humour, though this was
sparingly expressed bi sign lmiguage.
A genetic tendency towards violence in autistic children is
more difficult to ascertain. The fact that not all babies who
have had an unduly close relationship with a depressed
mother develop autism makes one wonder if there is some
genetic predisposition at work in those who do? It could be
that different factors operate i i different children. Childhood
Autism is a rwe syndrome tliat probably results from a rare
combination of factors; the likelihood of their occurring
together bebig somewhat remote. We should also remember
tliat when a disturbance occurs in very early infancy, there is
the temptation to ascribe it to genetic factors. Whether genetic
factors are at work in sonie forms of autism is one of the
i~nponderableswe have to live with.
'Psycl~ogerric'or 'psychobiologiccll'?
Tliere is one more change in my thinking that needs to be
mentioned. In the present book, as i i others, I have used the
term 'psychogenic autism'. I did this to distinguish the type of
autistic child in whom no serious brahi dnniage could be de-
tected, from tlie type of autistic child in whom organic factors
had been clearly shown to be present. However, a review by
Charlotte Riley (1993) of the revised edition of A ~ ~ r i s r Sln/es
ic
in Children (1992) has sliown lile tliat tlie tern1 'psychogenic
autism' is misleading. Riley writes:
 PREFACE 11
The word 'psychogenic' becomes a red rag to the readers
who espouse the current popular conviction that autism is a
discrete diagnostic entity with entirely biological origins.
She goes on to say that we cannot know
with any certainty that a particular diagnosis is either psy-
chological or biological in origin.
She points out that the division of the human being into
'psychic' or 'somatic' is 'an artefact of our methods of study
m d acadenlic disciplines.
Quite rightly, Riley said that I have presented statements of
the complexity of tlie interweaving of biological mid psycho-
logical factors in autisni.
This has caused nle to revise niy termhiology. I now realize
that a more accurate term would be 'psychobiological autism'.
It would be helpful if readers of this book would bear this in
mind when they come across the phrase 'psychogenic autism'.
It will also become clear to the reader that throughout the
book I no longer think of 'autisni' as the name of a specific
discrete illness, but that, based on my findings from working
with children who have full-blown autism, I see the name
'autism' as designating a specific set of processes that deaden
awareness, and which niay be operating in other psycho-
pathologies in which 'an elemental trauma with its attendant
autistic reactions has been split off and has lain dorniant, to
surface later hi life. I developed this theme further in a subse-
quent book, The Protective Shcll in Children and Adults, also
published by Kaniac Books.
[I wish to express my gratitude to Maria Rhode for help in
org'mizing this preface.]
FI-ancesTustin
January 1994
296 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
Phil Mollon brings a vivid piece of clinical material, which
demonstrates the disaster that ensues if the paternal authority is
not sufficiently recognized. This material concerned a patient,
Miss D, who, in the terms of the chapters in this book,
obviously had a very operative autistic capsule. Her autistic
encapsulation began to crack when she made use of the couch
for the first time. Mollon writes as follows:
As Miss D made use of the couch she became more overtly
dependent and vulnerable, and began to talk of feeling in
a frantic, hungry and disorganized state, particularly
emphasizing a sense of having no centre. She pointed to a
picture in my room, an abstract painting which she con-
sidered very fragmented; she said 'I feel like that painting -
no core - it looks like it was painted by someone who wasn't
all there.' She then laughed and said, 'You didn't paint it, did
you?' I told her I thought she felt like a frantic, inwardly
falling-apart baby, confronted by a mother therapist who
seemed not quite all there - and that she was longing for a
hard nipple, a core around which she could organize and
orient herself. This interpretation seemed to calm her
considerably. I quote it here because I think the core she
sought could be a most basic and .concrete metaphor for the
paternal function required to provide boundary and
organization. (Mollon, 1985)
W.B. Yeats has described the demoralizing effects of this lack of
a central core to the personality. I n 'The Second Coming'
(1962, p.99) he writes:
Things fall apart; the centre cannot hold;
Mere anarchy is loosed upon the world,
The blood-dimmed tide is loosed . ..
John's material shows us that the 'Daddy button' is the central
core that has been lost. Ariadne found this core when she
estabished her 'rhythm of safety'. For this establishment to
occur, these patients had to be able to mourn for the tangible
 THERAPY IN PSYCHOGENIC AIJTISTIC STATES 295
It is knowing how and when to give stern guidance which is part
of the art of psychotherapy.
Paternal authority Another lesson I have learned from work
with autistic states is the importance of not allowing the
analyst's authority to be undermined. As we have seen in
previous chapters, these patients have often had a mother
whose confidence was being undermined in various ways, and
a father whose presence, for various reasons, was insufficiently
felt. T h e children have had to cope with more than their un-
developed psychic resources could deal with. In a naive state,
they have felt that they had to be strong and invulnerable. They
have also been left too much to their own devices, and have not
had sufficient support and guidance from experienced and
confident authority. As John's material in Chapter 4 indicated,
he had undermined and exploded away the 'Daddy' element in
his nurturing. This had been associated with what John called
the 'button', that is, with 'teat-tongue' experiences at the breast.
Clinical work compellingly indicates that the 'teat-tongue'
combination becomes associated with the hardness of the
'Daddy', and with authority which regulates the children's
impulsivity. This authority does not allow them to have
all their own way, and presents them with the reality of their
dependence on others. Autistic children have been allowed to
feel that they can make up the world in their own terms, and
that people are as clay in their hands. Thus, they have
destroyed their connection with the 'breast', that first
introduction to the outside world, with all the adjustment and
adaptation which such connection implies. In impotent rage,
they have exploded away the thing they have to share and which
is not for them alone. They never experience being an ordinary
member of an ordinary family. Like John who said, 'Make a
bigger breast,' they are always seeking that elusive 'extra bit'
which will make them extra-ordinary. They have rejected the
father's disciplining authority which sets limits.
In a paper concerned with the 'missing paternal dimension',
12 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
REFERENCES
Bowlby. J . (1944). 'Forty-four juvenile thieves: their characters and
hotne life'. International Jorrrnal of Psyclro-Analysis, 25: 1-57
and 207-228 [republished as a ~nonogrnphby Bailliere, Tindall
and Cox, London, 19461.
Hobson, P. (1993). Autism and the Developnlent of Mind. Hove,
Sussex, & Hillsdale, NJ: Lawrence Erlbaurli Associates.
Klein, S. (1984). 'Delinquent perversion: problems of assirnilation: a
clinical study'. Internutioncll Jorrrncll of Psyclro-Anc~lysis,65: 307.
McDougall, J. (1986). Tl~cutrcsof tlie Mind. London. Free Associa-
tion Books.
McDougall, J. (1989). Tlteutres of t11e Botly. London. Free Associa-
tion Books.
Riley, C. (1993). Review of F. Tustin, Atitistic S t u t ~ sin Chitir.cn,
revised edition (1992). Winnicott St~rtlics,8.
Tustin, F. (1981). 'Psychologicnl birth and psychologicnl catastro-
phe'. In: J. S. Grotstein (Ed.), D o I Dare D i s t l ~ r bthe Uniiu~rsc?
@p. 181-197). Caesura Press. [Reprinted London: Knrnnc Books,
1983.1 Also in F. Tustin, Alitistic Stutcs it? Chiltlrcw (revised edi-
tion) (pp. 96-1 00). London: Tnvistock/Routledge, 1992.
Tustin, F. (1994). 'The perpetuation of an error'. Jotirnul of Cltild
Psychotlzerupy: 20 (1).
Tustin, F. (in press). Letter: 'A c o ~ n ~ n opsychoanalytic
n error about
the etiology of nutistic disorders of children'. .lorrrncll of tile
Antrricun Psychounulytic Associcltion.

INTRODUCTION
In words, like weeds. I'll wrap me o'er.
Like coarsest clothes against the cold;
But that large grief which these enfold
Is given in outline and no more.
Tennyson, In Memoriuni, v
his collection of papers seeks to share insights
derived from my work with autistic children whose
autism seems to be primarily psychogenic in origin.
These insights have shed light on a hidden part of certain
neurotic patients-both adults ru~dchildren-which has con-
stituted a b'urier to their emotional ,and intellectual function-
ing. Thus, this book will be of wider clinical relevance than
my two previous ones, which were mostly restricted to the
study of psychogenic autistic childre~i.S o ~ n eof the papers
have been published in various psychoanalytic and psycho-
therapeutic journals, but others have been written especially
for this book. In a collection of papers some repetition is
inevitable, but this should help to familiarize the reader with
what may be an unfamiliar approach to the problem of getting
in touch with certain hard-to-reach neurotic patients.
Although the papers are concerned with a 'way-out' part of
the personality, this does not mean that it is a 'way-out' book.
294 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
interpretation as to why she should stop 'conning' herself that
she had a fleshly 'mother' always with her, at her beck and call
at any time, which ensured her continuous existence forever.
Of course, active intervention should always be associated with
an explanation as to why the deleterious behaviour should be
giver1 up. Such direction only works when the therapeutic
alliance is firmly established. For many years, Ariadne had
been in the second phase of treatment, but hidden bits of autism
still clung around her like bits of eggshell. Emergence from
autism is not a clearcut, once-and-for-all procedure.
When I presented the paper about Ariadne's treatment in
various psychoanalytic institutes, there was always a great deal
of discussion about this piece of directive behaviour on my
part. Such behaviour on the part of the therapist runs counter
to the usual psychoanalytic practice, which abjures active
intervention in the patient's life. But non-symbolic autistic
states are different from any others that we see. Autistic be-
haviour is on an almost reflex psychochemical level. Locked in
a primal crow-black sulk, such patients have gone along a futile
and self-destructive route of non-relationships. Something
incisive has to be done to help them back to relate to the 'breast'
properly - to bring them back to common sense. My telling
Ariadne to stop biting the insides of her cheeks was similar to a
caring parent who acts to prevent her impulsive toddler from
rushing across a busy traffic road. Following the giving up of
such idiosyncracies, there is usually some acting out of the
feelings which had been locked away in the autistic behaviour.
The therapist needs to be alert to these in order to bring them
under therapeutic control.
The patient in this state is relieved when the analyst comes
down incisively on the side of living. In my view, we should
always do this with patients who have a strong 'pull back to the
inanimate', as Freud expressed it, since, for these patients,
suicide is the final bid to escape from what seem to them to be
unthinkable, irremediable difficulties. As I see it, in everything
that we do, we need to come down on the side of life and hope.
 THERAPY I N PSYCHOGENIC AUTISTIC STATES 293
The reaction to this has been to avoid any further repetitions of
such awareness. This seems to go into their avoidance of
looking directly at people. Patients in autistic states live mostly
in terms of peripheral awareness, listening to tones of voice, for
example, rather than to what is being said to them. In adult
neurotic patients this autistic part reacts in a devious way and
avoids straightforward, direct contacts with people. Everything
is approached in a roundabout way - one patient having to take
a very roundabout route to his analyst's consulting-room when
there was a much more direct route which would have got him
there much more quickly. Ariadne used to tell me stories in
which she went off at many tangents before getting to the point
of what she was telling me. I think it is for this reason that these
patients appreciate straightforward directness in their analyst.
With small children, it is no good pulling their faces round to
make them look at people until they have the motivation to do
this. They do not have the motivation to do this until their fears
of looking people in the eye have been to some extent worked
over and understood. For example, John said that he was afraid
of the 'black hole' in the middle of people's eyes. Other children
feel that eyes can do very dangerous things. For them, 'cutting
looks', 'piercing looks' or 'killing looks' are not just figures of
speech; they really feel that looks can kill, and so they avoid
looking. For them, as we have seen, the outside world is full of
unmitigated savage terrors, and so it has been shut out. They
have wrapped themselves in their own sensations. These
cannot be transformed into perceptions until their terrors are
worked through with an understanding and receptive person.
On the other hand, this does not mean being soft with such
patients. I have found that we need to be more firm and active
than is usual in most psychoanalytically based psychotherapy.
As a drug addict once said, 'Parents need to be stern in their
love.' With patients who have become addicted to autism the
therapist has to behave iri this way also. For example, in my
work with Ariadne, I firmly directed her to try to stop biting
and sucking the'iinsides of her cheeks. I associated this with an
14 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
It represents an attenipt to get in touch with idiosylicratic
preverbal states to try to bring them within tlie orbit of
human communication. I have called upon poets and writers
to help me in this task. It has seemed to me that we need
to be encircled by their integrating aesthetic embrace as we go
through the states of unintegration and disintegration that will
be discussed in this book. The attempt has been made to use a
kind of poetic science, hi tlie hope that it will hold both author
and reader through states of hypervuhierability such as are
experienced when the protective autism falls away. Thus
although this will inevitably be a disturbing book, it is hoped
that it will also be a therapeutic one.
One more importmit point needs to be made. It has seemed
to be niore useful to study in detail tlie disturbmice to the
psyche encountered in psychogenic autism than to adjudicate
'blame', either to parents or children. In such a study, tlie
attempt lias to be made to live inside the skin of ,an autistic
child in order to feel what it is like to be there. There are limits
to one's capacity to do this, but the fact tliat many mothers of
autistic children have said tliat what I have written in my two
earlier books on autism 'rings true' lias encouraged me to feel
that I have managed to do this to soirle extent. With each
book, I feel I have become more closely i11 touch with tlie
nature of psychogenic autism. Thus, tliis book will be divided
into two parts. The first part will deal with tlie nature of
psychogenic autism, based mostly on my work with autistic
children. Since tliis promises to throw light on the psy-
chogenic autism encountered in adult neurotic patients, the
second part of the book will deal with tlie capsule of autism
encountered in such neurotic patients.
In his paper, 'Autistic phenomena ui neurotic patients',
drawing on his work with autistic children, Dr Sydney Klein
has alerted us to the hidden autistic part of certain neurotic
patients. He writes as follows:
In tlie course of a periodic review of the progress of lily
analytic practice, and particularly of my patients' habitual
 INTRODUCTION 15
modes of communication, I became aware that certain
among whom I thought of initially as being only mildly
neurotic, some of whom were also 'analytic candidates, re-
vealed during the course of treatment phenomena familiar
in the treatment of autistic children. These patients were
highly intelligent, hard-working, successful and even
prominent professionally and socially, usually pleasant and
likeable, who came to analysis either ostensibly for p,rofes-
sional reasons or because of a failure to maintain a satisfac-
tory relationship with a husband or wife. It gradually
became clear that in spite of the analysis apparently mov-
ing, the regular production of dreams, 'and reports of
progress, there was a part of the patient's personality with
which I was not in touch. I had the impression that no real
fundamental changes were taking place. (S. Klein, 1980, p.
395)
I have quoted at length from the introduction to Sydney
Klein's paper because it describes so well the encapsulated,
well-nigh impenetrable, autistic part of the personality of
those neurotic patients who seem as though they will never be
ready to finish coming to analysis because a crucial empty
part of them has never been reached.
Some readers may have difficulties in accepting the thesis
that neurotic patients can have autistic impediments. This nlay
be because they have never worked with psychogenic autistic
children, 'and thus find it difficult to accept that such odd
children can have 'an affinity with people with whom they can
more easily identify. However, those of us who work with
such children find an answering echo in ourselves. Other
readers, p6uticularly those with a psychiatric orientation, may
have difficulties in accepting this thesis because they think of
autism as an irreversible, discrete syndrome, which is often
associated with brain lesions and always with mi inbuilt cogni-
tive defect. This has not been my experience. Sotile autistic
children are undoubtedly brain-damaged. But there are other
children whose autism seenls to be psychogenic in origin. It is
292 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
make-up. Autistic children are not a different species from
ourselves. There are many points where we can make contact
with them, and, in so doing, we talk directly to them and with
feeling, so that they feel understood. This gradually encourages
them to lower the barriers of their more extreme autistic
reactions.
As we do this, we begin to realize that psychogenic autism is
a fundamental disorder of perception. We come to see that the
shape-making dispositions of the human mind have gone along
a deviant and futile path. Elementary shapes are constellations
of sensation. In normal development, these sensation shapes
become associated with actual objects in the external world, at
first probably with the breast. This trans-formation of
sensations into concepts and percepts, through the shape-
making dispositions of the human mind becoming associated
with actual objects, is impeded in autistic children because of
their lack of trans-actions with the outside world. Instead,
actual objects are used to generate autistic objects and autistic
shapes which, being self-generated, are like mirages in the
desert. They have no existence in actuality. Patients in autistic
states are trapped in an unshareable world of self-generated
tactile sensations. Only things which can be touched and
manipulated seem real. Because they cannot be seen, touched
or handled, psychic experiences are outside the scope of these
children. Thus memories, thoughts, fantasies, imaginations
and play are not within the range of their possibilities. Symbolic
representational activities are not possible for them. It was a
great step forward when John, in Chapter 4, represented the
breast by placing two coloured pencils in the form of a cross,
saying 'Breast' as he did so.
We have also seen that an important reason for their shutting
out the outside world has been that, as particularly sensitive
children, for various reasons, they have felt that their overtures
were rebuffed by the suckling mother of their infancy. This has
provoked an agonized awareness of their separateness from the
mother who is their first representative of the outside world.
 THERAPY IN PSYCHOGENIC AUTISTIC STATES 291 16 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
of autistic objects and autistic shapes has an analogy with these latter children who have been the source of inspiration
getting through the heap of rubble which buried the newborn for the findings in this book. It will become clear that, as I
babies in the Mexican earthquake last year. Paediatricians tell have worked with these children, my understandings have
us that the babies survived for a longer time than older people been in a continual process of evolution. Chapter 2 traces the
because the newborn infant has an innate facility for slowing growth of this understanding.
down physiological processes such as breathing and heartbeat, Frances Tustin
and so could survive in this state of diminished response for
a longer time than might be expected. The diminished March 1986
physiological responsiveness can seem to have an analogy with
the diminished psychic responsiveness of autistic children; and
the tunnelling through the rubble can seem to be an apt
description for the work that the therapist has to do in the first
phase of treatment. But, like all analogies, it must not be
pushed too far. The babies in the earthquake survived for up to
a fortnight. We do not know that there is such a time-limit for
psychic survival. For some people, psychic resuscitation seems
to be possible even into old age, as witness the elderly patient
treated by Hanna Segal(1958).
As we talk to the human, sane part of the patients about their
use of autistic objects and autistic shapes, we offer them
something better by our behaviour and our words - we offer
them a firm but sympathetic understanding of their difficulties.
T o do this, we have to empathize with them in their distresses.
But empathizing with patients in autistic states does not mean
losing our own sanity. Rather it means finding points of contact
with them. Previous chapters have sought to describe some of
the battery of inborn responses which are shared by all human
beings. We have seen that, as the result of their restriction of
outside experiences, autistic children operate mostly in terms of
these inbuilt predispositions; and since these are relatively
unmodified by outside experiences, the children react in an
exaggerated and hypersensitized way.
In a less exaggerated form, we share these inborn dis-
positions and so, to some extent, we can identify with the
children. The book has sought to help the reader to do this. It
has hinted that all of us are likely to have a bit of autism in our

PART ONE
PSYCHOGENIC AUTISM
Autistic children are diagnosed by their behaviour or,
sometimes, lack of it. In their severest state they do not
speak, or only echo what someone else has said, either
immediately or after a period of time (delayed echolalia).
If they move about (some will sit all day long motionless
or producing one activity such as lifting and dropping an
object), they usually appear uninterested in their
surroundings.
In fact, the behaviour of severely autistic children,
unlike that of all except the most severely brain-damaged
child, appears purposeless, but compares notably with
that displayed by animals reared in strict isolation.
Attempts to interest them in alternative behaviour are
usually avoided or actively resisted, and can produce
severe tantrums or attempts to escape the situation. They
appear to have no sense of identity, and to inhabit an
empty world.
Brian Roberts, Introduction to Furneaux and Roberts
(eds), Autistic Children, p. 10
290 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
Used in this flexible way, a retreat can become a useful resting
time until the individual is strong enough to take the 'better
jump'.
The trouble with rigid, inflexible, more permanent retreats
from everyday life is that they trap the individual, so that
perception is restricted and untransformed sensations become
predominant. As always in autism, an innate disposition which
could have been useful has become over-used in a way which is
deleterious to ongoing psychic development. In such autistic
states there is a taboo on tenderness. However, when the
autistic capsule begins to crack open, we see the hypersen-
sitivity against which it has been a protection. This warns us
that we need to be careful but firm in modifying the autistic
protections. Also, as they encounter the part of their
personality which has been a hollow sham, such patients
experience great waves of despair. Modifying the autistic
protections is a sensitive but necessary task.
Modgying the autistic protections These artificial practices
have buried the natural human responses of such patients. In
autistic states, patients feel that they are inanimate things
surrounded by threatening inanimate things. T o get away from
these threats they bury themselves in autistic practices.
Ariadne, the interesting neurotic adult patient we met in the
previous chapter, once said to me, 'y' know, I feel I came to you
buried with a whole heap of rubbish and that you found the
flame of sanity underneath it, and fanned it into life.' Dr Bion
was very clear that this was an important function of the
analyst. He wrote: 'I have no doubt that the analyst should
always insist, by the way in which he conducts the case, that he
is addressing himself to a sane person and is entitled to expect
some sane reception' (Bion, 1977). It is by addressing this sane
human part, and by behaving sanely and humanly oneself, that
the therapist is provided with one way of modifying the autistic
encapsulation.
Getting through the heap of nonsense engendered by the use
 THERAPY IN PSYCHOGENIC A U T I S T I C S T A T E S 289
(Balint, E., 1986). It is such behaviour on the part of neurotic
adult patients that findings from work with psychogenic
autistic children can help us to understand.
When neurotic patients are in the grip of their hidden capsule
of autism, they seem hard and impenetrable. They talk as if
they know it all, with little respect for the analyst's experience
and interpretation. They do not seem able to take anything in.
In this state, they are adept at playing upon their analyst's
weaknesses and human flaws. They do this in the nicest pos-
sible way, so that it is hard to detect. It is only when the therap-
ist realizes that his or her authority has been undermined, that
(s)he realizes what has been going on. Children do this more
obviously than adult patients, by trying to push the therapist
out of his or her chair, or by sliding into it if, for any reason, it
is unoccupied. In this state, these patients become 'know-alls'
who try to teach us our job, and who are very affronted when we
will not conduct the analysis in the way they think it should be
done.
They do all this so charmingly that we are liable to become as
anaesthetized by it as they are by their use of autistic shapes.
Autistic patients have hoodwinked themselves and, if we are
not careful, they will hoodwink us also. An analysis conducted
on this basis can go on forever, with no hope of a satisfactory
termination. From infancy onwards, such patients have taken
'the bit between their teeth', and in an autistic state they are
impervious to outside influences which could modify their
bland complacency.
When this brittle self-sufficiency can no longer be main-
tained it is devastating for them. They experience a breakdown.
This can be of varying degrees of severity. One patient
described it to me by saying that 'the glaze is cracking'. She
went through a difficult time but emerged, with psycho-
therapeutic help, to an enriched mode of functioning. This
patient has done well, but before doing so, she had to go
through Phase 2, with many retreats into her autistic shell.
Gradually, these have become a reculer pour mieux sauter.

CHAPTER ONE
The nature of
psychogenic autism :
an overview
My mother groan'd, my father wept,
Into the dangerous world I leapt:
Helpless, naked, piping loud:
Like a fiend hid in a cloud.
Struggling in my father's hands,
Striving against my swaddling bands.
Bound and weary I thought best
To sulk upon my mother's breast.
William Blake, 'Infant Sorrow'
o one would dispute that psychogenic autistic children
are hard to reach. Indeed, the dispute might be as to
whether they can be reached at all. However, it was my
experience, as I became increasingly in touch with their
idiosyncratic mode of functioning, that some young autistic
children (though not all) could be reached by psycho-
analytically based psychotherapy. However, before discussing
psychogenic autism, let me say a word about the organic
hypothesis.
The organic hypothesis
I respect the concern of the organicists who feel that it is
irresponsible to raise hopes in parents who have already
suffered so much. It is regrettably true that in the early days,
following Kanner's distinguishing 'early infantile autism' from
mental deficiency, in an outburst of enthusiasm, psycho-
288 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
1 Modifying the autistic barriers so that relationships with
people can be set in train.
2 Healing the damaged psyche. (Psychotherapy can begin.)
3 Psychoanalysis as it is ordinarily practised. (This need not
be discussed as it is well known.)
Phase I Modifying the autistic bameus
The autistic encapsulation of autistic objects and autistic
shapes When we have become alerted to them, the use such
patients make of autistic objects and autistic shapes is very
obvious, and examples of it have been given throughout the
book. Later, as the patients emerge from the paralysing effects
of the autipm, they tell us about their illusion of being damaged,
and we begin to understand the usefulness of these practices in
seeming to protect them from the existential dreads which have
been discussed in other chapters. As such, they perform very
important functions and need to be respected. But they prevent
healing influences from playing upon the patients, and thus
they need to be deterred from using them. It is only by under-
standing their function that we can help them to find more
realistic and effective means of protection. These practices
mean that autistic children's capacities for empathy and
imagination have not developed. Thus it is important that the
therapist should have these qualities in good measure, so that,
as it were, they 'rub off' on to the autistic child.
All that has been said so far in relation to autistic children also
applies to adult patients who we suspect have a capsule of
autism which is impeding psychoanalytic work with them. D r
Nini Ettlinger had a woman patient whose costume jewellery
was used as autistic objects (personal communication). Mrs
Enid Balint has very recently described Mr Smith, an adult
patient whom she recognized as having marked autistic fea-
tures. This patient quite literally 'cushioned' himself against
the impingement of disturbing experiences by using the
softness of a cushion on the analytic couch to generate autistic
shapes, and the hard corner of the cushion as an autistic object
 THERAPY IN PSYCHOGENIC AUTISTIC STATES 287
and psychoanalysts made undue claims for the benefits of a type
of psychotherapy which was not closely based on a detailed
understanding of the disorder, and they blamed the mothers.
Such a simplistic approach was found to fail and, naturally,
some mental health workers now completely reject psycho-
therapy for autistic children. They have come to view all types
of autism as untreatable conditions, and autism as being re-
stricted to autistic children. T o say, as I am saying, that if we
begin to understand better the nature of that autism which
seems to be psychogenic in origin, sonre autistic children can be
helped to normal functioning, will seem to such colleagues to be
unlikely, un-understandable 2nd even irresponsible. Also, to
say in addition that such work has thrown light on certain
neurotic disorders which have a hidden capsule of psychogenic
autism may seem to them to be preposterous.
For my part I am aware that to write about such work always
makes it sound easier and simpler than it is. In actual fact, it is
very difficult. There is much that we do not understand. Nor is
it work that all psychoanalytically based psychotherapists find
compatible with their personality. Finally, we come up against
the fact that our knowledge about the psychic situation of a
patient in a state of autistic encapsulation is, to some extent, a
matter of hindsight. It is only as they become freed from its
immobilizing influence that they can tell us about what it was
like.
Some analysts have been in touch with the states being
discussed in this chapter without specifically relating them
to autism. For example, Enid Balint, in 'On being empty of
oneself' (1963), describes a neurotic adult patient whom we
would now recognize as having autistic features, and whose
psychic development was freed and facilitated by work with
Mrs Balint. However, in clinical work with autistic children we
see autistic phenomena manifested in a simple context, and this
helps us to evolve a basic scheme for the psychotherapeutic
treatment of autistic conditions. There seem to be three main
overlapping phases in the treatment of psychogenic autism.
20 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
analysts and psychotherapists made unjustified claims for the
possibilities of the psychodynamic treatment of autism. Even
today, in some quarters, the psychodynamicists do not make a
clear distinction between psychogenic and organic autism, nor
between autistic-type and schizophrenic-type disorders, and
disorders arising from parental neglect.
Some autistic children are undoubtedly brain-damaged, and
thus have a cognitive defect. However, the organic hypothesis
- that they have a genetic defect in terms of a 'fragile chromo-
some' - does not seem to have been borne out by attempts to
replicate the treatment suggested for it. But these neuro-
physiological matters are not really my concern. As a psycho-
therapist, those children whose autism seems likely to be
psychogenic in origin have been the focus of my attention. For
those readers who have never worked with psychogenic autistic
children, here is a brief description of them.
Description of psychogenic autistic children
Such children seem to be in a massive, unmitigated primal sulk
such as was described by Blake at the head of this chapter. But
it is a much more intense sulk than that described by Blake. As
we shall see in later chapters, it is shot through with umbrage
and black despair such as have been described by Ted Hughes
in Crow. This has caused them to be unrelated to the mother,
and thus to people in general. They avoid looking at people, and
communication by language, play, drawing or modelling is
scanty, and often not present at all. T h e children I have treated
have all been mute at the outset of treatment, but some autistic
children are echolalic so that they communicate in a limited but
bizarre way. These latter children also sometimes 'play' in a
restricted, obsessional way. T h e late Margaret Mahler, in
illuminating papers and books arising from her long experience
with such children, has focused attention upon autistic chil-
dren's difficulties concerning separation and individuation, and
their fragile awareness of their own identity (Mahler, 1958).
Such children lack empathy (see Hobson, 1986). They also lack
 THE NATURE OF PSYCHOGENIC AUTISM 21
CHAPTER SIXTEEN
imagination (see Frith, 1985). These children have no inner
life. T o ascribe fantasies to them is incorrect. This makes
psychotherapy with such children different from that with our Psychotherapy with
other patients. Overall there is a gross early arrest of cognitive psychogenic autistic states
and affective development, although autistic children's
physical development is usually normal. Indeed, they often
have beautiful faces and well-formed bodies. Let me embody A warmth within the breast would melt
this description in a flesh-and-blood child patient who The freezing reason'ecolder part,
illustrated many of the features characteristic of psychogenic And like a man in wrath the heart
Stood up and answer'd 'I have felt.'
autism.
Tennyson, In Memoriam,CxxIII
A consultation with an autistic child
Six-year-old Stephen is brought to see me in my consulting-
room. He makes no complaint about coming. He has on a shiny
white plastic mackintosh with a zip up the front. He carries a
toy car clutched tightly in the palm of his hand. His mouth,
which is slightly open, seems limp and slack, but his body feels
tight and hard as I guide him into the room. He is mute.
Stephen stands before me with a well-formed body, an other-
worldly look and melancholy eyes which do not meet mine
'arious aspects of the psychotherapeutic process with
directly. Whilst I wrestle to undo the zip of his mackintosh, he
psychogenic autism have been referred to as the themes
stands stiff and inert like a statue. He does not co-operate with
of this book have been presented. In this final chapter,
me in any way. In fact, he seems to be oblivious of me.
it will be useful to gather together the insights into psychogenic
However, when I have half undone his zip, he steps out of the
autism which have been developed as the book has progressed.
mackintosh and, still avoiding looking at me directly, retreats to These will aid us in our attempt to develop psychoanalytic
a remote corner of the room, hastily grabbing a brown crayon psychotherapy which is closely in touch with the nature of
from the table as he does so. psychogenic autism.
In the corner, with this crayon, he immediately starts to draw Psychoanalysis was originally based on the study of patients
large sweeping lines on the floor in front of his feet. I feel more who had developed the basic possibilities for human re-
and more cut off from him as he multiplies the encircling lines lationships. Thus, in the early stages, our work with non-
around him. At last, I take his plastic mackintosh from the chair relationship autistic states will have certain differences from
and hold it in front of me. Although he seems so unaware of me, that with the more usual relationship-oriented ones. It is a lack
he is aware of this and runs forward to dive into the protection in England that there is not a research and treatment unit
of the mackintosh like a snail returning to its shell. devoted to studying the psychotherapeutic possibilities for this
Stephen shows many of the features which are typical of disorder. This may be because in the 1950s psychotherapists
autistic children. There is the avoidance of direct eye-to-eye
 T H E RHYTHM O F SAFETY 285
been worn smooth by use. They stimulate us to evolve more
feelingful ways of expressing things. As a result, the mental and
spiritual life of both analyst and patient is strengthened. T h e
reflective interactions which developed between Ariadne and
myself have meant that, for both of us, immortality has come to
be seen in less crude terms than mere bodily survival. Thus,
this chapter has been written as a tribute to Ariadne, as also
those recovered autistic children who, like her, have had the
courage to face those mortal terrors which these patients
experience with such hypersensitized intensity.
22 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
contact with me, although he has a fringe awareness of what I
am doing. He does not co-operate but cuts himself off from me.
He leaves his mother without a backward glance and shows
none of the normal responses to people. Physically, he is well
formed and his face would be attractive were it not so
expressionless. This is the case apart from his eyes which
sometimes look anguished and melancholy. He carries a hard
object clutched tightly in the palm of his hand.
I call autistic children 'shell-type' or encapsulated children.
Their parents often say such things as 'I can't reach him'. 'My
child seems to be in a shell all the time.' 'It's as though he can't
see or hear us, or won't.' Such children are often thought to be
deaf and some even try to walk through objects as if they were
blind. However, on being tested, thkir perceptual apparatus is
found to be intact; it is the processing of incoming information
which is faulty. This could be due to brain lesions or to
psychogenic damage. (Clinical work has given me clues as to
the nature of the psychogenic damage, which will be discussed
in various chapters throughout the book.)
This psychogenic damage causes autistic children to turn
their attention away from the things that the developing child
usually attends to. This seems to be because they are protecting
their bodies from 'not-me' threats which are felt to be over-
whelmingly dangerous. When working with these children, it
becomes clear that anything which is not familiar, and is 'not-
me', arouses intense terror. A grown man of twenty-five, who
had been diagnosed by Leo Kanner at age four as suffering from
early infantile autism, said that his outstanding memory of the
autistic state from which he had emerged to some degree was of
'terror' (Piggott, 1979).
In certain neurotic patients, both children and adults, the
autistic features which have just been described and ex-
emplified are overlaid by more normal functioning. The
instability of this becomes apparent as work at depth proceeds.
The origins of psychogenic autism
Clinical work with psychogenic autistic children in whom no
 THE NATURE OF PSYCHOGENIC AUTISM 23
brain damage can be detected by the investigative methods at
present available indicates that they developed, as infants, a
massive formation of avoidance reactions in order to deal with
a traumatic awareness of bodily separateness from the mother.
This impinged upon their awareness before their psychic
apparatus was ready to take the strain. You will notice that I am
emphasizing the organizational state of the infant rather than
the age at which the trauma occurred. This is because, in some
infants, the impingement occurred following a too-close
association with the mother which went on for too long,
whereas in other infants it occurred in earliest infancy.
Winnicott (1958) has described this latter situation as follows:
...certain aspects of the mouth.. .disappear from the infant's
point of view along with the mother and the breast when
there is separation at a date earlier than that at which [the
child] had reached a stage of emotional development which
could provide the equipment for dealing with loss. T h e same
loss of the mother a few months later would be a loss of object
without this added loss of part of the subject.
I n terms of Stern's recent formulations concerning the
development of self (1986), a traumatic awareness of sep-
arateness occurred in the state of being an 'emergent self', and
before 'the core of the self' had developed. I n other words, it
occurred before the suckling mother, and all that this implies,
had become well established as an inner psychic experience and
before a secure sense of 'going-on-being' had developed. Thus,
these patients are beset by such elemental dreads as falling
apart, of 'falling infinitely' (Winnicott's phrase), of falling with
a damaging bump, of spilling away, of exploding away, of
losing the thread of continuity which guarantees their
existence. These terrors were experienced in a state which was
preverbal, pre-image and preconceptual. They meant that the
infant's emotional and cognitive development was either slowed
down, or virtually stopped.
In a hidden area of their personality, certain neurotic
patients feel helplessly immobilized and at the point of death.
284 A U T I S T I C BARRIERS I N N E U R O T I C PATIENTS
couth, brutal aspects of her nature had remained unmodified
and had shocked her when she had encountered them.
Conclusion
Those fortunate individuals who, in early infancy, have been
able to enjoy and internalize emotional experiences of a
rhythmical, adaptive interaction of the mouth differentiated
from the breast are receptive to later experiences such as human
sexual love, and aesthetic and religious experiences. For such
people, these are not used in shallow and stereotyped ways as
autistic evasions of the inevitable realities of human existence.
They are deeply felt experiences which build upon, enrich and
revitalize that intrapsychic creation which Ariadne so aptly
called 'the rhythm of safety'. This intangible creation is
primitive but complex. It is what the autistic child should have
achieved but has not.
Experiences at the breast - or bottle experienced in terms
of an inbuilt expectation of the breast - provide a foretaste of the
inevitable life situations to come. In relatively normal
development these are met in the protected situation of the
reverie of maternal preoccupation (Bion, 1962a; Winnicott,
1958). If this is disturbed, the infant is left in the grip of
atavistic, savage terrors which played a part in human evolution
but which are now vestigial. In normal development this
savagery is humanized and civilized by that transforming
empathic communion between mother and baby which is the
earliest form of communication.
Early, basic, bedrock processes set the pattern for later
experiences. If, for any reason, evasion becomes the pre-
dominating reaction, evasion becomes the way in which all later
difficulties are dealt with. It is a long and arduous task for both
therapist and patient to bring about changes in these basic
structures. But the effort is worthwhile, for these patients give
us new ways of catching the meaning of those wordless
intangibles which are of such deep significance in human living.
They also free us from the jargon and cliches of words that have
 T H E RHYTHM OF SAFETY 283
Giannotti (1980) have shown, the caesura of birth is healed for
both mother and baby, in normal development, by their mutual
intereactions with each other.
The autism had been a kind of plaster cast which had
immobilized this wounded part of her. As she gave up her
autistic practices, Ariadne became aware of her own intrinsic
forces of healing, and also of the firm but tender care by which
she was surrounded. In short, she became aware of 'love', not of
the sentimental 'heart-throb' kind but as an adaptive ad-
justment to her needs which arose from reflective thought,
which also became possible for her. She began to be able to
experience the agony and the ecstasy of being a fallible, finite
human being who could die. Instead of evading them, she
began to face the conflicts, difficulties and pains of ordinary
living. She found that there were joys as well as sorrows and
that, as she experienced uprightness in herself and in me, she
became able to bear both. Her fear of madness associated with
dirt and disorder, against which the autism had been a
protection, was also alleviated. She no longer feared that the
discharge of uncouth feelings would pollute the absolute purity
of her body and cloud the absolute clarity of her mind. These
extreme splits were modified as she became aware of a shared
integrative rhythm of adaptive human reciprocity which em-
braced both the acceptable 'me' and the rejected 'not-me'.
For this development to become possible, Ariadne had
needed to be sternly encouraged to give up her massive evasions
of reality. Quite concretely, she had put her own narrow
construction upon the outside world. Her autistic contrivances
had made her stilted, narrow-minded and rigidly conforming,
to the point of passivity and timidity. But underneath this
shying away, she had felt very special. All this had protected her
from the inevitable pains of being a human being, but had also
shut her away from being aware of, and of becoming capable
of, love in its functions of empathy, interest, attention,
consideration, compassion, care and understanding. The un-
24 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
They are always trying to counteract this deathly arrest to their
'going-on-being' by overreaching themselves and by having
unlimited expectations of themselves and of other people. Since
they are usually well endowed they achieve a great deal, often of
a cerebral nature, but it is at great personal cost. Two dreams of
an intelligent man who coped efficiently with a professional job
vividly portray such autistic handicaps.
In the first dream, the dreamer was standing on the raised
veranda of a house looking down on a large expanse of water
through which a boat was very slowly making its way. The
progress of the boat was so slow that the season changed to
winter and the boat became frozen into the ice. The dreamer
noticed the rotting timbers of the boat. He set out in a snow-
mobile to release the boat but he went so fast that he overshot
it. This means that he went to the edge of the expanse of water,
which was now reduced in size from being a sea to being a lake.
Also, the boundaries of this lake were obliterated by the snow
that had fallen, so that the differentiation of land from water
was obscured. The dreamer went on trying to get to the boat by
other means, but he was always foiled in his attempts by
obstructions and confusions.
In the second dream, the dreamer saw a man falling from an
open window to the ground which was hard and damaging.
Before the surgeon could finish attending to his injured legs,
the falling process was reversed and, as sometimes happens in
films, the man shot up again, to fall from the open window as
before. But this time he had heavy casts on his legs which
seemed to be made of concrete. These made him fall faster and
more heavily than before, so that when he landed his injured
legs were embedded in the ground and he was immobilized like
the boat.
Discussion of autistic immobilization
These two dreams poignantly illustrate the autistic encapsula-
tion which develops to encase and immobilize the damaged part
of the personality which is concerned with understanding.
 T H E N A T U R E OF P S Y C H O G E N I C .4UTISM
Over-concretized thinking becomes the order of the day; the
capacity to make the abstractions necessary for imaginative and
reflective thought is restricted. The second dream also brings in
the notion of the catastrophic fall which provoked these autistic
reactions. Dreams are the only way neurotic patients can tell us
about this catastrophe. It is fortunate that they can use the
image-making capacities of the non-autistic part to do so. How-
ever, when they can talk, young autistic children can tell us
about this tragedy more directly (see the material of John in
Chapter 4).
The Fall from the sublime state of blissful unity with the
'mother' who, in early infancy, is the sensation-dominated
centre of the infant's universe, is part of everyone's experience.
However, for some individuals, for a variety of reasons, differ-
ent in each case, the disillusionment of 'coming down to earth'
from this ecstatic experience has been such a hard and injurious
experience that it has provoked impeding encapsulating reac-
tions. It has been the pebble which provoked the landslide. The
encapsulating reactions support and protect the damaged part
and shut out the fear of being killed but, metaphorically speak-
ing, their psychic functioning is frozen and immobilized. There
is no flow. Also, in the first dream, the dreamer was observing
these experiences as happening outside himself. He was in an
elevated state looking down upon them. In the second dream
they were happening to someone else. Such 'out-of-the-body'
experiences counteract the threat of dying. In most cases, the
threat is of worse than death. It is the threat of total annihila-
tion.
Encapsulating reactions mean that in an isolated area of the
personality, attention has been deflected away from the
objective world which presents such threats, in favour of a
subjective, sensation-dominated world which is under their
direct control. In certain neurotic patients (and, as Sydney
Klein says, some of them are only 'mildly neurotic'), this has
become an established way of life. These avoidance reactions,
which were necessary at the time of the catastrophic Fall, but
25 282 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
difficulties'. Sadly, at that time, I did not understand her
autistic handicaps and so could not help her as fundamentally as
I have been able to do in the second phase of her analysis.
I have come to realize that the autistic part of the personality
is the part that avoids comlng into the analysis. It is the
intractable part of infantile experience which could not be
'digested' and has been hidden away. As well as being locked
away in autistic objects and autistic shapes, it can also be locked
away in idiosyncratic movements and tics. Lam reminded here
of James Robertson's film of Laura, the two-year-old, very
controlled little girl who was separated from her mother by
being hospitalized. She shut away this 'unthinkable' experience
by the tic of brushing her hand across her face, as if wiping away
the tears she could not shed. On a more sophisticated level this
hidden autistic part can be seen in some children's excessive
preoccupation with tongue-twisters, conundrums and riddles.
This was also characteristic of the ancient Celts described by
Daphne Nash at the end of Chapter 8. It is the twisted part of
the patient which feels unknown and unknowing because
bodily separation from the mother has been experienced as an
obliterating catastrophe.
Autism is anti-life, but 'anti-life' is not synonymous with
death. Dying is an inevitable part of the life process. Autis-
tic techniques are reactions to avoid becoming conscious of the
'black hole' of separation, of ,partings, of endings, and
ultimately of death. In so doing, they cut the individual off
from life. It is only as we become aware of the fact of death that
we fully value life. In the second phase of treatment Ariadne
began to realize that, for her, endings and partings were not
merely experienced as rejections (as they would be by more
normal neurotic patients), they were experienced as a violent
tearing apart of her body from that of a being with whom she
had felt continuous, and who had unrealistically seemed to
guarantee the continuity of her bodily existence. The wounds
from this violent ripping apart needed to be healed before she
could bear to end her bodily contact with me. As De Astis and
 T H E RHYTHM OF SAFETY 281
a little girl up to the present day, she had bitten and sucked the
insides of her cheeks. Such autistic manoeuvres are hidden and
secret. I had never seen Ariadne using them, and she would
never have thought to tell me about them unless I had asked her
directly.
1 dealt with them in a similarly direct way by saying that it
was important that she should try to stop doing these things. I
explained to her that I thought that she did them in order to
delude herself that she had a fleshly bit of an everlasting mother
always with her, so that she could feel that her body was
continuous with that of an eternal fleshly being who completely
ensured both her safety and her existence. This was an im-
portant turning point in Ariadne's treatment and cleared the
way for the dreams which stimulated her awareness of the
'rhythm of safety'. This, at depth, arose from an acceptance of
the rhythm of life with its joys and with its sorrows. (I
remember an autistic child for whom this was exemplified by
the inevitability of the changes of the seasons as he came
through the country lanes to the converted pony-shed which 1
used as a therapy room.) Ariadne has since told me that my
disciplining firmness in telling her to stop sucking and biting
her cheeks made her feel that I really cared about whether she
grew up in the right way. She will now sometimes tell me that
in moments of stress she has found herself sucking her cheeks,
and has immediately stopped doing it. Benign authority was
becoming part of her experience of me.
After discovering Ariadne's use of part of her body as an
autistic object, I concentrated on showing her how these
'techniques' (as she came to call them) had prevented her from
coming to terms with the inevitable facts of bodily separate-
ness. She began to realize that her manibulative techniques had
led her to delude herself that absences and partings could al-
ways be avoided. Thus, mental activities which bridge the gap
of separateness - such as fantasies, imaginations, thoughts,
memories and metaphors - were very undeveloped. No wonder
that, as a child, she had been referred to me for 'learning
26 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
which have outlived their usefulness, become autistic barriers
to cognitive and affective functioning. T h e effort to keep going
and to maintain an appearance of nornlality is very hard work.
In an isolated area of their being, such patients feel that their
life goes in ever-decreasing circles, as is shown by the sea which
shrinks to being a lake.
T h e Fall and its accompanin~entstend to be repeated in later
life situations where ecstatic expectations have been built up to
be dashed to the ground by contact with reality. Thus, they can
occur in such situations as giving birth to a baby, in the midlife
crisis, after the 'honeymoon period' of marriage, in psycho-
therapy or psychoanalysis ... Such people compensate for their
unacknowledged sense of being irreparably damaged by
perfectionist expectations of themselves and of other people.
When these impossible expectations are disappointed, the
infantile experience of damaging disillusionment is re-evoked.
At the base of their being they live in an 'all or nothing' world.
It is an uncompromising black-and-white world in which
opposites cannot be tolerated because they seem to threaten to
destroy each other. These fears lead to narrow-mindedness, to
bigotry and fanaticism. They may be covered up by so-called
'progressive attitudes', often of an extreme ideological nature.
T h e instability of these extreme attitudes sometimes becomes
apparent when there is a sudden switch to those of a totally
opposite kind.
Primary psychic mishaps also lead to an obsessional need to
feel in control of what happens. They may also lead to phobic
reactions. A phobia is terror of a specific part of the outside
world, usually of one that has been attractive to the individual,
whereas autism is terror of almost the whole of the outside
world, particularly of the mother. When phobic patients are
analysed at depth, we are likely to find that bodily separateness
from the mother has been experienced as an insufferable
catastrophe. This,will be illustrated in various chapters in the
book. This catastrophe is also at the heart of the manic defence.
There are even some so-called borderline patients who are so
 T H E N A T U R E OF PSYCHOGENIC A U T I S M 27
frozen with terror that they do not know what feelings are, a
condition now termed 'alexythymia' (Grotstein, 1983). At this
point, I want to link what I have been saying to the findings of
other writers, so that readers with a different orientation from
my own may find themselves in familiar territory.
Thefindings of other writers
In the quotation cited earlier Winnicott described such
catastrophic separation experiences. He sees them as resulting
in what he calls 'psychotic depression': This type of depression
is associated with a sense of collapse - of what Winnicott (1958)
calls 'flop'. Edward Bibring, who has focused on the feelings of
littleness and helplessness, calls it 'primal depression' (Bibring,
1951.) Spitz writes of 'anaclitic depression' (Spitz, 1960).
Balint has written about such patients' 'basic fault' (Balint, M.,
1968). Bion writes of a 'psychological catastrophe' (Bion,
1962b). Influenced by Bion and also, of course, by Freud,
James Grotstein has described such patients' main 'deficit' as
the lack of a 'filter' for incoming and outgoing stimuli (Grot-
stein, 1980). T h e behaviourists write of autistic children's
incapacity 'to encode and process information'. They see this as
arising from an 'innate cognitive defect'.
Acquired cognitiz~eand emotional defects
This chapter has indicated that cignitive defects (as also
emotional defects, with which they are intertwined) are not
always innate but can also be acquired. All the chapters in this
book are concerned with how this can occur. T h e basic thesis is
that the autistic state is a reaction to a traumatic awareness of
separateness from the sensation-giving suckling mother. Au-
tistic reactions divert attention away from this mother, who is
spurned in favour of self-generated sensations which are always
available and predictable, and so do not bring shocks. These
bring about a state of diminished perception which leads to
diminished thinking and feeling. T h e autistic child, and the
autistic part of a neurotic patient, is numb and dumb. They
280 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
impression upon her. It was about the turtles which come up
from the water on to the seashore to lay their eggs, which are
immediately vandalized by humans. She realized that in walk-
ing through the evil amphitheatre she had been protecting her
'eggs' which were threatened with being vandalized.
As well as her biological potentiality to have offspring which
would carry her seed from generation to generation, and
so help her to achieve a kind of immortality, Ariadne realized
that these 'eggs' were also her creative capacities which had
been 'vandalized' by her autistic predations. Until we had
worked this over, she could not leave me. But we could not
work this over until her autism had been modified, and she had
developed more authentic means of feeling safe by realizing that
she was part of a creative process which would go on after her
mother's body and her own body were no more. T o extend
Marion Milner's saying (Milner, 1969), not only is the analyst
'the servant of a process', but so is the patient. Ariadne was
becoming able to be lived by her life, and so she developed a
'rhythm of safety', the capacity for which she had previously
been unaware of. It was beyond her manual and intellectual
control. Like growth and healing, this potentiality was a 'given'.
It occurred without her arranging that it should happen. It gave
her a much greater sense of safety than her own puny man-
oeuvres. The possibility for her awareness of this creative ca-
pacity was the result of a significant breakthrough in our work
together, which came about in the following way.
The significant breakthrough
About six months before Ariadne had the dreams which
stimulated her important forward movements, and when she
was in a state of despair about ever being ready to finish coming
to see me, I began to wonder whether she was using parts of her
body as autistic objects, as the autistic children did. So I asked
her quite directly whether she sucked or bit the inside of her
cheeks, or sucked and bit her tongue, or wriggled her bottom to
feel the faeces in her anus. She willingly told me that from being
 T H E RHYTHM OF SAFETY 279
bodily substances. The reassuring, enriching, intangible, safe-
making aspects of emot.ionsare not available to them.
It is the same with the reassuring, intangible processes of
growth and healing. These cannot be seen, touched and
manipulated and so they cannot believe in them. Such children
feel that they can make themselves grow by sticking extra bits
on to their bodies. This is imitation of a quite concrete kind.
Since they also feel that these bits are plucked from other bodies
who will want to retrieve them, these reactions bring terror in
their wake. Because they are so afraid of letting things happen
to them over which they have no control, the reassurance that
growth takes place naturally, without their having to do any-
thing about it, is not available to them.
Similarly, autistic children have no reassuring awareness
that they have inherent healing processes which will collaborate
with therapeutic interventions. The whole of their efforts are
directed towards 'covering' or 'blanketing' (to use Daisy's
terms) the many holes and wounds which seem to afflict them.
Thus, such children live almost wholly in terms of mani-
pulative, body-centred evasions and artificial fabrications
associated with sensuous experiences on body surfaces. They
derive no sense of safety from the natural, spontaneous
processes which go on unseen and uncontrolled by them.
As well as being cut off from the reassuring processes of
growth and healing, these children are also cut off from the
reassuring intangibles of fantasies, imaginations, memories and
reflective thought. Such children's potentialities for these
activities are relatively untapped and unused. Thus working
with autistic children we come upon unrealized potentialities.
As Ariadne's autistic constriction became relieved, she
became aware of another reassuring natural potentiality. This
was her biological reproductive capacity. Realizing this
assuaged her distress about not being eternal and immortal. She
helped me to be aware of this in the following way. She had
been to see one of the productions of a fringe theatre group. The
production, which was called Vulture Culture, made a great
28 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
seem to be in a state of suspended animation similar to that of
the babies in the Mexican earthquake in 1985 who were found
alive after many days of being buried by the rubble. T o use this
as a metaphor: as therapists with such patients, we have to
tunnel through the rubble to reach them. Having reached them
we need to give them all the psychic resuscitation and healing
that growing insight makes available to us. But this is a sensitive
and delicate task, and we need to be well in touch with, and to
understand the detail of, their autistic experiences. This book is
an attempt to do this.
When the psychic mishap of seemingly irretrievable loss first
occurred, these autistic reactions were appropriate and nec-
essary. But over the years they have become impediments to
psychic functioning. T h e only way that the autism can be
modified is by interaction with life and by a more spontaneous
use of their own inbuilt capacities. Many of the chapters in this
book are concerned with how we can help our patients to begin
to do this. T h e emphasis in this type of psychotherapy is not on
attempting to make up for what we infer may have been the
deficiencies of their infancy. (After all we were not there and we
cannot be sure about this.) T h e emphasis is on helping them to
go through primitive processes of mourning, which will heal
the wound of their too-early sense of loss, and relax the tensions
associated with the trauma, so that they can begin to use the
capacities with which they are usually well endowed. This is a
very realistic and unsentimental procedure.
I n some psychoanalytic formulations, the mother seems to
be held to be totally responsible for her child's psychogenic
autism. It is as if the child is viewed as a lump of clay to be
moulded, instead of the bit of dynamite the human baby is. As
well as distorting our views on aetiology, such an approach
distorts our views on psychotherapy. T h e patients' natural,
inbuilt propensities for growth, healing and creativity are not
given sufficient weight in attempts to free them from their
autistic impediments. Recognition of these biological 'givens'
immediately promotes a more hopeful approach to therapeutic
 T H E N A T U R E OF PSYCHOGENIC AUTISM 29
endeavours. Instead of trying to compensate our patients for
what we think they may have lacked, we try to free them, with
stern but compassionate understanding, from their autistic
practices so that they can begin to use the abilities they have,
often in very good measure. T o do this, they need to feel that we
believe in their capacity to do so. Thus, it is implicit throughout
this book that the patients' own nature and their capacity for
response, as well as external nurturing circumstances, will have
played their part in psychogenetically induced autistic pa-
thology, whether it is well nigh total as in the autistic child, or
partial as in certain neurotic patients.
The importance of early suckling experiences
In order to understand such patients, it is necessary to be in
touch with the nature of the infant's early suckling experiences.
This is where relationships begin. Clinical work indicates that
the sensation of nipple-in-mouth (or teat of the bottle expe-
rienced in terms of an inbuilt gestalt of the breast) is the focus
for the development of the psyche. Associated with the
mother's encircling arms, her shining eyes and the mutual
concentration of their attention, it becomes the core of the self.
It becomes associated with regulation, with bearing the
suspense of waiting, with tolerating human limitations, with
boundaries and with the sorting out of sensations. T h e way in
which the 'breast' is given and the way in which it is taken leaves
a mark for good or ill on the developing psyche. This will be
affected by the child's responses and by the quality of the
mother's relationship to the infant's father, and by the
circumstances of the parents' own infancy.
In normal development, the heightened degree of re-
sponsiveness and the especial quality of attention of both the
suckling mother and her infant partake of the sublime, and even
of the 'mystical'. It is a physically based psychic experience.
This empathic communion is the earliest form of com-
munication. It fosters the growth of the psyche. Patients who
are prone to autistic ways of behaving have had this early state
278 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
patients' functioning. Purity (cleanliness) becomes associated
with the intellect and, because primitive emotions are
associated with bodily discharges, the emotions become
associated with dirtiness and are experienced as 'evil'. The
scrupulously 'clean' intellect becomes overvalued at the
expense of the 'dirty' emotions. As Dr Sydney Klein has said:
'The sooner the analyst realizes the existence of the hidden part
of the patient,' by which he means the autistic part, 'the less the
danger of the analysis becoming an endless intellectual dialogue
...' (Klein, S., 1980). Becoming aware of the hidden autistic
part of such patients enables us to understand their deeply
rooted fear of emotion, and also helps us to avoid becoming
trapped by their arid intellectualism. Let us now study their
fear of emotion and other intangibles.
The autistic fear of intangibles
For autistic children, feeling safe is dependent upon the
delusion of feeling in absolute control of a mother's body which
is felt to be a part of their body. The manipulation of autistic
objects supports this delusion. These are not symbols of the
mother's body; they are felt to be actual tangible bits of the
mother's body experienced as part of their body which can be
controlled at will. (In Hanna Segal's (1957) terms they are
'symbolic equations'.) The intellect can be used in a formal way
in the service of this control and manipulation. It can narrow
things down to what the child feels they should be, rather than
helping him to see what they are. But emotions are a very
different kettle of fish. They cannot be controlled and
manipulated as tangible physical objects. T o autistic children,
however, only what can be controlled and manipulated in a
tangible way seems real and safe. Thus, emotional states either
feel unreal or are felt to be bodily substances which are
exceedingly evil and dangerous. If we talk to these children
about emotions, they either do not know what we are talking
about, or they turn away because it feels dangerous and unsafe.
They may even feel that we are pelting them with dangerous
 T H E RHYTHM OF SAFETY 277
I talked with Ariadne about this in relation to the explosive
shit of her tantrums, which were provoked by the frustration
and terror of bodily discontinuity from the elemental being
with whom she had struggled to feel eternally continuous. This
shit was felt to be evil and obnoxious and offended her prudery
about bodily processes. I suggested that her reaction was to see
the dirty evil of the panic and rage of her tantrums in other
people. Following this interpretation, Ariadne had a'flash of
inspiration about the delusional jealousy which had plagued her
for many years, and about which I had not been able to give her
fundamental insight. She said, 'I've just thought that perhaps I
do the same with my ecstasy. I can't bear it so I see other people
enjoying it and then I'm jealous of them.' (This piece of insight
was typical of the reflective interplay which characterized the
session. )
But why had Ariadne been driven to such desperate extremes
of splitting between the 'me' and the 'not-me'?
Splitting between the 'me' and the 'not-me'
Autistic children have shown me that at elemental levels
the rage, panic and grief of their infantile tantrums about
frustrations, and their infantile ecstasy about satisfactions,
were associated with bodily discharges. (You will remember
that Daisy talked about 'discharging' 'savage and sad thoughts'
and 'blissful thoughts'.) Such discharges are not acceptable to a
depressed or obsessional mother who feels them to be
obnoxious and unclean. Thus, they were not acceptable to the
developing sense of 'me-ness' of the baby, for whom parental
approval is important. This means that they are experienced as
'not-me'. The passive baby often becomes the 'unusually good
baby' described by so many mothers of autistic children. As
several writers have found, those autistic children who have an
early history of tantrums (or fits without organic cause) usually
have a more favourable prognosis than those with the 'un-
usually good baby' type of early history.
This splitting also operates in another sphere of such
30 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
of communion traumatically disturbed. This means that, in-
stead of a psychic core which holds them together, they have an
unmourned sense of loss - a 'black hole with a nasty prick', as
John, who is discussed in Chapter 4, so graphically described it.
Remedying the 'black hole'
This 'black hole' cannot be filled by 'autistic objects' nor glossed
over by 'autistic shapes'. (Autistic objects and autistic shapes
will be discussed in later chapters.) It can only be healed by co-
operative activities with people and creative activities with the
outside world. These stimulate the biological 'givens' for
psychic growth and healing. States of autism prevent these
'givens' from being recognized, because such patients are afraid
of anything which cannot be brought under their tyrannical
control. These 'givens' are unseen and mysterious. When they
come into play, they are much more powerful for influencing
the way in which we live our lives than are our puny efforts at
controlling what happens to us. They work within us without
our doing anything about it. T h e effectiveness of psycho-
therapy depends upon their release. We never really know how
it happens. But we find that as patients in an autistic state
gradually work over their experience of separateness, and begin
to relate to human beings who are experienced as separate and
different from themselves, they become able to let unseen,
intangible forces which are beyond their control begin to work
within them. Hope and trust start to develop. This means that
there is the basis for reality-based beliefs about themselves and
about the outside world. I n short, inbuilt impulsions come into
play which have previously been blocked.
ilfod$ying the autism
But before this can be achieved the autistic blockage has to be
modified. In an autistic state, patients are not in touch with
their own humanity, nor that of other people. In this state they
cannot make the abstractions needed for imagination and
 T H E NATURE OF PSYCHOGENIC AUTISM 31
empathy. They are stuck in a sensation-dominated, over-
concretized mode of functioning. This is a great stumbling-
block to psychoanalytic work. In such states, these patients are
suffering from a miscarriage of motivation. They have turned
away from commonly agreed reality. Instead of attending to the
life-enhancing possibilities that are available to them, both
within themselves and in the outside world, their attention has
become fixated upon autochthonous (self-generated) sensation
objects and shapes. These patients are creative and resourceful,
but these gifts have gone in a sterile direction because they have
generated artefacts which were unshared and unshareable. Our
task is to help them to turn from these automatic, idiosyncratic
ways of behaving and to begin to tolerate the sadness and the
frustrations, and to enjoy the delights of deep, interactive
relationships with other people. These patients cannot be
bullied or coaxed out of their simplistic, isolating modes of
behaviour. These will only be modified as their need for them
is understood, and they experience being held in a warm, firm,
sane, caring, disciplined and disciplining relationship which
gets in touch with the part of them that has been left to go its
own whimsical and eccentric way. As they experience this, the
psychic mishaps of their infancy begin to be healed. This occurs
through the medium of the infantile transference, in which they
repeat the situation of tragic disillusionment. We need to be
aware of this form of transference and to have some under-
standing of it, if we are to get in touch with autistic states and
to modify them. Thus, neurotic patients can be relieved of their
fear of a breakdown which has already occurred (see Winnicott,
1974).
T h e healing and disciplining type of psychotherapy needed
by patients with such an injured psyche will be discussed in
Chapter 16. It has seemed to me that in enlightening us about
the idiosyncratic, restricted world in which they live, autistic
children enable us to get in touch in a realistic and meaningful
way with neurotic patients who have an immobilized, frozen
part of their personality. They demonstrate for us the autistic
276 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
from feeling a sham, they react by naive, ill-judged, obsessional
attempts at 'total honesty', which leads them into trouble with
the people around them.
Let us now study the origins of what is felt to be so
superlatively good. In terms of inbuilt hygienic dispositions
cleanliness is felt to be 'good', and this notion is embodied in the
homely maxim, 'Cleanliness is next to godliness.' However, for
patients such as Ariadne, 'dirtiness' became associated with
unmitigated 'evil', and 'cleanliness' became associated with
absolute purity. Although Ariadne had a great deal of charm,
she was also a goody-goody and a prig. Her holier-than-thou
attitude caused her friends to call her Miss Perfect. This notion
of herself as being pure and perfect had been achieved by
dissociating herself from the dirty, smelly, unacceptable'parts
of herself which became 'not-me'. Thus, the amphitheatre of
the outside world into which Ariadne feels that she is 'born'
(both physically and psychologically) from the constriction of
her autistic, 'me'-centred existence is a 'not-me' situation which
has become imbued with the 'evil' which was 'not-me'. She had
felt that she had been born into a world that was hostile to her
'going-on-being'. This had been made even more 'evil' by her
own 'not-me' projections.
Also, anything which comes from inside the body is felt to be
contaminating, contaminated and dirty. So, being born from
inside a mother made her dirty. Such patients make a rigid split
between the inside and the outside of the body. They feel that
their inside is turgid with the stink and filth of their unaccepted
and unacceptable erotic excitements, rages, panics and griefs,
all of which are experienced in a sensation way as irritating,
dangerous body stuff which will be there forever. This is partly
because what is inside cannot be seen and is, therefore,
uncontrollable and dangerous. Thus, they live an artificial sort
of life. They are an empty fake- a hollow sham. They live solely
in terms of outside appearances and body surfaces in order to
avoid the inner, unknowable darkness about which they are in
despair.
 THE RHYTHM OF SAFETY
autism she became aware of her vulnerability and her fears of
being assailed by evil. Let us now study the possible origins of
Ariadne's sense of evil, which she became able to face when she
got in touch with her 'rhythm of safety'.
275 32 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
operation of pre-image, preverbal, preconceptual ways of beha-
ving. They show us that this behaviour has inhibited their use
of their capacities and caused them to feel excessively insecure
and underconfident.

Ariadne's sense of evil

Work with autistic children has alerted me to the fact that one
of the earliest differentiations is between 'clean' and 'dirty'.
This differentiation would seem to come from the inbuilt
hygienic dispositions which human beings share with the other
animals. Instead of the normal differentiations, autistic
children and obsessional patients such as Ariadne have
developed rigid splits between 'clean' and 'dirty' - as also
between other sensuous conditions such as 'full' and 'empty',
'wet' and 'dry', 'hard' and 'soft', 'light' and 'dark', 'strong' and
'weak', etc. They are afraid that if they experience the opposing
contrary alongside the opposite state, one will destroy the other
in a total way. For example, 'dryness' will totally dry up
'wetness'; 'hardness' will totally destroy 'softness'; 'darkness'
will totally extinguish 'light'; 'weakness' will totally weaken
'strength'; and so on.
A dictionary definition of the word 'rhythm' goes as follows:
'movement or pattern with regulated succession of strong and
weak elements, opposite or different conditions'. It would seem
that a regulated rhythm - that is, a shared rhythm which is
outside the bounds of exclusively 'me'-centred restrictive
practices - provides the possibility for contraries to be exper-
ienced safely together, for they can modify and transform each
other. A creative intercourse is born. Having developed this
rhythm of safety, Ariadne could now become aware of what she
felt to be 'evil', because she no longer feared that it would totally
destroy what she felt to be superlatively 'good'. Prior to this, her
autistic practices had enabled her to feel 'good' by covering up
what she felt to be the evil part of herself. Such patients often
feel that they are whited sepulchres; in an attempt to get away

CHAPTER TWO
The growth of understanding :
a personal statement
Nobody can tell you how you are to live your life,
Or what you are to think,
Or what language you are to speak,
Therefore, it is absolutely essential
that the individual analyst should forge for himself
the language which he knows,
Which he knows how to use,
and the value of which he knows.
W.R.Bion, 'Evidence'
his chapter is a much revised version of a paper which
was written for the French psychoanalytic journal
Patio (1984) 3 :109-21. Originally, the paper was for an
issue which was to be devoted to innovations in psychoanalysis.
The editor asked me for an interview-article to describe the
growth of my thinking with regard to the psychoanalytic
treatment of psychogenic autistic children. Thus, the paper
was the story of how I came to be involved with these children
and was driven to try to understand them.
Dr Peter Medawar, the well-known British research sci-
entist, whose sayings I shall quote from time to time in this
chapter, has rightly stressed the part that luck and opportunity
play in making new discoveries, however small these may be
(Medawar, 1979). This chapter will be an account of the many
privileges I have had which encouraged me to embark on the
difficult task of trying to get in touch with these seemingly
274 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
hoped to ensure that my physical presence would always be
with her. However, on the day when she, reported the de-
velopment of a 'rhythm of safety', a reflective interaction de-
veloped between us in which she recognized more fully than
ever before that I was separate and different from her. For one
thing, she recognized in a deep way, and not merely verbally,
that the five weeks' gap had arisen from our mutual adaptation
of each other's activities. Between us, we evolved the phrase
'adaptive reciprocity' for this way of responding. Ariadne
realized that this was very different from the 'me'-centred,
mechanical routines which she had valued so highly. These had
consisted in expecting the sessions to occur with clockwork
regularity, in coming precisely on time, and of going through
the same procedures each time she came.
I had often pointed out to her that such expectations arose
from the notion that I was part of her body like the beating
of her heart. As a child and adolescent, Ariadne had been ad-
dicted to romantic women's magazines, and she reacted to me as
if I were her 'heart-throb' forevermore. This sentimental,
individualistic and body-centred notion was now being
replaced by a rhythm which was the creation of both of us. It
was a shared experience. This was a much better protection
against the evil that she now became aware of than the slippery
evasive reactions which had previously dominated her
functioning. The dream was a kind of parable about dealing
with evil.
Verena Crick has drawn my attention to the similarity of
Ariadne's dream to the theme of Mozart's opera The Magic
Flute, in which, by the playing of a magic flute, the hero and
heroine go safely through the dangers which beset them.
Indeed, the coming into being of the intangible 'rhythm of
safety' from tangible, sensuous, physical interactions between
mother and baby is a kind of magic. Such a transformation is
beyond our rational understanding. It is an everyday miracle.
As Ariadne emerged from the constricted enclosure of her
 T H E RHYTHM OF SAFETY 273
know her baby, mother and child adapted to each other. From
the baby's rhythms and from the mother's rhythms, a new
rhythm developed. It was a 'creation' they had made together.
The student commentator records as follows: 'The baby's
mouth formed a safe hermetical seal around the nipple of the
breast so that mouth, tongue, nipple and breast worked to-
gether and a synchronized rhythm came into being.'
In Ariadne's terms, the infant developed a'rhythm of safety'.
Brazelton speaks of mother and baby interacting with each
other to create what he calls 'a reciprocity envelope'. For-
tunately, due to the flexibility of human nature, this infantile
interactive situation can be created in later life. This is
especially the case in an analytic situation in which the use of the
'infantile transference' is understood. The primitive mind
works in terms of correspondences, clang similarities and
analogies. In certain states, the analytic experience is so deeply
felt that it feels analogous to the baby feeding at the breast.
For the 'rhythm of safety' to occur, Ariadne had had to
develop an interactive reciprocal relationship with me which
had deep infantile roots and in which the upright father element
came into focus. This father element is hinted at in the 23rd
Psalm, which is dealing with these elemental levels. You will
remember it says:
Yea, though I walk through the valley of the shadow
of death, I will fear no evil.. . thy rod and thy staffthey comfort me.
(my italics)
Ariadne's behaviour, in which she used the phrase 'rhythm of
safety', indicated that a deep, reciprocal relationship with me
was developing. It was unusual for her to plunge straightaway
into a deep discussion as she did on this occasion. The previous
pattern of most of her sessions had been that she would tell me
in minute detail all that had happened to her since we had last
met. This helped her to feel that we had not been separated and
that our bodily continuity was re-established.
It had other satisfactions also. She was a charming and
amusing raconteuse, and by thus capturing my interest she
34 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
inaccessible children. Dr Medawar quotes Fontanelle, who
said, 'Ces hasards ne sont que pour ceux quijoient bien!' ('These
strokes of good fortune are only for those who play well.') But
to 'play well' we have to remember the words of Pasteur, who
said, 'Fortune favours the prepared mind.' Thus, this contrib-
ution must acknowledge the many people who have shed light
upon my path and helped to prepare my mind for the daunting
task of entering the mind of an autistic child in such a way that
changes in his view of the world could be initiated.
Preparation for the task
Firstly, I have been helped and supported by being married to
a physical scientist who, in his own speciality, has been an
innovator. (In his war work on automatic control, he pioneered
the early formulations for what is now called systems theory or
cybernetics.) My personal analysis with Dr W.R. Bion also
brought me into contact with an original mind. In addition, in
my training as a child psychotherapist at the Tavistock Clinic in
London, I had the great good fortune to have as my teachers Dr
Esther Bick and Dr John Bowlby, both of whom, from their
different points of view, impressed upon their students the
value of detailed observations and the importance of specific
rather than general formulations. Supervision from Dr Herbert
Rosenfeld and D r Donald Meltzer was also a very important
preparation.
Having finished my training at the Tavistock Clinic, I was
fortunate in that I accompanied my husband to the United
States for a year in 1954 and, on Dr Bowlby's advice, went to
work at the Putnam Children's Center in Boston, Mas-
sachusetts. At that time this was a research and treatment
centre for young 'atypical' children (as they called them),
amongst whom were a number of autistic children whose
disturbance seemed to be mainly psychogenic rather than
organic in origin. Here, as well as working as a psychotherapist,
I went to look after some of the autistic children in their own
homes. I was very moved by the tragedy to the parents of these
 T H E GROWTH O F UNDERSTANDING 35
unresponsive children, and felt very strongly that I wanted to
see if something could be done so that they became more
accessible. I was again fortunate when I returned to England in
that Dr Mildred Creak, who was very knowledgeable about
childhood psychosis and also a superb diagnostician in this
field, sent me several autistic children as private patients.
Eventually I went to work with her at Great Ormond Street
Children's Hospital in London. Of course, all these possibilities
would have passed me by, had it not been that my own
temperament and pathology made me interested in shy,
inhibited children. Also, I had always had a tendency to study
the basic aspects of a subject, one of my early pieces of work
being a study of 'Plant movements and tropisms'.
Thus, the privileges, the good fortune, the prepared mind,
the motivation and the opportunities were all there. What was
needed now was a capacity for patience and hard work. I had
always been persevering and this stood me in good stead. So,
after the first twenty years of working with psychogenic autistic
children, and as a result of a profound disturbance in my own
emotional life from which I learned a great deal about the roots
of phobic inhibition, I was driven to write my first book, Autism
a n d Childhood Psychosis. This was written as the result of great
emotional pressure from within myself. The second, Autistic
States in Children, written ten years later, was a less
emotionally-charged book and was the result of lectures I had
given, on yearly visits over a period of five years, in Rome
University's Institute of Childhood Neuropsychiatry. Here
there is a special unit for the psychoanalytic treatment of both
autistic and schizophrenic-type children, under the unflagging
and humane care of Professor Adriano Giannotti, with
Professor Giovanni Bollea in overall charge of the Institute. In
the early days of the unit the two senior psychotherapists, Dr
Guilianna De Astis and Eleonora Ft D'Ostiani, flew over to
England separately each month, over a period of two years, to
discuss every single child they had in treatment. Thus I could
see psychotherapeutic work being carried on in a unit which
272 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
infant must develop a sense of safety from its primary back-
ground object of primary identification.' 'Yes,' I thought, 'what
Ariadne has lacked is a primary background object of safety.'
(Since then, I have also come upon Joseph Sandler's paper on
the background of safety ( 1960).)
However, Ariadne had also been reflecting on this matter
of safety for, as soon as she was on the couch, she said
thoughtfully, 'You know, over the past week I think I've
developed a rhythm of safety.' I was surprised and delighted,
both by this insight and by the phrase she had used to describe
it. I asked her to tell me more about it. Ariadne went on to tell
me a dream she had had following the session about the black
wave. She had been in a very constricted space and had thought
to herself, 'I must get out of here.' She had looked for a way out
and had seen a chute down which she slid. But this sliding did
not bring her to safety.
Metaphorically speaking, she went out of the frying pan into
the fire, for sheround herself in a large amphitheatre which was
full of extremely evil people. She thought to herself, 'I can't
possibly walk through this place.' However, although she was
very frightened, 'taking her courage in both hands'-significant
phrase - she had walked through the evil amphitheatre to the
other side; whereupon she had said thankfully, 'I've got a
rhythm of safety.' The way in which she said this made it sound
like a paean of thanksgiving. I suggested to her that having the
courage to face her fear, instead of her usual practice of sliding
away from it, had enabled her to become aware of resources
within herself that had helped her to cope with it.
Let us think about the possible origins of this 'rhythm of
safety'. Ariadne's use of the word 'rhythm' brought to my mind
a tape recording made by a former student of mine, of a baby
feeding at the breast in the first two months of life. At first the
baby could not co-ordinate the rhythm of its own sucking and
breathing, so that it synchronized with the pulsing rhythms of
the milk from the nipple of the breast. However, as the baby's
muscular co-ordination improved, and as the mother got to
 T H E RHYTHM OF SAFETY 271
weeks' interruption had made her feel that I had left her in the
lurch of a huge black wave of tempestuous feelings which had
threatened to overwhelm her.
After this session I realized that in going towards the house
in which her forebears had lived, Ariadne was beginning to see
herself as part of a continuous process of generation succeeding
generation. This would have been a compensation for giving
up the unrealistic notion that her individual body could go on
forever without ever coming to an end. However, this move-
ment towards seeing herself in perspective as part of biological,
evolutionary and genealogical continuity had been abruptly
broken by the upsurge of overwhelming terrors about her
personal survival. In the elemental depths, Ariadne did not
'think' about death; she experienced it in a sensation way.
This was not the threat of death as we know it as an objective
fact about what happens to people. It was a horrifying sense of
bodily discontinuity which brings rage, grief and terror of
endings. The body seems to come to an end in a fulminating
way. The child feels forever at risk. T o get some sense of safety,
there is a reaction to re-establish the delusion of bodily con-
tinuity with an everlasting 'being' who is for them alone. This
'being' is not shared with a father or other children. It is
difficult to find words for this elemental phenomenon; it is
sometimes called 'the environmental mother', and sometimes
'the earth mother'. It is a 'being' who is felt to guarantee the
child's own sense of being. These are 'all or nothing' states.
Everything is total and forever. Ariadne was freeing herself
from these constrictional autistic delusions. Let me describe
this more realistic forward movement, which she called a
'rhythm of safety'.
T h e rhythm of safety
In my reflective preparations for Ariadne's next session, I read
James Grotstein's paper about primitive mental states in
borderline patients (1980) and was struck by the phrase, 'the
36 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
had far more resources than I had had in private practice; the
parental relationship and the mother-child couple, in par-
ticular, could be studied much more fully than I had been able
to do.
I have found the scientific rigour and orderliness of the
Kleinian psychoanalytic technique to be very suitable for the
treatment of autistic children. However, since Melanie Klein's
findings were drawn from schizophrenic-type chilren, it was
inevitable that work with autistic children would generate new
insights. The only autistic child seen by Mrs Klein was the boy
called Dick whom she describes in her paper, 'The importance
of symbol formation in the development of the ego' (see next
chapter). Mrs Klein was writing in 1930, fourteen years prior to
Kanner's differential diagnosis of early infantile autism.
Although she anticipated many of Kanner's findings, she was
naturally perplexed about the diagnosis of Dick's condition.
Reluctantly and after much uncertainty, she finally interpreted
Dick's psychopathology in terms of the schizophrenic-type
children she had previously studied. Melanie Klein has given us
a great legacy, but it does both her work, and the cause of
scientific enquiry, a grave disservice if we blindly apply her
insights to autistic states for which they are not appropriate, at
least in the early stages of treatment.
I had to learn this after many heart-searching9 as to whether
I was being treacherous to someone to whom I owed so much.
But John, the four-year-old autistic boy whom I have already
mentioned, taught me about the 'black hole with the nasty
prick' (Tustin, 1972) which I also became aware of in myself.
This made me realize that there were even earlier states than
those described so courageously by Melanie Klein. I then found
that Michael Balint (1968), Winnicott (1958) and Mahler
(1961) had described the phenomenon of the 'black hole',
though in other terms: Balint's 'basic fault', Winnicott's
'psychotic depression', Mahler's 'loss and restoration of the
symbiotic love object'.
Following Mahlerl and also James Anthony whose classic
 T H E GROWTH OF UNDERSTANDING 37
paper on autism broke new ground (Anthony, 1958), 1began to
use the term 'autistic' for the earliest state of normal infantile
development, as well as for pathological states. T o use the term
'autism' in this way was appropriate at the time when Mahler
and Anthony were writing, but since then the word 'autism', as
first used by Bleuler in 1913 in terms of its etymology, has
become so contaminated with pathological associations that it
can no longer be usefully used for normal states. For example,
if we use the adjective 'autistic' for early infantile states, it gives
the impression that such states are being viewed as inactive and
passive, instead of the aware, questing states they obviously
are. Thus I have come to use the term 'auto-sensuous' for the
earliest states of normal infancy, and autism for pathological
ones. This will be discussed more fully later. At this point, let
me discuss the understandings I have found to be mutative in
psychotherapy with autistic states.
Mutative understandings
My particular contribution to understanding psychogenic
autistic children has been to realize the tactile, sensation-
dominated nature of their world, and to highlight the way in
which what I have called 'autistic objects' and 'autistic shapes'
(described later in this book) have impeded such children's
cognitive and emotional functioning, as also their sense of
identity and relationships with people. These findings from
work with autistic children have made very meaningful to me
certain passages of Dr Peter Medawar's Advice to a Young
Scientist, where scientific methods and discoveries are dis-
cussed. Even though Medawar is mainly writing about the
biological sciences, what he says has much relevance to
psychological investigations.
For example, in writing about Thomas Kuhn's two books,
The Structure of Scientific Revolutions and Essential Tension,
Medawar says : 'The "essential tensionJ' to which Kuhn refers in
the title of his latest book is between our inheritance of doctrine
and dogma as they affect science and the occasional upheavals
270 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
meet again. She had asked anxiously, 'Won't that break the
continuity?'
As an infant Ariadne had had an overly caring mother who
had been grief-stricken as the result of the death of an earlier
boy child. This caused the mother and the infant Ariadne to
have an unduly close association with each other from which
the father had been virtually excluded. Ariadne had remained
over-dependent on this mother who had been used as her con-
stant prop, support and stay. This over-dependence had been
transferred to me.
In the session I reminded Ariadne of her anxieties about the
breakdown in continuity caused by the five weeks' interruption
of our meetings. I said I thought that the undue closeness to her
mother, as an infant and small child, had engendered false
hopes that her body was continuous with that of an external,
ever-present mother and so could never come to an end. When
she could no longer avoid awareness of their bodily separateness
from each other, she had felt catastrophically let down. She had
realized that she was mortal and that her body could come to an
end. Since then, she had spent her whole life trying to reinstate
the delusion of bodily continuity with this everlasting mother.
T h e difficulty was that she was forever hoping that I was this
immortal being, and she tried to manipulate the analytic
situation to give credence to this belief. She did this because her
whole sense of existence and of identity seemed dependent
upon bodily continuity with an immortal being who went on
forever.
T h e recent five weeks' interruption to the continuity of
coming to see me had re-evoked the catastrophic infantile ex-
perience of finding that her body was, in fact, separate from
that of the mother. It was possible that her going to boarding
school, which had interrupted the flow of her first analysis, had
been a similar re-evocation of what she felt to be an irremediable
wound. (As I hope to show later, this feeling of irre-
mediableness came from her lack of belief in the creative inner
forces of healing.) In the session I went on to say that the five
 T H E RHYTHM OF SAFETY 269
The patient
Ariadne was first referred to me at ten years of age for learning
difficulties. As a result of this childhood treatment her capacity
co learn in a formal way improved, but I never felt that I was in
touch with her very fundamentally. At thirteen she went to
boarding school. At age twenty-five, on her own initiative, she
returned to me for more psychoanalytic help because she had
had a very frightening panic attack in which she had gone cold
and frozen like a corpse. She had spent the whole night begging
the woman friend who was with her to take her to mental
hospital. We arranged that she should have two sessions a week.
A dream which started off the train of thoughts to be
developed in this chapter occurred after Ariadne had been back
in treatment for three years. Although both she and I were
concerned that she should be able to finish treatment, we never
seemed to reach the point where it seemed safe to do so. The
dream and the understandings it stimulated to both of us have
now made termination a real possibility.
The dream
The dream occurred in a session following a five-week interval
during which, for various reasons, we had been unable to meet.
In the dream, Ariadne was going happily towards an inter-
esting, characterful house in which she knew that both her
grandparents and great-grandparents had lived, and where her
parents lived now. However, before she could reach the house,
she found herself in the chasm of a huge black wave which was
arching over her. The arch of the wave had glistening black ribs
of water, in which there struggled drowning people rather like
the people in a Hieronymus Bosch painting. The wave was so
high that Ariadne could barely see the white crest on the top.
She was terrified that it was going to engulf her.
This dream brought to my mind the remark Ariadne had
made when we had both realized that because my lecturing trips
abroad would be followed by events in her own professional
life, there would be an interval of five weeks before we could
38 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
that inaugurate a new "paradigm" ...' (p.92). Medawar sees
scientific exploration as a dialogue 'between two voices, the one
imaginative and the other critical, between conjecture and
refutation, as Popper has it' (p.85). (In my case, my husband
has often supplied the 'critical voice'!) Later, Medawar says:
..
'. scientific research, like other forms of exploration is, after
all, a cybernetic - a steering process, a means by which we find
our way about, and try to make sense of a bewildering and
complex world' (p.86).
In the case of autistic children we have to try to 'make sense'
of a 'bewildering' elemental 'world', haunted by primeval
forces. In studying this world we can again draw guidance from
Dr Medawar when he says: 'Heroic feats of intellection are
seldom needed. "The scientific method", as it is sometimes
called, is a potentiation of common sense' (p.86). The need for
common sense was never more urgent than in studying the
world of the psychogenic autistic child. We do not need esoteric
theories, but we do need to train ourselves not to disregard the
obvious.
I also think that at the beginning of our work we should not
confuse ourselves with tpo much reading of what other people
have said. Some papers seem to be like a Tower of Babel
amongst which the writer's own voice is lost. Fortunately, the
Tavistock child psychotherapy training was a somewhat
cloistered affair in which we digested Freud and Klein, with Dr
Bowlby introducing us to ethology and researches in child
development (Dr Bowlby's critical voice keeping the balance
alongside Mrs Bick's imaginative one). The Kleinian psy-
chotherapeutic technique, with its simplicity and its emphasis
on the dynamic transforming influence of the infantile trans-
ference, is a very good instrument for studying what is going on
in the psyche of the child. It is as if we put the child's psyche
under our mental and empathic microscope to study it in detail.
So long as we have not developed 'tunnel vision', we do not see
only Kleinian phenomena.
From this secure base of sound training in observation and
 THE GROWTH OF UNDERSTANDING 39
psychotherapeutic technique, the work with autistic children
gradually led me to the writings of other psychoanalytic
workers who were not members of the Kleinian school in which
I had been trained. This happened in the following way. When
I wrote my first paper on autism in 1966, in which I described
John's revelations about the 'black hole', it was an eye-opener to
me when I was told by a colleague that Winnicott, in a paper
entitled 'The mentally ill in your case load', as long ago as 1958,
had mentioned in passing this very early type of depression
which occurs when the loss of the mother is experienced as the
loss of part of the body (Winnicott, 1958). I also learned that
Margaret Mahler had written a paper about this with reference
to childhood autism (Mahler, 1961).
Similarly, after I had finished my first paper on autistic
shapes, and after it had been accepted for publication, I heard
a paper given by Dr Piera Aulangier of Paris who, from her long
experience with schizophrenic adult patients, described what
she called 'tactile hallucinations' (Aulangier, 1985). She
distinguished these from the usual type of schizophrenic
hallucinations. From her description of them they sounded
very like the tactile autistic shapes I had learned about from the
autistic children; indeed in a paper published in the
International Review of Psycho-Analysis in 1984, I had said
that these autistic shapes seemed to be a kind of 'tactile
hallucination' (see Chapter 7).
I also found that Michael Fordham (1976) had coined the
term 'self-object', and that Winnicott had used the term
'subjective object' (Winnicott, 1958), for similar phenomena.
(However, although the self-object and the subjective object
have certain features in common with autistic objects, I have
found it necessary to distinguish between normal and path-
ological manifestations. Normal auto-sensuous objects are
sucked and are such things as the finger, the fist, the knobs on
the cot, a piece of shawl, etc. They are associated with a
developing sense of self. Autistic objects are pathological. They
are not sucked but are hard objects which are clutched. They
CHAPTER FIFTEEhT
T h e rhythm of safety
And came on that which is, and caught
The deep pulsations of the world,
Aeonian music measuring out
The steps of Time - the shocks of Chance -
The blows of Death. At length my trance
Was cancell'd, stricken thro' with doubt.
Tennyson, In Memonam,XCIV
his chapter was originally presented as a paper to a
T conference in Paris organized by the Continuing
Education Seminars of Los Angeles. T h e neurotic
adult patient discussed in it was one of those seemingly pe-
rennial patients whose functioning is based on the avoidance of
endings. Insights derived from my work with autistic children
have released this patient from the fetters of her autistic prac-
tices, so that she has become able to generate fundamental
understandings which have made termination a reasonably safe
possibility for her.
Clinical work which is influenced by psychopathology as
elemental as childhood autism is bound to seem strange to those
psychoanalysts who work in terms of ego psychology. It may
also seem somewhat different, at least in the early stages, from
clinical work which has been influenced by Melanie Klein. T h e
influence of Bion and Winnicott on the chapter will be ap-
parent. With this introduction let me present to you the patient
who is the subject of this chapter, Ariadne.
 ANOREXIA NERVOSA I N AN A D O L E S C E N T GIRL 267 40 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
are associated with states in which there is no sense of being a
75 self .)
I found these separate confirmations from various sources
70
unconnected with each other, and with a different orientation
-
g
2 (15 from my own, very reassuring, in that they indicated that my
or
2
4
findings were not idiosyncratic to me alone. You will remember
60
that Spitz has said that such confirmation is the only validation
S5 we can have in psychoanalytic investigations. Schizophrenic-
type children (or 'confusional entangled' children, as I call
so
Scpt, Oct. Nov. I)ec, Jali. Fch. hlar. .Apr. hlay June Jut!. .Aug. Scpc. Oct. No\. I)ec. them) are very open and tell us about their strange mis-
conceptions quite clearly. The encapsulated autistic children
are very different in that they are closed up and secretive. It is
16 November Seen in paediatrics department difficult to feel sure about what one has inferred, so
23 November Admitted to hospital confirmation of one's insights is very necessary. The fact that I
29 November-29 December Physical investigations
was not the first in the field was outweighed by the relief that
2 January Seen by psychiatrist -told she
other workers had seen what I had seen, though in different
is to start psychotherapy
9 January Started psychotherapy
contexts. As Medawar so picturesquely exprdsses it, the growth
20 February Aunt in hospital to have baby of scientific ideas 'is not at all like cooks elbowing each other
26 March Discharged from hospital ward from the pot of broth'. Usually, in developing new under-
26 March -9 April Easter break standings, unbeknown to ourselves, we are developing ideas
9 April Returned to school which are 'in the air' and waiting to be developed further; to
21 May Weekly weighing recommenced continue with Medawar's image, 'the broth' is waiting to be
28 May Whitsun break stirred by experienced cooks (1979, p. 33).
30 July Summer break commenced
My job has been that of a synthesizer and harmonizer. I have
Pevsonal data
been able to relate the phenomenon of the 'black hole' to autistic
Date of birth: 2 March 1942
objects and to autistic shapes, as part of the pathological
Age on referral : 13 yrs 10 mths
network which we call psychogenic autism. These phenomena
Height: 5 ft 2 in
have been integrated into a scheme of understanding which
Estimated normal weight (as reported by mother) : 80 Ib
helps us to enter the encapsulated states of autistic children,
and the capsule of autism of neurotic patients, in a tactful,
sensitive, mutative way so that more normal psychological
functioning can be facilitated.
As well as learning from my patients I have, of course,
learned a great deal from the psychotherapists and psy-
choanalysts who have discussed their clinical work with me. I
 T H E GROWTH OF UNDERSTANDING 41
would like to mention all these people by name, but this is not
possible. As an illustration of the enlargement of my un-
derstanding from such a source, I will quote a recently
published paper by Mrs Sheila Spensley, a psychoanalytic
psychotherapist who discusses her work with me from time to
time. The paper was called 'Mentally ill or mentally han-
dicapped? A longitudinal study of a severe learning disorder'
(1985b).
In this paper Mrs Spensley recounts the sad story of A, a
twenty-seven-year-old young woman who, as the result of a
misdiagnosis when she was seven years of age, had been
constantly moved back and forth from psychiatric hospital to
mental subnormality units, none of which had been appropriate
or helpful. Finally, by great good fortune, she was seen by Mrs
Spensley, who had treated psychogenic autistic children.
T o everyone's surprise and dubious incredulity, Mrs
Spensley suggested individual psychotherapy for A. In the
summary of her paper Mrs Spensley writes of this patient as
follows: 'Psychotherapy has disclosed a significant component
of autism in the personality which is resorted to regularly and
which seems to drag the patient into a passive acceptance of
half-life which she tries not to mind.' Mrs Spensley also says:
In the course of some eighteen months of psychoanalytic
psychotherapy, this young woman of twenty-seven, once
deemed brain-damaged at the age of seven years, has shown
herself capable of sustaining once-weekly psychotherapy.
Against all expectations she has taken responsibility for her
own attendance, travelling by public transport alone to her
sessions. She has also taken initiatives in relation to finding
work for herself.
I should also add that she has been able to live amicably at home
with her parents, who had previously found her impossible.
Mrs Spensley's report of this patient has made me realize the
value of the understandings derived from clinical work with
266 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
measles, which coincided with her mother's return from
hospital with the new baby. After this she lost weight, gave up
walking, resumed wetting and soiling, and had temper tan-
trums when her mother nursed the baby. Mother dealt with this
strictly and, at two, she again became a model child. When she
was three years old the father returned and the patient, who
until then had slept with mother, reacted violently to being
turned out by father. When she was four years old and the
mother began a further pregnancy, she responded by becoming
cranky, disobedient, babyish, and then severely anorexic.
It would seem that the adjustment to the complexity of her
emergent feelings by obsessional and compulsive mechanisms
breaks down with the uprush of feelings caused by her mother's
new pregnancy. In adolescence the intensification of the
instinctual drives would have a similar result in patients whose
innate predisposition and early developmental situation pre-
disposed them to anorexia. The material would seem to sug-
gest that, for some reason, integrations which result in the de-
velopment of the capacity to accept the reality pri~lciplewith
regard to psychic factors, particularly the depressive feelings
associated with loss, have never been securely established. The
graph which follows illustrates that as these integrations became
established, Margaret's extreme oscillations of mood were
stabilized. A 'rhythm of safety', as the patient who is described
in the next chapter called it, came into being.
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 265
potentialities for contraries - such as presence and absence,
frustration and gratification, love and hate, restriction and
freedom, life and death, creation and destruction, health and
sickness, hope and despair, fruitfulness and sterility -coexist in
one and the same person. The material would seem to indicate
that the way in which they come to terms with this conflict
determines the stability of their adjustment.
When Margaret increased her capacity to bear the depression
and anxiety associated with bringing these contradictory as-
pects together, her progress became more stable and she was
more able to experience the reality of my feelings as well as her
own. The depression that arose at this stage was different from
the depression that came from the breakdown of her feelings of
omnipotence earlier in the treatment. In the later depression
she was far more in touch with the complexity of her own
feelings, and had marked feelings of guilt and sadness about her
capacity for cruel and invidious behaviour, together with a
sense of responsibility for her actions.
Edward Bibring (1953) has described in detail the earlier
type of depression and has traced it back to the 'infant's or little
child's shock-like experience of the feeling of helplessness'.
Sylvester is the only writer to give details of the babyhood
history of her patient, who, interestingly enough, was reported
to have been weaned at four months (as was my patient). In
both cases also the father was absent during babyhood. It may
be that overwhelming disappointment in the early relationship
with the mother, followed by a similar intense disappointment
with regard to the father, leads to the development of anorexic
symptoms in individuals who have certain constitutional
predispositions. The fact that the baby had an unusually close
relationship with the mother which was disturbed by a sudden
appearance of the father may also be important.
Dr Sylvester's case may throw light on.why this disorder
occurs so frequently in adolescence. In her case, after the early
weaning, the baby's development was accelerated and she
became a model baby. At thirteen months she developed
42 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
psychogenic autism, in making our diagnoses more precise, so
that fewer patients waste their time in inappropriate placements
and in receiving inappropriate treatments.
I have also been greatly helped by the constructive criticism
of some of my British colleagues. They have helped me to see
where I had not made myself clear in Autistic States in
Children, and also where I needed to modify certain of my
suggestions about early infantile development. Again, as
Medawar so well expresses it, 'A senior scientist is much more
flattered, by finding that his views are the subject of serious
criticism than by sycophantic and sometimes obviously sim-
.ulated respect' (p. 55). (In this connection I want to thank
Anne Alvarez who, in the midst of a busy programme, found
time to enter into a discussion with me by means of an
interchange of letters.)
Such constructive criticism, and further evidence, have
meant that the thinking embodied in my two books on autism
has been in a constant state of revision. As Medawar says: 'As
for revolutions, they are constantly in progress: a scientist does
not hold exactly the same opinions about his research from one
day to the next, for reading, reflection and discussions with
colleagues cause a change of emphasis here and there and
possibly even a radical appraisal of his way of thinking' (p. 93).
Clanjkation and revision of previous views
Let me now outline some of the clarifications and revisions of
my views which have occurred since writing Autistic States in
Children. As mentioned earlier in this chapter, one of these
revisions has been to use the term auto-sensuous for normal
early infantile developments, and to reserve the term autistic
for pathological ones. Making this distinction has thrown light
for me on the current psychoanalytic controversies concerning
awareness of bodily separateness in early infancy. I should like
to discuss this.
The work of observers such as Trevarthen (1979), Tom
Bower (1977) and Brazelton (1969) implies that when early
 T H E GROWTH OF UNDERSTANDlNG 43
differentiations are proceeding normally, there are likely to be
flickering moments of awareness of bodily separateness from
the mother even from the very beginning of life. Also, arising
from their work with autistic children, De Astis and Giannotti
have suggested that, in normal development, the caesura of
birth is healed by responsive interactions between mother and
baby (De Astis and Giannotti, 1980). They have shown - and
-
my own work confirms this that in autistic children this
healing has not occurred. In my experience, every subsequent
awareness of bodily separateness from the mother reactivates
the unhealed primary wound of bodily separateness. Psy-
chotherapy heals this 'wound', which in autistic children is
often experienced as a 'hole' because, for them, bodily sep-
arateness from the mother has been experienced as a traumatic
breaking away from an inanimate 'thing', rather than as a grad-
ual process of differentiation from an alive human being.
One reason for this traumatic breaking away is that the
mother of an autistic child has often been depressed and
unresponsive in the child's early infancy. She may have
experienced the child in her womb as a comfort for her sense of
inner loneliness. In such a situation, when the infant is born,
the mother feels that she has lost a reassuring part of her body.
The baby also seems prone to this elemental 'black hole' type of
depression. (This will be discussed more fully in Chapter 4,
and should become clearer to any reader who may be having
difficulties in understanding it.) In this state, the need for a
continuous tangible bodily presence is very intense, as also the
disappointment that this is not possible.
I would suggest that in normal early infantile development,
there is an awareness of separateness which is made bearable by
auto-sensuous activities such as sucking and bodily interactions
with other people, particularly with the mother. But, in
pathological autistic development, as, the result of the lack of
responsive interactions, any awareness of bodily separateness,
however slight, has been unbearable. It has provoked an agony
of consciousness. This painful awareness has been muted, and
264 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
image of the mother was split into two contradictory aspects;
from one point of view it represented the powerful body with
the magic quality of growing things in her body, while from the
other it appeared as a destroyed bloody mess.' Later, he says,
'Sometimes during the sessions she expressed the desire to take
me in, the whole of me - that is, she wanted to eat me up.' He
later refers to this as the 'libidinal need to merge with the
object'. In contrast to this 'she experienced hostile, tearing and
biting impulses ...directed against the penis.' T h e patient
brought material which made him conclude that 'the drive
pattern to tear something from the mother's body and eat it, in
this patient at least, was clearly related to her penis envy.' H e
concludes by saying: 'A complicated set of factors, not all of
them necessarily recognizable, will decide whether or not an
eating disturbance results.'
We are still far from understanding the complicated set of
factors which determine the life-and-death struggle we see
taking place in anorexic patients, but each reported case
confirms or adds to previous data. From the foregoing review,
although each therapist presents the material within the con-
cepts of his own theoretical framework, we can see that even
when we drive our investigations deeper, there is still a striking
similarity in the material presented by such patients. In par-
ticular, we see the major role played by the early longing for a
close relationship with the rnother and a craving for the
contents of her body, including the father's penis and with it the
mother's exciting relationship with the father. In my patient
this led on to the fantasies of imprisonment mentioned by one
other therapist.
This review also brings out the importance of the early
conflicts in relation to the mother's body, and the failure of such
patients to come to terms with the contradictory aspects of their
own impulses and of the mother with whom they so closely
identified in infancy in the bodily way characteristic of that
early period. We see that they have not achieved a stable
capacity to tolerate the depression that arises from the fact that
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 263
fascinating detail her play analysis with a four-year-old child
who showed acute symptoins of psychogenic anorexia. She
writes: 'During the first period of her treatment her intense
wish for gratification by way of undivided possession of a
mother figure was clearly expressed.' Later, after a detailed
description of the child's play with a doll, she says: 'However,
the significant point is that the rage against the pregnant mother
evokes these phantasies and these are benevolently modified
only when the analyst lovingly repairs the mother doll.' Later
..
she shows '. her envious, aggressive, incorporative attitudes
towards the males of the family ... in order to be as close to
mother as they are and to have their advantages'. During this
time she modelled a mother doll 'with both titties and stickies'.
She then became like a baby, 'a level at which gratification
was not yet endangered by her hostile competitiveness ... The
following period is characterized by new phenomena of ego-
growth when her depressive reactions to the first separation
from the analyst are worked through.'
Emmy Sylvester summarizes thus :
Her neurosis showed the characteristics of a depression. The
conflict arose on an oral level from her inability to integrate
incompatible libidinal and destructive tendencies, both of
which were expressed through incorporation. The decisive
process in the treatment was the strengthening of the ego to
an extent that enabled her to separate her loved and hated
objects, and to deal with them differentially on a realistic
basis rather than on the former basis of a delusional fused
incorporation.
Dr George Gero (1953) describes his work with a female adult
patient who had a history of longstanding eating difficulties
and phobic symptoms. The anorexic symptoms went back to
her fifth year, when her mother gave birth to a much-desired
boy child. He describes the girl's struggle against accepting
her feminine role, her dissatisfaction with her body, and her
comparison of her body with her mother's. He says: 'The body
44 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
restricted by the use of autistic objects and autistic shapes.
These autistic manipulations and stereotypes replace the
normal responsive interactions between mother and baby, and
prevent normal differentiations and integrations from taking
place. It has seemed to me that merging with the mother, who
is experienced as an inanimate part of the subject's own body,
is apathological reaction which is both sought and feared.
Further thought on work with psychogenic autistic children
has also enabled me to make another clarification. At least to my
own satisfaction, I have become able to distinguish more clearly
between the 'ego' and the 'self'. Early ego activities would seem
to arise, in the first place, from the neuromental system. At
first, the newborn infant who is lacking in experience of the
outside world can only react in terms of inbuilt neuromental
propensities which become expressed through auto-sensuous
activities. The early ego is an auto-sensuous ego. This view is
consonant with Freud's statement that 'the ego is first and
foremost a body ego' (Freud, 1923, p.26). In normal de-
velopment, increasing experience of the outside world
facilitates the maturation and sophistication of this elemental
ego. But the traumatized autistic child shuts out experience of
the outside world. Thus, his ego development is morbidly
fixated at an uncouth, crude bodily level of precocious, over-
concretized and hypertrophied reactions. This leads to the
sense of having a swollen empty shell fabricated from the
subject's own bodily activities. This is a barrier to intercourse
with the outside world.
Patients in encapsulated autistic states also lack a sense of self
and of individual identity. This is because the sense of self and
of individual identity is dependent upon relationships with
other people. Autistic children are averted from such re-
lationships, and so they have no sense of self. Thus, I have
come to realize that I was incorrect in attributing to
psychogenic autistic children a 'false self' as described by
Winnicott (1960). I have also come to realize that states of
autism are not narcissistic. This is because a sense of self is
 T H E GROWTH O F UNDERSTANDING 45
obviously a prerequisite for the development of narcissism.
Schizophrenic-type patients and neglected children have
developed relationships with people, albeit these are fragile and
disturbed. Thus they can be said to have a 'false self' and to be
narcissistic. The psychogenic autistic child, and neurotic pa-
tients in an autistic state, avoid human relationships. Thus they
are empty of a sense of self, and cannot be said to have a 'false
self' or to be narcissistic. (As early as 1963 Enid Balint
described such an empty state in a paper called 'On being empty
of oneself'.)
For these reasons I agree with Dr Sydney Klein who, in
describing neurotic patients who manifested autistic phe-
nomena, writes about them in the following way:
.
There is an obvious parallel with what Winnicott.. has called
'the false self', and which Rosenfeld (1978) has termed
'psychotic islands' in the personality, but I do not think these
terms quite do justice to what may be described as an almost
impenetrable cystic encapsulation. ..which cuts the patient
off from both the rest of his personality and the analyst.
(Klein, S., 1980)
I suggest that the 'impenetrable cystic encapsulation' is the
expression of a hypertrophied, crude body 'ego' which had been
startled into precocious development along an aberrant path by
the impingement of unbuffered awareness of bodily sep-
arateness from the mother. This puffed-up ego is not a 'true'
ego formed by bearable contact with the outside world, It is
both a deceit and a conceit. Lacking object relations, and thus
being empty of a sense of self, the psychogenic autistic patient
can best be described as having an ego which is an 'empty fake'
or a 'hollow sham'. He does not have a 'self' to be 'false'.
Another revision I have made in my thinking is that I have
come to realize that psychogenic autism is a defence against the
confusion and entanglement of pyschosis, rather than psychosis
itself. It seems more accurate to see it as a gross arrest of mental
and emotional development. When the autism is lifted, a
262 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
who were treated by long-term, intensive therapeutic methods
to see if they exhibit similar features. In one case treated along
the lines of a universal collective unconscious, the therapist
(von Weiszaecker, 1937) came to the conclusion that 'one of the
various ways in which patients might deal with conflicts about
their relationship to the mother and father, to imprisonment
and freedom, to pregnancy and sterility, and to life and death
was by becoming anorexic.'
In 1943 Lorand reported a case treated by classical psy-
choanalysis. His patient was in her early twenties. He says:
In this patient this symptom complex seemed to indicate a
serious disturbance. It was an expression of many conflicts
besides those which referred to the sexual sphere - which
some investigators maintain is the outstanding or main
symptom. There was deeper struggle going on within the
patient - a struggle involving not only fight and defence
against sexual drives, but drives which were more diffuse and
pertained to disturbances in the whole personality structure.
These referred mainly to the very early period of the patient's
attachment to her mother, and successful therapy resulted
from the solution and working through of this early
attachment in detailed analytic therapy.
In her early childhood she remembers being like a little beast
who wanted to eat up and tear up everything and everybody.
The desires which primarily concerned the mother's breast,
food and getting love from the mother became in later stages
identified with desires to have everything the mother pos-
sessed, including father's love. This in turn was associated
with early ideas of oral impregnation.
In another place he says: 'At times she felt herself like a cannibal
having the desire to strangle, to yank out the penis.' He also
says: 'From the therapeutic aspect, depression is one of the
most difficult symptoms to handle, and is responsible for the
strong wish of these patients to die.'
In a paper published in 1945, Emmy Sylvester describes in
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 261
good many obstacles, although she still had phases when she
felt very hostile towards me. She weathered the crisis of a
pregnancy and subsequent long illness on my part and, at the
time of writing, is coming to see me once a week. The current
problems Are centred around her menstruation, which has
made a tentative beginning but is not yet regularly established.+
This case demonstrates very well those features of personality,
emotional preoccupation and family situation which the earlier
writers showed to be so typical for anorexia nervosa. There is
the family where there is an exaggerated concern about food (in
this case because of the mother's diet), there is the feeling of not
being wanted by one of the parents, and there is the intense
rivalry with her brothers. Prior to treatment, Margaret pre-
sented all the personality traits which had been described as
typical for patients who develop this illness.
She showed the stubbornness, the scrupulous cleanliness,
the reticence, the withdrawal, the difficulty in making friends
and the intense retreat from sexuality. In addition, she
illustrates the predisposition of adolescent females to develop
this disorder, although cases of boys have been reported. Her
symptoms of non-eating and loss of weight were associated with
the other typical symptoms - inhibition of menstruation,
gastro-intestinal disturbances, poor circulation and vomiting.
In the treatment situation she showed the 'obsessive, comp-
ulsive and depressive' features described by other writers.
She was also preoccupied with the pregnancy fantasies? which
she acted out through her body which the early psychiatric
investigators found to be so characteristic. She also exhibited
other fantasies and details of family pattern which were not in
the earlier descriptions.
Her material will now be compared with that of other cases
*This patient is now happily married and has two children of her own.
tIn this paper I use 'fantasy' for conscious processes, 'phantasy' for uncon-
scious ones. I t is sometimes difficult to tell the difference between the two.
46 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
vulnerable, clinging, confused, helpless child is revealed who
may become psychotic unless we realize his need for safety and
protection, and can provide it for him by our understanding.
The autism has been a protection for this hapless creature. It is
a serious responsibility to deprive such patients of their autistic
protections. We need to be able to help them to develop
something better to replace them. The more accurately we
understand the& patients, the greater will be the possibility
that they will develop 'basic trust in other people, and
confidence in themselves. These are very necessary de-
velopments, since the autistic encapsulation means that they
have been cut off from the outside world, and so are liable to a
psychotic breakdown.
Michael Faraday, that great pioneer in the field of electrical
phenomena, defined innovation as 'finding the "go" of things'.
With the help of the children, their concerned parents, and
friendly professional colleagues, I have come to understand a
little of the 'go' of autistic development. There is much that
remains to be understood. But the insights outlined in this
paper, and those of other psychodynamic workers, have
enabled us to enter the psychogenic autistic children's world in
a therapeutic way so that they could begin to respond to other
people and become aware of the outside world. Thus, they are
glad to be 'born', both physically and psychologically. Let me
end by a quotation from Dr Medawar, whose sayings have
illuminated this paper. He writes: 'Those with enough
hopefulness in their make-up willingly go along with the belief
that ... the pursuit [of understanding] is truly via lucis, the way
of light' (p. 106).
An alternative title to this paper could have been 'The
dawning of enlightenment'. It has been a slow dawn, but the
efforts of dedicated workers, some of whom are mentioned in
the references, are ensuring that this crepuscular light will be
increased, so that more patients who are entrapped by autistic
reactions can be helped to normal functioning. But it requires
professional workers who do not impose theoretical con-
 T H E GROWTH OF U N D E R S T A N D I N G
structions, evolved for other psychopathologies, upon such
patients' behaviour. We need to realize that these patients are
different from any other patients that we see, because they have
not developed relationships. .Also, in the growth of under-
standing, we are always trying to evolve language which is a
closer fit to the phenomena we are observing. I hope that this
will take place as the book proceeds.
47 260 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
attitude of mind of being able and willing to tolerate psychic
pain for a desired outcome, i.e., she now operated more ac-
cording to the reality principle as described by Freud in his
paper 'Formulations regarding two principles of mental
functioning' (191 1). This institution of the reality principle was
achieved at the critical point in development when the patient
realized that both hard, frustrating experiences and soft,
comforting ones emanated from the same source. This seemed
to be an elemental forerunner of Klein's depressive position.
This integration did not mean that the analysis entered
calmer waters (Bion, 1953). Margaret began to show more
openly and to experience more directly the mood swings
and conflicting feelings she had previously expressed through
somatic rather than psychic channels. She began to show
the neurotic behaviour of which the anorexia had been a
physical expression, and against which it had been a defence.
Material came up to show her terror of and guilt about her
sexuality. There was a good deal of material about her blood
circulation and its association in her mind with menstruation.
There was also material concerning her sexual wishes towards
her father and her desires to have a penis. She suffered from
sleeplessness and found it a great effort to come to analysis.
However, she always manged to come, and her material was
easier to understand in that she talked more coherently and
fluently.
Her life outside became fuller and more interesting. Her
school achievements were of a higher standard than they had
been before her illness, and she scored 90 per cent in a ty-
pewriting examination, which meant that she was top in her
form in this subject. On leaving school she secured a post in an
office where she seemed to have friendly relationships with
other girls, although these seemed to some extent to be de-
pendent on having one girl who was her bZte noire. After
starting work she continued treatment with me on a once-a-
week basis. This involved a long bus journey to my home
instead of the hospital, but she managed to come in spite of a
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 259
were in this vein of growing up, having a life of her own and
daring to be feminine.
It will be seen on the graph that during this period, 21
September to 24 October, her variations in weight reflected the
swings in mood she felt towards me. On Tuesday 24 October
she again talked about her brother's tonsillectomy, and again I
interpreted the unconscious fears that I would cut into her and
take away parts of her body. The deprivation of the Friday
session had aroused feelings associated with the frustrations she
had experienced in babyhood, and her unconscious phantasies
were concerned with biting her way greedily into my body to
take out the desirable supplies I had there. Her unconscious
feelings were that I had done the same to her. On previous
occasiotls she had dealt with the recognition of the 'bad'
relationship she felt to be going on between us either by
projecting her aggressive feelings, or by using all the facts she
could muster to bolster up the unconscious phantasy that we
could each create inexhaustible supplies that were readily
available and with which we could replenish each other
endlessly. But on this occasion, as I interpreted to her, she put
her head on her arms on the table in front of her and sobbed
bitterly. She was obviously experiencing painful feelings of
sadness. As her sobbing subsided, she said as she wiped her
eyes: 'It's that I'm afraid I shall always be like it.'
It will be seen that when she came on the following Monday
her weight had increased by 2M lb. From then onwards her
increases were steady until normal weight was achieved. After
this there were no undue fluctuations in her weight. The tic
disappeared and she had no more colds during the rest of the
year, although the colder weather was now upon us. She did not
have aches and pains during her sessions. Her eye-watering
ceased, and in situations where this had formerly occurred she
cried with all the other physical signs associated with weeping
and as though it were associated with emotion. Her associations
in the sessions immediately following 24 October showed a new
CHAPTER THREE
Thoughts on psychogenic autism
with special reference to
a paper by Melanie Klein
'There was, on his side, no affective tie to people. He
behaved as if people as such did not matter or even exist.
It made no difference whether one spoke to him in a
friendly or harsh way. He never looked at people's faces.
When he had any dealings with persons at all, he treated
them or rather parts of them, as if they were objects.'
Paul, aged five years, described in Leo Kanner's original
paper on autistic disturbances of affective contact (1943,
p. 217)
his revised paper was originally published in the
T Journal of Child Psychotherapy (1983) 9 :119-3 1, and
discussed a paper by Meianie Klein entitled 'The
importance of symbol formation in the development of the ego'
(1930a). She described her analysis of a four-year-old boy
whom she called Dick, and whom we would now recognize to
be autistic. I sought to discuss Mrs Klein's paper from the point
of view of autistic pathology.
Mrs Klein's paper
When Mrs Klein wrote her paper in 1930, Leo Kanner's classic
paper differentiating the syndrome he called 'early infantile
autism' from mental deficiency had not been written. We had to
wait until 1943 for his findings to be available to us. It is a mark
of Melanie Klein's originality and perspicacity that in her paper
she anticipated many of Kanner's findings. For example, of
 PSYCHOGENIC AUTISM AND MELANIE KLEIN 49
Dick's case she wrote: 'many cases of this sort are classified as
... mental deficiency' (1930a, p.230). Also, compare Mrs
Klein's description of Dick with the extract from Leo Kanner's
description of Paul which headed this chapter. Mrs Klein
wrote :
This child, Dick, was largely devoid of affects, and he was
indifferent to the presence or absence of his mother or nurse.
From the beginning he had only rarely displayed anxiety,
.
and that in an abnormally small degree .. He had almost no
interests, did not play, and had no contact with his environ-
ment. For the most part he simply strung sounds together in
a meaningless way, and constantly repeated certain noises.
When he did speak he generally used his meagre vocabulary
incorrectly. But it was not only that he was unable to make
himself intelligible; he had no wish to do so. More than that,
Dick's mother could at times clearly sense in the boy a strong
negative attitude which expressed itself in the fact that he
often did the very opposite of what was expected of him ....
When he was hurt, he displayed very considerable
insensitivity to pain, and felt nothing of the desire, so
universal with little children, to be comforted and petted ...
he also ran round me, just as if I were a piece of furniture ...
(1930a, pp.221,222)
As an infant, Dick had had great difficulty in sueking. Klein
describes how his mother tried to breastfeed him, but he would
not suck and nearly died of starvation (p.222). I have found
early difficulties in sucking to be characteristic of all the autistic
children I have seen, and also of those cases I have supervised.
Dick's weaning difficulties were also characteristic of autistic
children. Klein reports: 'When the time came for him to have
more solid food, he refused to bite it up and absolutely rejected
everything that was not the consistency of pap' (p.223). Time
and again, the parents of an autistic child have told me such
things as 'he will only eat soft food and rejects hard lumps' or
that 'he will only accept semi-liquid food'. Thus, if Dick were
258 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
September. She wanted to get in touch with her but feared a
snub. She then showed that she had similar feelings towards
me. She wanted 'to take the plunge' and to risk the pain she
feared if she allowed herself to experience loving feelings
towards me. She also wanted to sleep with me as on one
occasion she had slept with her girl friend.
On the following day, 16 October, her mind was full of her
brother, who had come into hospital for a tonsillectomy. I was
seen as associated with the surgical activities of the hospital and
she had strong unconscious fear's that I would cut into her and
take away parts of her body; this being in retaliation for the
predatory attacks in which she felt that, among other things,
she had cut out the baby brother from my pregnant body. If I
talked about this she winced as though I were actually doing it
to her. Her eyes watered copiously and she had pains, first in
her throat and then in her back, which went away after I had
interpreted her fear that I would attack her.
This was a dramatic session and we began to see that to some
extent she was re-experiencing fears which had originated and
been elaborated from situations when she had been bathed,
dressed and toileted by her mother and had felt very afraid that
parts of her body would be taken away. In one way, my
acceptance of the situation where she had no Friday session had
seemed like an attack upon her - an attack which was aimed at
all her sources of pleasure. At the end of the session she told me
how her aunt's baby 'cried and cried' when her aunt went out of
the room. She nodded in intense agreement when I said that she
was feeling that she 'cried and cried' because it was the end of
the session. Her eyes were watering as she did so, but she had
no other signs of weeping. During this week she lost 1 lb in
weight.
On the following Monday, 23 October, her associations were
about leaving school and what work she would do. She had been
to tea with the friend she had mentioned previously. On
another occasion she had worn lipstick. All her associations
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 257
friends.) Towards the end of the session she gave me a long
association, talking with a new fluency and describing for the
first time an incident in her childhood. The gist of this story was
that she had nourished the illusion that she could help herself to
things in shops, and she suddenly found out that she had to pay
for them. Her eyes glinted with amused resentment when she
thought of how mistaken she had been.
In this session she also showed that she was grateful for the
help she had had from treatment, and that her mood was one in
which she was feeling disillusioned with me in the same way as
she had done about the shop. She had had the phantasy that we
were completely at each other's disposal. By seeing us both as
equal in this way she had avoided all feelings of envious
comparison and of dependency. She was now feeling that I
possessed certain things that she would like to have and re-
cognizing that she had to be willing to spend something (to
suffer some frustration) to get them.
On the following Monday, 1 October, she had lost 1 Ib in
weight and on 8 October she had a cold and saw me as a hard,
punishing, retaliatory mother who had taken away the Friday
session to punish her for going to the dancing class and for
having a life of her own. It became clear that one of her reasons
for asking to leave early for the dancing class, and for mistaking
the time it began, was that she still had a grievance about the
earlier occasion when I had suggested that she should try to do
without the Friday session. She hated and feared the feeling of
being dependent on me, and wanted to triumph over me and to
show that she was now developing an interesting life of her own.
These feelings of grievance, of rivalry and of triumph conflicted
with her feelings of gratitude and the desire that I should have
pleasure and freedom. On 9 October the tic-like movement had
returned and her associations showed that she was again in
conflict about whether to make progress or to regress. (It will be
seen from the graph that her weight stood still.)
On 15 October her weight was unchanged. Her associations
were concerned with the former friend she had mentioned on 25
50 A U T I S T I C BARRIERS IN NEUROTIC PATIENTS
seen now he would certainly be diagnosed as autistic, his autism
being seen to be akin to that described by Kanner. This
Kanner-type autism needs to be distinguished from the autism
which arises from disorderly rearing practices, or from de-
tectable brain damage, or from hospitalization or surgical
intervention in early infancy, or other interruptions to early
ongoing infantile development.
Since he had made some developments before coming to see
Mrs Klein, Dick would be likely to be assessed as having a
hopeful prognosis. For example, he had become toilet-trained
and he used a few words appropriately. H e also responded very
quickly to Mrs Klein's unique ability to be in therapeutic touch
with a withdrawn and frightened child, even though this fear
was not shown openly. Mrs Klein herself writes: 'The fact ...
that analysis made it possible to establish contact with Dick's
mind and brought about some advance in so comparatively
short a time suggests the possibility that there had already been
some latent development as well as the slight development
outwardly manifest' (p.231). She goes on to say: 'But, even if
we suppose this, the total development was so abnormally
meagre that the hypothesis of a regression from a stage already
successfully reached will hardly meet the case' (p.231). She
says this because she was puzzled about the diagnosis of Dick's
condition, Leo Kanner's paper not being available to her. She
realized that Dick was different from the schizophrenic
children she had analysed. She writes: 'Against the diagnosis of
dementia praecox is the fact that the essential feature of Dick's
case was an inhibition in development and not a regression'
(p.230, my italics).
However, she finally decided that Dick's illness was a variant
of schizophrenia, although she obviously felt uneasy about this
diagnosis, because later in the paper she wrote about Dick's
illness as follows: 'It is true that it differs from the typical
schizophrenia of childhood in that in him the.trouble was an
inhibition in development, whereas in most such cases there is
a regression after a certain stage of development has been
 PSYCHOGENIC AUTISM A N D MELANIE KLEIN 51
successfully reached (p.231). This coincides with my own
experience. On the basis of an entangled relationship with his
mother, the schizophrenic child has made tenuous psy-
chological development from which he regresses when faced by
difficulties which are too much for him. T h e autistic child
appears to be cut off from the mother, and manifests an almost
complete arrest of emotional and cognitive development at an
early stage. T o use Winnicott's terms, the autistic child is 'un-
integrated', whereas the schizophrenic child is 'disintegrated'.
Making this distinction between childhood autism and
childhood schizophrenia affects our views on early infantile
development, and the processes to be inferred there. It also
affects our views on the aetiology of autistic illness, and the
interpretations that we give in the early stages of the analysis.
However, in these early stages, the therapeutic ambience of the
analyst's own personality, and the disciplined orderliness of the
therapeutic setting are as important as what is said to the child.
For example, it is important that the child is not allowed to
wander from room to room with the therapist following in his
wake, as is the case in some forms of psychotherapy. Those of
us who use Melanie Klein's technique of child analysis have
come to value highly the procedure she bequeathed to us. Its
sensible orderliness with, for example, each child having his
own drawer or box of toys seems to be a safe hammock in which
child and analyst swing. This containment is important for all
children, but particularly so for the unintegrated autistic child.
Klein, fifty years ago, was ahead of her time in realizing that
not only adults but also children could be psychotic, and in
realizing the need for a more precise differential diagnosis, from
a psychoanalytic point of view, between the various types of
childhood psychosis. She writes:
I think that one of the foremost tasks of analysis is the
discovery and cure of psychoses in childhood. T h e
theoretical knowledge thus acquired would doubtless be a
valuable contribution to our understanding of the structure
256 . 4 U T I S T l C BARRIERS I N N E U R O T I C PATIENTS
accompanied by a colleague, I boarded the same bus as my
patient, who felt very rejected by observing my relationship
with someone else. T h e Friday appointment had become
increasingly inconvenient for me, and, in the light of her re-
quest, I made other arrangements for the Friday and freed
other times for her.
On the following Monday, 24 September, she came looking
pale and depressed. (Her weight was 71 lb, which was the same
as the previous week.) She said that she had a cold and had
earache in her left ear which made her deaf. As we sat down in
our usual places (we now sat side by side) it turned out that the
deaf ear was the one that was nearest to me. It seemed very
meaningful to her when I interpreted that she was shutting her
ear as she had shut her mouth in babyhood, because she wanted
to reject my food; she felt I had rejected her by letting her go
early on the Friday and by having a relationship with someone
else. T o hear this interpretation she turned her head so that her
other ear was towards me, but after this she said her earache
was better and she listened to me with her left as well as her
right ear.
We then discussed the Friday session and it appeared that the
dancing class started later than she thought and that she could
now use the Friday time. I explained that I had now filled in the
Friday time and offered her several others. She gave reasons
why she could not manage to use any of them and decided,to try
to do without the Friday session. It was typical of her behaviour
that if I could not give her the exact thing she wanted, she could
not let me have the satisfaction of giving her a satisfactory
alternative. In this case she left me feeling anxious and guilty
about a situation which she herself had created.
T h e next day, Tuesday 25 September, she said her cold was
better but she looked thin and pale. She talked fairly freely and
for the first time her associations were concerned with the work
she wanted to do when she left school. She also talked about a
former friend who had come to live near her and with whom she
wanted to renew the friendship. ( U p to now she had no close
 ANOREXIA NERVOSA IN A N ADOLESCENT GIRL 255
in her own inside which, in her unconscious phantasy, she felt
was the result of her secret internal biting of the mother she had
condemned to imprisonment there. In addition, it confirmed
her worst fears that her own inside was bleeding and a place that
was 'unfit for babies' as the result of being identical with a
mother whom she had attacked in such envious and hostile
rivalry. Evidence from the analysis was now coming together
sufficiently for us both to be able to begin to understand why
the anxieties associated with the events described by the mother
in the history-taking interview, and experienced at a critical
time in her development, had been so overwhelming as to
precipitate her into an illness which represented a life-and-
death struggle about growing up.
Up to this state in her analysis her unconscious conflicts
about growing up had been expressed mainly through her body
in such things as gains and losses of weight, and the tic-like
gesture I have described. Her unconscious feelings of rejection
were expressed in colds which occurred on the days when she
did not see me. Before the end of a session, her eyes would
water, but she showed none of the other physical signs of tears
and gave no sign of having the emotions associated with
weeping. She would say in explanation that her eyes always
watered when she felt cold and this could even happen when the
room was warm and she had no cold. Throughout all this time
she had related to me on a fantastic and unrealistic basis and her
progress was insecurely founded. It was not until September
and October that a crisis in her relationship with me modified
her repeated patterns, and she began to relate to me with more
realism in her perception of both of us.
I propose now to give the material of the September and
October sessions in some detail. The crisis began with a session
on Friday 21 September when she came looking pink and
vivacious. She said she had started a ballroom dancing class
which met on Friday evenings, and she wondered whether her
Friday appointment could be changed and whether she could
leave early that day. I let her go early, and unfortunately,
52 AUTISTIC BARRIERS IN NEUROTIC PAI'IENTS
of the psychoses and would also help us to reach a more
accurate differential diagnosis between the various diseases.
(p.231)
Orthodox psychiatric opinion has now accepted that children
can be psychotic, but Mrs Klein is still ahead of orthodox
opinion today in thinking that some psychotic children can
respond to psychoanalytic therapy. This hopeful view has been
confirmed by individual child analysts and child psycho-
therapists. It has obtained indubitable confirmation from
workers in the Institute of Childhood Neuropsychiatry of
Rome University, who have made a statistical analysis of the
results of their psychoanalytic work with thirty-nine psychotic
children treated in the Institute's special unit for such children.
Their results are striking and rewarding.
Later, Klein again anticipates Kanner when she says of
Dick's case :
I have reason to think that ... it is not an isolated one, for
recently, I have become acquainted with two analogous cases
in children of about Dick's age. One is therefore inclined to
conjecture that, if we observed with a more penetrating eye,
more cases of this kind would come to our knowledge.
(p.231)
What a pity Mrs Klein's 'penetrating eye' did not have the
opportunity to become focused upon more autistic children.
Her theories might have been extended, and certain un-
fortunate controversies avoided. As it was, she finally in-
terpreted Dick's clinical material in terms of the theories she
had formed from her work with other psychopathologies. Mrs
Klein states this quite frankly when she says:
I would emphasize the fact that in Dick's case I have
modified my usual technique. In general, I do not interpret
the material until it has found expression in various re-
presentations. I n this case, however, where the capacity to
represent it was almost entirely lacking, I found myself
 PSYCHOGENIC A U T I S M A N D MELANIE KLEIN 53
obliged to make my interpretations on the basis of my general
knowledge, the representations in Dick's material being
relatively vague. (p .228)
Thus her interpretations in the early stages of Dick's analysis
would seem to be more applicable to schizophrenic children
than to autistic ones. I have analysed ten autistic children, and
have supervised several psychoanalytic workers with other such
children, as well as observing autistic children for long periods
of time, some of these being in their own homes. I have also
analysed two schizophrenic children and have supervised other
psychoanalytic workers with children of this type. This work
has made it very clear to me that, on deep investigation, the
psychopathology of an autistic child is very different from that
of a schizophrenic one. Thus it has seemed to be important to
study childhood autism in its own right, and not to confuse it
with childhood schizophrenia, as is often the case.
Let me outline what I have found to be some of the essential
differences between a young autistic child and a young
schizophrenic one. (I use the terms 'confusional' or 'entangled'
rather than schizophrenic, since these terms describe the
predominating features of their pathology.)
Dr3fferencesbetween young autistic and schizophrenic children
The schizophrenic child is in a confused entanglement with
his mother. Mahler refers to this as 'pathological symbiosis'.
By this means, the child makes some degree of insecure
psychological development because, in spite of the interpene-
tration of mother and child, he has a confused awareness of
their bodily separateness from each other. Thus the processes
of projective identification as described by Klein are very active
and obvious. Such a child is aware of insides and outsides and
of objects which, in Klein's terms, he 'phantasies9* are inside
*'Phantasy1refers to unconscious processes, 'fantasy' to conscious ones (see
Isaacs, 1952).
254 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
incurable, depressed, exhausted mother whom she depleted
and attacked and who attacked and depleted her, then she felt
unable to grow up. This meant regression and death. These two
aspects of herself, and of the mother she felt she embodied,
were brought together and expressed in a tic-like gesture of
hands and body. She would come forward towards me with a
fluttering movement of her hands, and then fall back stiffly
with her spine rigid against the back of the chair. ,
Her associations during this second phase of her analysis
showed that she felt that the loving relationship, in which we
were so close that we were inside each other, could all too easily
slip over into being the possessive imprisonment associated
with the greedy, destructive relationship and from which
neither of us could escape. Her associations began to show that
in this latter type of relationship she felt that we were one inside
the other greedily and enviously biting at the contents of each
other's body, particularly the penis. Progress again could only
be at each other's expense and the one who made progress made
it at the cost of leaving the other depleted and dying. Her
ultimate fear was that we should both be left exhausted and
dead.
There was vivid material in which she showed that she felt
that I was a 'condemned' mother whose inside was 'unfit for
babies'. There was also material about her successful dancing
companions who were 'in shows', and we began to see that,
in her unconscious phantasies, 'shows', examinations and
menstruation were equated and feared. Menstruation was felt
to be another examination which she feared because of what it
would show. It could not be welcomed as a sign of growing up
and of her hopes of having children, since it was felt to be
evidence of her own and her mother's disappointed hopes that
she was a boy. As with the pseudo-pregnancy it brought into the
open her secret rivalry with her mother, and was also felt to be
achieved at the expense of leaving her mother incurably ill,
bleeding, exhausted and even dead.
It was also feared because it would reveal the 'bleeding mess'
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 253
If, on the other hand, my behaviour made her feel that I was
fitting in with her wishes, she responded by feeding me as she
felt I fed her and by putting on weight, which, when she did so,
was felt to be something that could be offered to me as a gift.
For example, on 18June I suggested that she should come twice
a week and that she should try to do without the Friday session.
It will be seen from the graph that there was a great loss in
weight following this deprivation. On 2 July I reinstated the
Friday session fearing that I was putting too great a strain upon
her, and because I could not cope with the feelings that were
aroused. She immediately responded by drawing a bright,
cheerful and connected picture of a table laid for tea. (she had
started to draw in the second phase of her analysis. Her first
pictures had been of stiff, isolated but whole objects, with no
apparent theme, similar to the verbal associations in the early
sessions.) After she was weighed on the following Monday she
told me with great pride that she had put on 1%Ib.
At this time, when the relationship was 'good', she felt that,
quite concretely, we gave each other weight. When it was 'bad'
she felt that we took it away from each other. She talked a great
deal about her mother's periodic weighings and showed that she
felt she was in rivalry with her mother in this area also.
It became increasingly clear that she was seeing me as a
person with two distinct facets. Sometimes I represented the
lively, 'playful' mother of her phantasies who had a healthy
body from whom she wanted to feed. At other times I was the
depressed, unresponsive mother with the ill body from whom
she feared to feed. Her infantile desire for closeness, which was
sometimes expressed as wanting to come right inside me, or
that 1 should go right inside her, meant that she felt she had
taken into her body my moods and state of health as well as my
exciting life. If she felt identical with, or inside me, as the
creative, healthy, responsive mother whom she could refresh
and revive by her effortsand who refreshed and revived her, she
grew and moved forward. This meant progress and life. On the
other hand, if she felt identical with, or inside me, as the
54 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
the mother's body. He has a capacity for relationships of a
bizarre kind. He is 'object-seeking', and has usually developed
speech, although this may be slurred and the sentences may be
incomplete or have words missed out. Such a child will meeet
the eyes of other people, but his own eyes may be blurred and
unfocused.
T h e autistic child's functioning is very different. His is a
sensation-dominated world in which he seeks set~sntiorlsrather
than objects as such. He is not responsive to people as people,
but mostly in terms of the sensations they engender. His is a
primal state of seeking correspondences, in sensation terms,
from the outside world which coincide with his inbuilt patterns.
If he becomes aware of lack of fit to his inbuilt pattern-seeking
propensities, he blocks it out so that he feels continuous with
the outside world and not separate from it.
He lives in a world of forms and shapes and patterns. If such
a child responds to psychological tests at all, it is to those to do
with shapes. He seems to be in a state of imitative 'identicality'
with the world around him, such as we see in a normal young
baby who will put out his tongue in response to his mother
doing the same. I n the autistic child, this state has become
pathological and he is stuck there. In terms of his imitative
fusion with objects in the outside world, he relates to them in
terms of the contours of his own bodily parts. Thus, cupboards
and chests of drawers are 'equated' (to use Hanna Segal's term)
with stomachs; openings in things are equated with mouths. I
have much evidence to show that pencil sharpeners are often
felt by the child to be equated with his cruel biting mouth. For
example, he will put part of a toy into the 'mouth' of a pencil
sharpener, whilst at the same time making circular biting move-
ments with his mouth.
T h u s when Dick saw some pencil shavings, he said, 'Poor
Mrs Klein.' T o him, they were a cut-up Mrs Klein. He was
sorry for this 'Mrs Klein' whom he perceived solely in terms of
his own activities, and not as a person in her own right. Indeed,
he did not see her as a person at all, but as an inanimate thing.
 PSYCHOGENIC AUTISM A N D MELANIE KLEIN 55
(Mrs Klein said that he ran around her as if she were a piece of
furniture.) As I hope to show later, it is his incapacity to work
through such prematurely induced 'sorrow' which has played a
major part in his autistic disorder. It seems as if these children
have reached the 'depressive position' as described by Klein in
a state in which human beings are not clearly differentiated
from inanimate objects and are merely experienced in terms of
hard and soft sensations.
It is difficult for us, as differentiated human beings, to
understand such undifferentiated states in which 'me' and 'not-
me' are scarcely differentiated. Everything is experienced in
terms of 'me', 'me' being the flux of bodily sensations which
constitute the child's early sense of 'being', even before the 'not-
me' has been clearly differentiated, although there will be
flickering moments of awareness of it. Work with autistic
children has convinced me that this primal sense of 'me-ness'
has to be well established before longstanding awareness of
the 'not-me' can be tolerated. Without it, the necessary self-
confidence is lacking.
I n autistic children, this primal sense of 'me-ness' has been
disturbed. Thus, beneath their autistic impenetrability they
feel exceedingly vulnerable. T o offset this, they feel that they
bite off sticking-out bits and pieces. I n the process of analysis,
it becomes clear that they have felt that sticking these extra
'titbits' to the surface of their body would protect them
and ensure their survival. (Bodily survival is their main
preoccupation.) But this feeling that they have bitten off
'titbits' means that, in flickering moments of awareness of
separateness, they feel surrounded by cut-up, broken things;
the mournful wail of 'broken' often being the autistic child's
first word. In Winnicott's terms, in a state which should be one
of 'pre-ruth', they have experienced 'ruth'. Biting, which has
precociously supplanted sucking, is feared. T h u s they dare not
take the breast in the energetic ruthless way of a normal infant,
and during weaning the biting of solid food is avoided.
Their main emphasis is on surfaces to which they can adhere
252 AUTISTIC BARRIERS IN KEUROTIC PATIENTS
impulses and submitted to restraint out of terror of the possible
consequences of her greedy and destructive wishes. In this fear
of her biting impulses we have another potent cause for the
restriction of her eating. This adjustment, although
unsatisfactory, allowed her to feed from me so long as she did
not bite. Thus she kept me unused and untouched, as her
mother had described how she had preserved her toys in
childhood. Also during this time she told me that she rolled the
food around in her mouth until it was soft enough to be
swallowed, i.e., she did not bite.
In the few weeks that remained before the Easter holiday she
again put on weight, and it was decided that she was strong
enough to be discharged from the hospital ward to continue
treatment with me as an out-patient. It will be seen from the
graph that during the holiday her steady progress was con-
tinued. This happened during every long break in treatment. It
was noticeable that before a holiday she always made great
efforts to adjust her relationship with me so that she left in a
mood in which the unconscious phantasies of our having a good
reciprocal feeding relationship were uppermost. It became
clear that she could tolerate separation if she was sustained by
the phantasy that we each drew upon an inexhaustible source of
supply which meant we could feed, restore and replenish each
other endlessly.
Her idea of a 'good' relationship was one in which we
gratified each other endlessly. When I frustrated her wishes,
however unrealistic they might be, I became the epitome of
all that was malicious, spiteful and restrictive; for example,
when I was guided by the paediatric staff as to when she could
leave the hospital. She responded by revengeful, punishing
behaviour and then she felt we were locked in a destructive
relationship that boded ill for both of us, and from which she
feared there was no escape. She mistrusted our intentions
towards each other and unconsciously feared that I would
poison her as she felt she poisoned me. In these periods she lost
weight presumably because she feared to eat.
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 251
is obvious that her mother's incurable illness must have re-
inforced the phantasies we saw expressed in the session on 27
January that her productions were worthless and inadequate.
We now saw further reasons for her fear of taking the dancing
examination in November.
In later sessions we came to see that her dancing was partly
an attempt to satisfy her mother's own unful.filled ambitions,
which also contributed to her overwhelming desire to have a
baby. In some moods she wanted to satisfy all her mother's
disappointed wishes. Her dancing was also an attempt to bring
her depressed, dead (comatose) mother to life. It had its roots
in the dancing up and down which she had done on her mother's
knee and which had pleased and cheered her. Since all
movement was equated with life it came to be looked upon as a
life-giving activity and was elaborated into her masturbatory
movements from which dancing was a derivative. From earliest
times her uncertainty had been whether she could (and should)
grow, move forward, dance, be lively, be 'playful' (her own
association to feeling better); or whether she should stand still,
regress, depress her playfulness, stop growing, die. T o decide
to grow and to live, among other things, meant draining her
mother's resources and facing the problems that this created for
her. It also meant satisfying her feminine impulses and, besides
bringing her into rivalry with her mother, disappointed some of
her mother's wishes. In her treatment she again faced these
problems in the transference relationship with me. Her agi-
tation in this session was over how she could get the care and
attention she needed because of her helpless dependence,
without draining me of all my supplies and without arousing my
frightening envy and hostility.
In the next session she dealt with this problem by becoming
the submissive, docile child. Her angry, greedy, biting im-
pulses were seen in another girl in the ward who was 'naughty
and bit Sister'. Her rebellious feelings were inhibited and I was
seen as the mother who quite rightly restrained this child who
was liable to be so destructive. She was shocked by her biting
56 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
in order to acquire some sense of bodily definition. Such a child
lives mostly in a two-dimensional world. If he goes inside a box,
or a tunnel, or a cupboard, it is the sensation of being hidden
and protected which is significant to him. It is not the going
inside. For most of the time, he he has little awareness of the
difference between outsides and insides, and also little
awareness of time and space. (Some children even try to walk
through objects as if they were not there.) Thus, unlike the
' schizophrenic child, the autistic child has little curiosity about
the inside of the mother's body, which Melanie Klein sees as the
starting point for all learning. This may be because he has
become aware of insides too soon, or because he has never
reached this stage. In any case, it is clear from their de-
velopmental histories that such children's experience of their
mother's body has been very limited. They have sucked very
little, and only limply when they did so. Thus they have not
learned much and appear mentally defective.
k n autistic child avoids meeting the eyes of other people. He
does not relate to people in the normal way. They are only
significant to him as inanimate objects. If these objects - and
people are included in this - seem to become obstreperous (that
is, they do not do what the child expects of them) they provoke
tantrums of rage and terror. These are dealt with either by
ignoring the offending object or by manipulating it to seem part
of their auto-sensuous flow. Thus, for most of the time, these
children appear 'affectless', as did Mrs Klein's Dick. Apart
from these primitive emotions of rage and terror, autistic
children do not manifest the emotions associated with
sociability such as we see in neurotic children, and even in
schizophrenic ones. As treatment proceeds, and they begin to
tolerate bodily separateness, the social emotions of love, hatred,
envy and jealousy begin to become manifest, but they are not in
evidence at the beginning of treatment, when the child is
averted from relationships with people.
Lacking contact with people as people, such a child has little
 PSYCHOGENIC AUTISM AND MELANIE RLEIN 57
motivation to communicate in the usual way. Language is
either absent, sparse or echolalic. All the child's energies are
concentrated on engendering a protective covering of 'me'
sensations to keep the 'not-me' at bay. The fact that Dick had a
few communicative words (for example, he said 'cut' to Mrs
Klein) shows that he was not as completely cut off from human
contact as many of these children are. Those who care for them
feel that they cannot get through to them, and speak of their
being in a 'shell'. In treatment, it becomes clear that the child
also feels that his body surfaces are hard and shell-like. For
example, he often turns his hard back to protect his soft front.
It is for this reason that I have termed them 'encapsulated' or
'shell-type' children. However, there is always an opening,
however minuscule, through this seemingly impenetrable fa-
sade, and it is this which makes psychoanalytic work possible.
For example, such children usually understand something of
what is said to them, and they are responsive to the analyst's
moods and attitudes, the latter being shown by such things as
tones of voice, muscle tensions, body movements and the like.
Another feature unique to autistic children is their use of
what I have called 'autistic objects'. These will be discussed in
Chapter 6. T o the child they are not objects as we see them, but
are experienced in terms of the sensations they engender. Since
there is no delay in getting the sensations he wants, the child can
feel that these objects are part of his body. By means of these
sensation objects, he feels completely self-sufficient and
without the need for other people.
These children will spin or twiddle hard objects, or carry
hard objects such as toy cars around in their hand. They cling
tenaciously to these objects and will not be parted from them.
If they are parted from them, it is as if they have lost a part of
their body. Dick was intensely interested in cars and door
handles, but he was open to their being used by Mrs Klein as a
means of communicating with him. This is not the case when
the use of an autistic object has become entrenched, as is the
250 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
because of the envious hostility it aroused, separation from me
was feared because it seemed to confirm her deep fears that she
had exhausted me. She tried to talk a great deal but she showed
clearly her mistrust of her capacity to produce anything that
would revive my interest in her.
I saw the feelings of this session as a reactivation of the
situation at four months when her mother's milk failed and she
was cared for by a depressed and unresponsive mother - a
situation which had been reactivated, and the impression of it
deepened by her responses to later difficult situations when,
because her mother's attention had been temporarily
withdrawn from her, she had feared that she had exhausted her
mother's supplies of loving care and attention. Such situations
would be the onset of her mother's illness, the return of her
father, her mother's difficult pregnancies when she had to be in
hospital a great deal, and her experience of her mother's comas.
She had clung tenaciously to the phantasy of my om-
nipotence because if I were not omnipotent I could be hurt by
her attacks and, in her imagination, I became ravaged and
despoiled. If she dared to entertain the thought of my fallibility,
I could die and she could die. United and identical with me as
this mother, she felt possessed by an ill, almost dead mother
from whose grip whe was unable to free herself. Thus she felt
hopeless, exhausted and almost dead.
Material in later sessions confirmed that she felt she
exhausted me by her greedy demands for my care and attention,
and that she had the unconscious phantasy of herself as the baby
inside me who exhausted me by greedy feeding and insatiable
demands for love, care and attention, and who spoiled my
grown-up life by her envious greedy attacks upon it. The anx-
iety about these attacks was another important factor which
contributed to the inhibition of her interest in food and to the
restriction of her life. In the session under discussion she was in
a state of agitation to produce something which would revive
and replenish me so that my care returned to her; but she was
desperately afraid that her productions would be ineffectual. It
 ANOREXIA NERVOSA I N AN A D O L E S C E N T G I R L 249
phantasy on 18 February. There was also material to show that
she felt I preferred boys to girls. As a girl she feared I would
punish her as a potential rival or as a disappointing sexual
partner. We saw now that one of her many reasons for avoiding
the dancing examination was the fear that her femininity would
be disclosed. It will be seen later that menstruation was looked
upon as a similar examination.
The next session, 21 February, was an important one. Ever
since she had become aware of our separateness, she had been
clamouring that by such things as presents, reassurances and
constant visiting (none of which in the end would have satisfied
her), I should help to bolster her illusion that I was an in-
exhaustible source of supplies. She now faced the terrifying fact
that she was dependent upon a human being who was heir to all
the human frailties such as fatigue, moods, illnesses and even
death. The collapse of her pregnancy phantasy, the recognition
of the fact of our separateness, and, with this, the realization
through interpretation of her envious rivalry and consequent
hostility, the fact that she was losing weight, the observations
she made in the ward which showed that the hospital staff did
not always understand how to control other patients' gains and
losses of weight by special diets; all these worked together to
make it impossible for her to maintain the phantasy that she had
found a being to care for her who knew everything, who would
gratify her every wish, who was ever-present, who was never ill,
never tired, never depressed, who was a source of inexhaustible
supplies, whose exciting private life was unspoiled and happy,
and who she could always feel was supremely well-disposed
towards her. This breakdown in her omnipotence was
experienced as exhaustion and tiredness.
In this session Margaret became aware of her feelings of
helpless dependence upon me. For the first time she recognized
that if she did not eat she would die. She feared that she had
exhausted my supplies of goodwill, patience and understanding
(my 'food'), that I would thus withdraw treatment from her,
and that therefore she would die. As well as being feared
58 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
case with many autistic children. The attempt to use it to get in
touch with them is felt by some of these children to be a threat
to take away an important part of their body.
In autistic children, the manipulation of pathological autistic
objects has pre-empted the sucking of normal auto-sensuous
ones such as the thumb, the fist, or the fingers. In the un-
differentiated state of early infancy, the mother's fingers, the
nipple of the breast or the teat of the bottle will also be
experienced as auto-sensuous objects. When they first come
into treatment, a marked feature of autistic children is that they
do not suck their fingers or other objects. This is in marked
contrast to the schizophrenic and environmentally deprived
young children who usually suck avidly. Instead of sucking,
autistic children manipulate hidden parts of their body. These
shut out the terror of the unfamiliar 'not-me'.
But why does the autistic child have this terror of the 'not-
me'? It has become clear to me that a crucial factor in the
precipitation of the autism was the realization that the nipple of
the breast was not part of the mouth, but was separate from it,
and could be 'gone'. This had been enraging and terrifying.
As I have said, I was first alerted to this by the four-year-old
autistic boy whom I have called John (see Chapter 4). I was
startled by this boy's revelation to me about 'the black hole with
the nasty prick', since it was not part of my Kleinian training.
Later, having written a paper about this, I was told by other
workers that Winnicott had mentioned this phenomenon in one
of his papers, and that Margaret Mahler had just published a
paper on this topic. Looking up the references I found that
Mahler had written of the autistic child's 'grief and mourning'
when he lost what she terms 'the symbiotic love object'
(Mahler, 1961, p.332). Winnicott (1958, p.222) had written:
'This loss was experienced as loss of part of his body and not as
the loss of the mother and her breast.' Both Winnicott and
Mahler saw this as the starting point for childhood autism.
Mahler (1961, p.332) writes: 'What we seldom see, and what is
rarely described in the literature, is the period of grief and
 PSYCHOGENIC AUTISM A N D MELANIE KLEIN 59
mourning which I believe precedes and ushers in the complete
psychotic break with reality.' Anyone who sees the mournful
eyes of an autistic child will not question that he is grief-
stricken.
I have come to see that a significant factor in the precipitation
of psychogenic autism is the fact that the child experienced loss
in such an immature state of psychic organization that he had
not been able satisfactorily to work over the grief and mourning
entailed by the loss. Satisfactory mourning entails giving up the
lost object and establishing it as a mental construct. Hanna
Segal has shown the importance to symbol formation of dealing
with feelings of loss (Segal, 1957). The autistic child has not
been able to mourn because the nipple he felt he had lost had
scarcely reached the status of an object; it was mostly
experienced as a cluster of sensations.
A turning point
My experience with John's 'black hole with the nasty prick'
marked a turning point, not only for John but also for myself.
Finding that other workers had had similar experiences to those
I had had with John, I was encouraged to explore outside the
boundaries of the theoretical school in which I had been reared.
This made me realize that there are states other than those
which Mrs Klein explored and described with such courage and
penetration. For example, seeing Dick's illness as a schi-
zophrenic one, Mrs Klein placed its fixation point in nar-
cissism. There is much evidence that the roots of psychogenic
autism are in the earlier pre-narcissistic condition identified by
Freud in the following quotation from his paper on narcissism.
The auto-erotic instincts are there from the very first so there
must be something added to auto-erotism, a new psy-
chological action, to bring about narcissism. (1914, p.77)
I would modify this statement and suggest that undif-
ferentiated auto-sensuousness is there 'from the very first' and
248 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
In the following session she expressed dissatisfaction with
her auburn hair and showed openly that she envied me my
freedom and my pretty clothes. By comparison she felt
restricted and dowdy. She wanted to leave the hospital. In the
next session she showed that unconsciously she felt that I was as
envious of and hostile towards her as she felt towards me.
Unconsciously, she felt that out of malice and spite I neglected
her (did not visit her) and restricted her (kept her in the
hospital) to prevent her from growing up and being feminine.
This was interpreted to her as a reactivation of similar feelings
in infancy directed towards her mother. She was hopeless about
this situation where we seemed to mean ill by each other, and
her weight continued to fall.
On 17 February her aunt came into the maternity part of the
same hospital to have her baby, and on 18 February Margaret
identified with this pregnant aunt to the extent of having severe
abdominal pains which, on very thorough investigation by the
paediatrician, were found to have no physical cause. This
episode is reminiscent of the gastro-enteritis when she was three
years old and her mother was pregnant with her second child.
It also threw considerable light on her behaviour during the
sessions previous to her aunt's confinement. I n these sessions
she had made occasional references to this aunt. She had also
shown great concern about the noisy rumbling in her stomach.
It was now clear to me that one of her unconscious phantasies
had been that I was the pregnant mother in whose exciting
experiences she could share if we were identical and insep-
arable.
On Monday she did not look at me and was very reticent. The
isolated and halting associations she gave showed that she felt
she had taken in my words (eaten my food) and so had been able
to make progress, to put on weight, to get fatter. In her
unconscious phantasy this was equated with making a baby at
my expense. We now saw one of the root causes of her non-
eating. Ever since she had begun to eat again, she had been
feeling that in secret she was growing the baby she produced in
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 247
like inseparable, identical sisters and so did everything tog-
ether. I pointed out to her that by this means she hoped that she
might participate in my exciting outside life. In the Tuesday
session her associations showed that she was troubled because
the breaks between the session's threatened the closeness she
desired and aroused feelings of frustration and anger. However,
she preserved our close relationship by directing her angry
feelings towards her father and her brothers. After
interpretation, she saw how she behaved similarly in the family
situation.
On Friday I pointed out to her how she was still trying to
preserve the illusion of our identical 'togetherness' by urging
me to visit her in the hospital ward to stay with her there. On
Monday 23 January she weighed 1M Ib more. It will be seen that
these gains of weight had been possible on the basis of an
illusion that she was identical with me as a life-giving, powerful
person.
On Monday and Tuesday, 23 and 24 January, she ceased to
look at me and was withdrawn and reticent. On Friday 27
January it became clear that this was because she could no
longer avoid the fact of our separateness. She said directly that
in the times when I was not with her she felt that I had an
exciting life .in which she could not share. It was clear that this
aroused her anger. She was afraid to be angry with me and
wanted to produce something to please me, but because of her
feelings of admiration for me, she compared herself with me so
much to her own disadvantage that she felt she could not
produce anything good enough. She was constipated and, on
this occasion, the analytic situation evoked the feelings she had
had in the. toilet situation in childhood, when she had felt
unable to produce anything good enough for the mother she
admired so much. Her associations showed that examinations
stirred up the same feelings, and we saw some of her reasons for
avoiding the dancing examination in November. During this
period the ward sister reported that she had withdrawn from
the life of the ward and her weight continued to fall.
60 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
that, in normal development, this gradually differentiates into
auto-erotism and auto-sadism. It is suggested that in aberrant
development, auto-erotism and auto-sadism have developed
precociously, which means that erotism and sadism are not
directed towards external objects in an appropriate way. This
has happened in psychogenic autism which, as was suggested in
the previous chapter, is not associated with narcissism, because
the autistic child has no sense of being a self. Kohut has cast
additional light on this, in that he suggests a further factor
which sets in train 'the psychological action to bring about nar-
cissism'. He writes: 'We may thus conclude that the mother's
exultant response to the total child (calling him by name as she
enjoys his presence and activity) supports, at the appropriate
phase, the development of auto-erotism to narcissism' (Kohut,
1971).
T h e mothers of psychogenic autistic children almost in-
variably report that they were depressed around the time of this
particular infant's birth, or prior to the autism, if this occurs
some time after the birth. For such subdued mothers, the
lively, 'exultant response' towards their infant described by
Kohut would not be possible. Thus, such infants become
trapped in an aberrant auto-erotic and auto-sadistic condition.
This has a precocity and artificiality, interlaced with stark
terror, which are not part of normal development. Un-
manageable erotic excitements and sadistic biting almost
obliterate the urge to suck.
Maternal depression as a factor in the development of
psychogenic autism
In connection with the effect of a mother's depression on a
young infant, I was impressed by Brazelton's observation of a
normal three-week-old baby when the mother intentionally
presented him with what Brazelton describes as a 'still,
unresponsive face'. Brazelton records the baby's reactions as
follows: he becomes visibly concerned, his movements
I . . .
become jerky, he averts his face, then attempts to draw her into
 PSYCHOGENIC AUTISM AND MELANIE KLEIN 61
interaction. When repeated attempts fail, he finally withdraws
into an attitude of helplessness, face averted, body curled-up
and motionless' (Brazelton, 1969, p.137). This description
could be that of an autistic child; the 'still, unresponsive face'
could be that of a depressed mother who feels herself to be a
'non-person', which is how some of the mothers have described
their depression.
T h e normal infant soon recovers from such a transitory
experience of non-responsiveness in the mother. But for 'stress-
susceptible' autistic children, it has been a constantly repeated
experience which has had tragic consequences for their ongoing
mental and emotional development. I have come to realize that
this lack of mental connection with the mother has caused them
to overvalue the physical bodily connection to her by means of
the nipple of the breast (or the teat of the bottle experienced in
terms of inbuilt responses to the breast). For such a baby, the
frustration of the inevitable realization that this is not a part of
his mouth is a bitter blow from which he does not recover.
I agree with Meltzer (1975) and Tischler (1979) in seeing the
mother's depression as a factor in the breakdown of normal
relations between the mother and her autistic child. I have a
great deal of sympathy for these mothers. I n my view, Kanner
started a regrettable fashion in seeing them as being 'cold and
intellectual'. Ever since he said this, phrases such as
'refrigerator mothers' have been bandied about to describe
them. I do not subscribe to this view. Such a mother's de-
pression was not usually a clinical one entailing hos-
pitalization. It was associated with events which are part of the
ordinary vicissitudes of life, which impinged upon a sensitive
mother at a particularly vulnerable time. For example, the
family may have moved house, or the father may have had to be
away from home a good deal, or the mother may be living in a
foreign country, or it may be a mixed marriage (racially or
religiously, or both), or an emotionally important relative may
have died, or there may be interfering relatives, or there may be
important anniversaries around the time of the child's birth.
246 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
relationship with me during the week, and had affected her
behaviour outside the analytic situation.
It would be useful to try to analyse what these experiences
had meant to her. We can infer that she felt that she had found
someone who seemed willing to spend a good deal of time and
trouble on her, and this flattered and reassured her against the
deep fears which were to come up later that she was unlovable
and worthless. She began to hope that all her needs and wishes,
however unrealistic, were going to be satisfied. I suspect that
my seeing her constituted a reassurance, as though I were
saying, 'It is all right, I will make you better.' It soon became
obvious that she saw me as a wonderful, omnipotent person
who would perform the miracle of making her better and that
she felt that nothing short of a miracle would do this. It also
became clear later that 'better' did not mean only better in
health but 'better' in a moral sense also, and that in both senses
she felt out of the reach of human aid.
On the other hand, very intense responses had been called
into play which had their prototypes in the feeding situation in
early infancy, and this had become abundantly clear to both
of us. T h u s the stage was set for the continued evocation of
her unconscious phantasies about feeding and the social
relationships this entailed, and a reliving of her early problems
through the transference relationship to me in the hope of
finding new adjustments. In addition, her impulses to live had
been stimulated by her interest in me and my affairs.
I think the situation of being separated from her home and
parents, of living the restricted life of the hospital ward, of
being in bed and thus dependent upon the nurses for care and
attention, of being physically so weak and helpless, and of being
in a starved condition predisposed her to re-experience very
vividly the babyhood feelings that we find evoked in all our
patients by the special circumstances of the analytic situation.
On Monday and Tuesday (16 and 17 January) she gave more
associations and spoke more audibly. I gathered from these
associations that she wanted to come so close to me that we were
 ;INORESI:I NERVOSA IN A N ADOLESCENT G I R L 245
This first session well shows the mixture of hope and
hopelessness which was such a marked feature of this girl's
analyis. The increase in weight on hearing that she is to start
psychotherapy is similar to the M Ib increase which occurred
when she first came into the hospital for physical investigations.
In the light of her behaviour throughout the treatment, it
probably occurred in response to a resurgence of hope that she
had found someone who would understand her needs, only to
give place to despair and loss of weight when her hopes were
disappointed and she was left in the grip of her conflicts.
In the beginning of the next session she did not speak but lay
looking at me as she had done towards the end of the first
session. It seemed very meaningful to her when I said I thought
she wanted to be a baby, and that she felt she was feeding from
every word that came out of my mouth. After a pause, in
response to a slight movement of her body, I said I thought that
she wanted to talk to me with her body as she had done to her
mother before she could talk. At this she moved nearer to me
and spoke in the same almost inaudible, halting voice. She said
that she liked watching the dancing on television. I said this
seemed to mean that although she did not like to take things in
with her mouth she still liked to take things in with her eyes, as
she was doing now with me. A flicker of a smile passed across
her face and she continued to look at me.
After a long time of looking at me, she momentarily glanced
out of the window and whispered something, of which I only
caught the word 'exciting'. I responded to this by saying I
thought she felt that there was an exciting life going on outside
the hospital, something like the dancing on television, and that
I took part in this life. For some reason she only dared to take
part in it by watching.
After her session on the Friday of that week (13 January) I
heard from the ward sister that she had started eating again and
was joining the life of the ward. On Monday she weighed 1'/z Ib
more. It seemed that her positive attitudes to feeding had been
reinforced and stimulated by experiences in the transference
62 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
Part of such a mother's difficulty seems to come from feeling
unsupported by the father. (This may be a repetition of feelings
from her own infancy or childhood.) Thus, she clings to her
child as if he is still part of her body. She does this in order to
keep going in spite of her depression and lack of confidence.
This can happen both when the child is inside her womb and
also after he is born. She fears the'black hole'of recognizing his
separateness from her. When, for various reasons, the child
experiences his separateness from her, she cannot hold him
through his states of alarm because they coincide too much with
her own. It is not only through states of alarm that he needs her
support. Uncontrollable states of pleasurable excitement are
threatening also. T h e father of an autistic girl has described
how she could not stand states of what he called 'rapture'.
However, many relatively normal mothers become de-
pressed as the result of certain disturbing happenings, but their
children do not become autistic. I am convinced that there is
something in the nature of the child which predisposes him to
autism. T h u s it has seemed to me to be more fruitful to
investigate the child's contribution to his disorder than to
concentrate on that of the mother. We may be able to do
something about the child, whereas we cannot change the
mother of his infancy. When an autistic child is in analysis,
work with the parents would seem to be best directed towards
helping the father to support the mother who needs to regain
both her own self-confidence and also her love for her now-
recovering child.
Critical factors in the child
Recent research work by T o m Bower (1977) and also by
Meltzoff and Barton (1979) has thrown light on some of these
critical factors. It has indicated that in normal development in
relation to certain significant gestalts, the integration of tactile
and visual perceptions takes place in the first few days of the
infant's life. T h e baby who later becomes autistic seems to be a
hypersensitive child, unduly prone to panic reactions. I n these
 PSYCHOGENIC AUTISM AND MELANIE KLEIN 63
children the 'startle response' seems to have become excessively
exaggerated. In such children the normal integration of sense
modalities seems to have been prevented by uprushes of
unmitigated primal panic. The insufficiently buffered shock of
bodily separateness from the mother means that the normal
integration of touch and sight has been halted, and the child
lives in a flat, tactile-dominated world of mere surfaces.
Such a child's experiences are superficial and limited, and do
not include an interest in insides. In contradistinction to the
schizophrenic-type children studied by Mrs Klein, who feel
that their insides are full of objects which have dramatic
interplay with each other, the autistic child feels empty and
objectless. The hard tactile sensations of autistic objects on
body surfaces, and the soft touch of autistic shapes, dominate
his world. (These are to be discussed in later chapters.) For
these children, touch is magical. Only what is tangible seems
real to them. The autistic child is trapped in what Spitz has
rightly called a 'dead-end street'. But it is a 'dead-end street'
with primeval horrors lurking in the shadows.
Primeval terrvrs
Whence do these primeval terrors come? Let me make some
tentative suggestions about this. Just as in the physical womb of
the mother's body the foetus goes through some of the bodily
forms of our evolutionary past, so it seems possible that in the
post-natal 'womb' of the mother's 'maternal preoccupation'
(Winnicott's term) the infant goes through states connected
with our evolutionary heritage. Some of these atavistic states
seem to be associated with inbuilt fears of animal predators
which ensured survival in past ages, but which are now
vestigial. In normal development, the infant will be buffered
from acute experiences of these atavistic terrors by an ultra-
responsive mother who acts as a shock-absorber. A baby who
lacks such shock-absorbing primary caregivers is thus exposed
to primeval terrors which are not the lot of the normally
sheltered infant.
244 ,\LJTISTlC B.4RRIERS I N N E U R O T I C P A T I E N T S
and immobility were the most marked features as she lay stiffly
under her blanket. T h e bones of her face showed white through
the blue, tightly drawn skin. I explained to her that treatment
entailed her telling me any thoughts that came into her mind so
that together we could try to understand why she was not
wanting to eat. She made no reply to this explanation and lay
looking straight in front of her. When she made an uneasy
gesture I interpreted her anxiety about me as another new and
strange person amongst the many new people she had seen since
she came into the hospital. She made no response and
continued to lie looking straight in front of her.
After a long pause she spoke haltingly and in such a whisper
that I had to lean forward to hear what she was saying. As I did
so I became aware of the unpleasant smell that came from her
body and it was only with an effort that I stayed close enough to
hear that her teacher, who had been supposed to be coming that
morning, had not come. I said I thought she was telling me that
when she had seen these other people in the hospital she had
been hopeful that they would help her, that she had been
disappointed that they had not done so, and that she had not
seen them again. She felt that they had raised her hopes and had
then let her down, just as the teacher had disappointed her this
morning. She was afraid that I would raise her hopes and then
let her down in'the same way. I then told her I would see her on
three mornings a week and that the days would be Monday,
Tuesday and Friday.
After this interpretation and explanation she looked a little
less pinched and cold and gradually moved her body so that she
was curled up under her blanket in such a way that a picture of
a baby feeding came immediately to my mind. She stayed like
this for the rest of the session. Her next whispered, halting
sentence was given when she was sitting up ready to go to the
ward. She said she had been weighed that morning and that she
had put on 1/2 Ib. I said I thought she was telling me this so that
I felt rewarded for the work I had done, and so that I would see
her again tomorrow.
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 243
on the transference situation which is seen as evoking early
preverbal experiences, particularly in the preliminary phase of
treatment. It is in this phase that it is difficult to make contact
with patients suffering from anorexia nervosa due to their
extreme reticence and withdrawal. Although many ways exist
to establish and maintain contact with such patients at this
stage, in the method used here the analytic situation was not
modified, and an attempt was made to keep contact with
Margaret by understanding in detail the play of feeling evoked
by the analytic situation and to talk about this to her in simple
and direct terms.
It will be obvious that in such a situation, where there is a
paucity of verbal associations, other details have to be used as
evidence for interpretations which are deduced from different,
and in some cases more slender, evidence than that available
when the patient is more verbally communicative. Thus,
interpretations in this early period were based upon slight
changes of posture, fleeting facial expressions and tiny hand
movements, as well as on the patient's isolated associations.
One difficulty in dealing with early material in this way is that
an attempt has to be made to reconstruct, through the
sophisticated medium of words, a play of affect first ex-
perienced at the preverbal stage of development.
T h e first phase of treatment will be described in some detail
in order to demonstrate initial difficulties, and to give a working
example of the technique. T h e succeeding phases will of nec-
essity be condensed to fit within the compass of the chapter.
On 9 January Margaret came from the ward to my room for her
first session. She was accompanied by a nurse, and, in spite of
looking as though her skeleton-like body would be broken into
pieces by the weight of the hospital blanket draped around her
shoulders, she walked steadily and unaided.
In view of her physical weakness it was natural for her to lie
on the couch. I sat at the right-hand side of her pillow. Stillness
64 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
D r John Bowlby (1973) has come upon this fear of predators
in children who have suffered traumatic geographical sep-
aration from their mothers in their early years. This fear is also
in evidence in psychoanalytic work with autistic children who
have suffered psychological separation from their mothers in
early infancy. Their fear of predators does not always seem to
come from an active projection of their own predatory
impulses. Rather, these passive children seem to feel at the
mercy of terrors of which they are the helpless victims.
The foregoing is an imaginative attempt to make sense of
some of the savage terrors encountered in psychotherapeutic
work with autistic children. In these children, phylogenetic and
ontogenetic factors seem to be intertwined. These atavistic
terrors have poisoned the child's relationship to his mother.
Insightful, professional intervention can draw the fangs of this
poison by realizing the part that autistic objects and autistic
shapes have played in these children's pathology. These have
been reactive protections against the threat to their survival
posed by the vestigial terrors to which they have been
abnormally exposed, but they have damaged the child's re-
lationship to the mother. This is because the inanimate, tactile,
autistic objects and autistic shapes are always available in just
the way the child wants them. When their use has become
entrenched, the human mother, by contrast, seems very
unsatisfactory. Thus, autistic children expect an impossible
mechanical 'perfection' from their mother (and their therapist).
For example, they expect her to be always with them, always to
give them what they want in the exact terms they have wanted
it, and to be for them alone. The autistic delights, comforts and
seeming invulnerabilities have completely replaced and made
impossible the relationship with a real mother who, supported
by the father, can give them safeties and satisfactions of more
permanent value. Through the infantile transference, informed
by insights such as have just been described, the therapist can
negotiate the development of a more trusting relationship
between autistic children and their parents. As this occurs, the
 PSYCHOGENIC AUTISM A N D MELANIE KLEIN 65
parents' desire to respond to their offspring finds an answering
echo in the children themselves.
The use of autistic shapes and autistic objects, which have
been developed to deal with a situation of mental and emotional
disconnection from the mother, results in this disconnection
becoming intensified. The 'hole' of disconnection becomes a
'black hole' as the child 'negates' the mother because she is not
always as available as are his autistic concoctions. Also, his
dependency needs are denied and a pathological self-sufficiency
results. This is based on fear. Although they do not show it at
the beginning of treatment, autistic children are terrified of the
'black hole' or the 'blacked-out' mother. As treatment proceeds,
their fears of being 'blacked out' by her are revealed. These are
grave misconceptions on the part of such children which, in the
early days of psychodynamic investigation, led some workers to
think that the mother was 'to blame' for her child's tragic state.
This rubbed salt into the wounds caused by the years of
unremitting rejection by her child which the mother had
experienced. T o say, as Bettelheim does, that these mothers
have had 'death wishes' towards their child, before as well as
after birth, is both cruel and erroneous. After years of cour-
ageous struggling with their own troubles and with their
unresponsive child, is it to be wondered at if, as a passing
thought, they wish him or her out of the way? But these parents
do not get rid of their autistic child. Far from it, they go to many
agencies seeking help. In my experience, if they come to a
psychotherapist when the autistic child is under seven years of
age, and if there are no detectable organic impairments, these
insights into autistic objects and.autistic shapes promise to open
the closed doors of autism.
There are other insights which it is more difficult to make
meaningful to the reader. These concern the tactile, sensuous
extremes in which such a child lives and moves and has his
being. They are difficult for us to understand because these
children's predominantly tactile reactions are so different from
our own experiences, in which touch and sight are closely
242 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
full programme at the hospital. For the first two-and-a-half
months of treatment she was an in-patient in the hospital; after
this she returned home and came to see me on the same days as
before as an out-patient.
In the early days as we sat together in the often silent room I
was caught up in her own despair about herself and felt hopeless
about helping her. In addition, my own anxieties were in-
tensified by those of the paediatric and nursing staff, who were
very upset when she lost weight or stood still, or did not put on
weight as fast as they would have liked. T h e fact that my
psychiatrist colleague saw his role as that of absorbing and
dealing with these anxieties contributed an indispensable part
to the help I was able to provide this child.*
T h e analysis of the transference relationship was the main
instrument of my therapeutic work with this girl, which
followed the principles outlined by Melanie Klein. This means
that both the negative and positive aspects of the transference
relationship were taken u p and that reassurances were not given
other than the ones that were implicit in the analytic situation.
I did not offer food to my patient or reassure her that it was all
right to eat. I did not visit her in the hospital ward, or give her
presents, or reassure her against her despair that she was
untreatable and unlovable (the integration of this despair into
the fabric of her personality being a therapeutic aim). However,
I tried always to be on time for her sessions with me. I rarely
cancelled or altered her sessions and, as can be imagined, this
girl provoked much reflection in me, both in and out of the
analytic situation.
It will be seen that in this technique there is much emphasis
*I wish to express my gratitude to Dr Sydney Klein, who took medical
responsibility for this case, and was a great support to me during this girl's
treatment; in particular, in seeing, his role as receiving the anxieties which
came from outside sources, such as the parents, the nursing staff and the
paediatrician. In this protected situation, I was free to concentrate on my own
and the patient's anxieties.
 ..\IVOREXIA NERVOSA IN AN ADOLESCENT GIRL 241
gastro-enteritis. When father first came home there was a good
deal of tension between the parents, and mother said that it took
them a year to get adjusted to each other.
Until Margaret was six all the family slept in one bedroom.
When they obtained a council house Margaret had her own
room, but she was sometimes called in to help father to look
after mother when she was in an insulin coma.
At the time of referral the family consisted of mother and
father; Margaret, 13; Robin, 11 ; Dennis, 8; Jack, 6%. Mar-
garet and the boys were always quarrelling. Father openly said
that he preferred the boys and ignored and rejected Margaret.
However, when she was in hospital he visited her and brought
her presents. Mother reported that she and Margaret had a very
close relationship with each other, and that Margaret would tell
her how she hated father. She also said that Margaret was like a
younger sister with whom she could share everything.
However, in the treatment situation it became clear that
Margaret had strong hostile feelings towards her mother.
Mother had wanted to be a dancer when she was a young girl.
She had also wanted to have six children but, because of her
diabetes, she was sterilized after the birth of her fourth child.
Mother and father each had a close relationship with their
own parents, and each expressed resentment about this attitude
in the other. In short, it seemed that the family adjustment was
a good deal on the basis of one section uniting against another
section - boys versus girls - father versus mother - father's
family versus mother's family.
After the first history-taking interview neither of the parents
was seen by the psychiatric social worker. When the parents
were anxious they were seen by the psychiatrist who took the
medical responsibility for the case. I did not see Margaret prior
to the beginning of treatment. When treatment started I saw
her three times a week for sessions lasting half an hour, which
was the maximum amount of time 1 could give her due to my
66 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
associated, and where mental states are distinguished from
tangible 'things'. The shock of unbuffered awareness of bodily
separateness from the mother seems to have polarized and
fixated the autistic child's sensuous experiences at a tactile
level. He lives in a world in which tactile, sensuous opposites
such as 'hard' and 'soft', 'light' and 'dark', 'big' and 'little', 'full'
and 'empty', 'nice' and 'nasty', and so on, are felt to be in
opposition to each other. In the non-cooperative state in which
he is immured in which savage rivalry holds sway, he fears that
an opposing sensation will totally destroy its opposite: for
example, that 'darkness' will extinguish 'light', that 'emptiness'
will annihilate 'fullness', that 'bigness' will crush 'smallness',
that 'nastiness' will poison 'niceness'. If the 'nasty' sensations
cancel the 'nice' ones, he fears that he will be made into a
'nothing' - losing his sense of existence being the autistic child's
greatest dread. Such a catastrophe will be fatal. There will be
no hope of recovery from it. It is difficult to empathize with
these states in which qualities are experienced as fluids and
substances. For example, one autistic boy felt that by drawing
tall towers he could draw their 'tallness' into himself, and that
this 'tallness' would counteract his 'shortness'. Similarly
'shortness' could nullify 'tallness'. In these states, sensuous
perceptions seem to have been experienced as tangible 'things'
which needed to be controlled and manipulated so that they did
not crash into and destroy each other. If he fails in this rigid
manipulative control, the child feels that he will cease to exist.
It is only as an area of co-operation and reciprocity develops
that these opposing states can come into creative conjunction,
to transform and modify each other so that other more subtle
states are born.
Concluding note
Rereading Mrs Klein's pioneering paper has made me realize
how much those of us who work with childhood phychosis owe
to her far-sightedness (Klein, 1930b). It is primarily due to her
example and inspiration that some of us have had the courage to
do so.

CHAPTER FOUR
A significant element in the
development of psychogenic autism
Black was the without eye
Black the within tongue.
Black too the muscles
Striving to pull out into the light
Black the nerves, black the brain
With its tombed visions
Black also the soul, the huge stammer
Of the cry that, swelling, could not
pronounce its sun.
Ted Hughes, 'Two Legends', Crow
T
his chapter, which is a considerably revised version of
a paper published in the Journal of Child Psychology
and Psychiatry (1966) 7:53-67, concerns a particular
type of elemental depression manifested by autistic children.
Rank and Putnam (1953) used Edward Bibring's term 'primal
depression' (1953) for this type of depression. Winnicott (1958)
has called it 'psychotic depression'; Margaret Mahler (1961)
has written of such children's 'grief'. My own work has
confirmed that this elemental depression has been crucial in the
massive arrest of emotional and cognitive development which
afflictspsychogenic autistic children. Clinical material will now
be presented which illustrates the specific characteristics of
such autistic children's grief, and demonstrates why it has been
so damaging to their psychic development.
240 AUTISTIC BARRIERS IN NEUROTIC PATlEN7.S
almost untouched. She also would not eat any food which she
suspected had a speck of dirt on it. Her blood circulation was
poor and she suffered badly from chilblains in the winter. She
had not yet started to menstruate.
In her interview with the psychiatric social worker,
Margaret's mother dated the anorexia back to September 1955,
the beginning of the new school term when Margaret an-
nounced that she wanted to slim because she was afraid that she
would be too fat to take her dancing examination in November.
She had learned ballet dancing since the age of nine and already
passed one examination. She virtually stopped eating in spite of
bullying and coaxing from both parents. At the same time her
class were shown a sex instruction film and Margaret fainted.
She said that talking about or seeing blood made her sick and
that she did not wish to know about sex or menstruation. In
September, too, Margaret became very interested in an aunt's
pregnancy and also in that of a neighbour.
Father was in the Navy when Margaret was born during the
war. She was breastfed for four months when her mother's milk
stopped as a result of her anxiety and distress when she heard
her husband's ship was missing. She did not hear from him for
three months and was very depressed during this time,
although later she heard that he was alive and in good health.
Margaret did not take well to the bottle and was a sleepy feeder.
From then until she was ten years old she was a finicky eater.
After that, Margaret still had specific foods she would not eat.
One of these was sugar, which she refused after mother had
explained why she herself had to have sugar to prevent her from
going into an insulin conla. Mother frequently had to go to
hospital to be weighed because of her difficulties in stabilizing
on a diet.
Mother had started to suffer from diabetes when Margaret
was two years old. When she was three, father was demobilized
and mother immediately became pregnant with her second
child. During this time Margaret went into hospital with
 ANOREXIA NERVOSA IN AN ADOLESCENT GIRL 239
limia which is sometimes a marked feature of these cases. It will
also be apparent that although the onset of the anorexia
appeared to be sudden, in actual fact the ill~lesshad a long
history and was the expression of a deep-seated and long-
standing neurotic disturbance. This paper is an attempt to add
to our understanding of the factors involved in this disturbance.
In the preparation for writing this paper an analysis was
prepared of the full notes made during the first one-and-a-half
years of treatment. T h e material of each session was briefly
described in one column and my inferences concerning this
material were summarized in the adjoining column. It is from
these summaries that the following description has been pre-
pared. A graph (p.267) was drawn to show gains and losses of
weight during this period of treatment; As the description of
the treatment progresses, the patient's variations in weight will
be related to the unconscious phantasies which I inferred were
emerging in her relationship with me. I aim to give a simple
descriptive account of the work done with ohe patient, using the
minimum of specialized terms, so that therapists with training
different from my own will readily be able to compare their
experiences with similar patients.
Clinical materid
Margaret, the subject of this paper, was treated many years
before I saw Jean. She was thirteen when she was first seen on
16 November 1955 in the paediatric department of a large
general hospital. From there, after extensive physical in-
vestigations had revealed no organic cause for her non-eating
and loss of weight, she was referred to the psychiatric depart-
ment of the same hospital. Before she started psychotherapy
on 9 January 1956, Margaret weighed only 3 stones 13% Ibs.
She was cyanosed and the paediatric staff were convinced that
if she did not get immediate help she would die.
Her teachers described Margaret as a quiet, well-behaved
girl. Her mother confirmed this and said that from an early age
she hardly played with her toys, preserving them clean and
68 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
Clinical material
John's parents became worried by his lack of speech and the fact
that he seemed different from and slower in mental de-
velopment than other children of his age. When aged 2 yrs 6
mths, he was seen by a psychiatrist who feared mental defect.
However, on being seen again six months later John was found
to have made a small, hopeful development in that he now put
toy motor cars the right way up. (Previously, he had kept them
upside down all the time in order to spin their wheels.) On the
basis of this, John was referred for a second opinion to Dr
Mildred Creak, at Great Ormond Street Children's Hospital,
who had an international reputation as a diagnostician in the
field of childhood psychosis. She gave a diagnosis of autism,
and then referred John, now aged 3 yrs 7 mths, to me for
intensive psychotherapy with the following report:
There has been a failure almost from birth to take his
milestones in his stride, as if there were a reluctance and drag
back at each stage. He now shows so many of the attitudes we
associate with autism. His chief interest seems to be to tap
different surfaces, orto spin round objects. He is fascinated
by mechanical moving parts, and has always been quite
clever at learning to move his body. Although he is sure-
footed he still does not feed himself; not that he cannot - it
seems as if he will not. This is what I mean by jibbing at
milestones. He shows excessive anxiety at times, with days of
screaming, but this aspect is much less evident. He has no
useful speech, and only communicates very tentatively by
trying to use your hand. Nevertheless, I felt sure he was
capable of making a primitive contact at this sort of level, and
that therefore there was something on which one could build
an attempt at therapy. My deepest anxiety is as to whether
the basic determinant of all this may be an inherent degree of
mental retardation.
A 'bad family history on the paternal side' was reported.
Father's only sister was a hospitalized schizophrenic, and there
 T H E DEVELOPMENT OF PSYCHOGENIC AUTISM 69
were other eccentric and psychotic relatives. It was also
reported that there had been 'tremendous strain' between the
child's mother and an aunt who had been mainly responsible for
the care of the father during infancy and childhood. John was a
first baby. On the physical side pregnancy and birth were
normal, but the mother, who came from a remote village in
Europe, had been upset by what she felt to be the foreign
procedures of an English maternity hospital.
She also felt that the nurses prevented her and the baby from
getting together in a good feeding relationship. She had a great
deal of milk and was very disappointed when breastfeeding
could not be established. T h e baby seems to have been a poor
sucker and the mother reported that for one week after birth he
did not open his eyes. When mother and baby left hospital they
went to live with the paternal aunt. Again, the mother felt she
was prevented from getting together with her baby, this time by
the interference of the aunt. The father was working in another
town for the first few months of the baby's life and the mother
was insecure and unhappy during this time, but her depression
was not such that she had to have treatment.
When I saw the parents, they reported that John had had no
traumatic experiences such as separations or serious illnesses.
He had shown little reaction to the birth of his sister when he
was eighteen months old, and had always been a quiet baby.
They could give no details about the time at which he first held
up his head or sat up, but in the locomotor sphere his
development seems to have been quite normal. They began to
worry when he failed to learn to talk, and by the strange nature
of his play. Bizarre hand movements were reported; he moved
his fingers in front of his face in a queer, stiff way. He could not
be to put pencil or crayon to paper. Soft fbods would
be eaten but he rejected hard lumps. He seemed to confuse his
mother's mouth with his own. Bowel and bladder control had
not been achieved. I had the impression that the mother had
had special difficulty with this aspect of childcare.
Remembering her own childhood in which she had exper-
238 A U T I S T I C B.4RRIERS I N N E U R O T I C PATIEN'TS
The literature
As early as 1694 Richard Morton wrote of anorexia nervosa as
'nervous consumption' and regarded the 'immediate cause of
this distemper' to be in the 'system of the nerves'. T h e early
papers on anorexia nervosa, notably those by Laskgue (1873)
and Gull (1873), were concerned with establishing the prime
importance of emotional factors in its causation. Both papers
give descriptions of the strikingly consistent clinical picture
presented by such patients. Later papers accept the psycho-
genesis of anorexia nervosa, and two important American
papers, one by Rahman, Richardson and Ripley (1939) and
the other by Waller, Kaufman and Deutsch (1940), demon-
strated, by comparative studies of several cases, that such
patients show similarity in regard to personality traits, phan-
tasy life and the importance oi specific details in the family sit-
ati ion, as well as in the symptomatic picture they present.
In 1948 D r Clifford Scott wrote of anorexia nervosa, '... as
yet little has been done to try to. trace specific connections
between the symptoms and the instinctive life, the imagination
and the interpersonal relations.' My aim is to try to trace such
connections by describing the emotional processes which
seemed to be associated with the fluctuations in weight and
eating difficulties in an adolescent girl who was diagnosed as a
severe case of anorexia nervosa, and which were observed in the
context of a particular therapeutic technique. I shall not be
concerned to advocate a particular method of therapy.
Following the description of the case, the work of other ther-
apists using different but intensive techniques will be quoted.
I hope that this comparison of the material obtained in long-
term treatments may throw light on the unconscious processes
that are called into play in shorter forms of treatment or in the
cases which clear u p spontaneously. It may also help to explain
why so many relapses occur after apparent cure. T h e
fluctuations in weight of my patient, and the unconscious
processes which seemed to be associated with them, may also
help us to understand the oscillation between anorexia and bu-

Anorexia nervosa
in an adolescent girl
I've built walls,
A fortress steep and mighty
That none may penetrate.
I have no need of friendship.
Friendship causes pain.
It's laughter and it's loving
I disdain
I am a rock,
I am an island.
I have my books
And my poetry to protect me.
I am shielded in my armour,
Hiding in my room,
Safe within my womb
I touch no one, and no one
touches me.
I am a rock,
I am a island.
And a rock feels no pain,
And an island never cries.
70 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
ienced, on the death of her father, the deprivation of living
mostly away from home in an institution, she spoke of her
impatience at being a child and her longing to be grown up.
The referring psychiatrist gave intermittent but important
supportive help to the parents (although, sadly, this was no
longer available when the psychiatrist retired). They needed
this support, because when the treatment 'holding situation'
(Winnicott, 1958) was ruptured on various unfortunate oc-
casions, John had screaming attacks and sleeping difficulties
which they found very difficult to bear. The parents were
sensitive, intelligent people, and it says much for their concern
for John that they maintained support for the treatment during
these times and brought him regularly. Without this, the
present relatively satisfactory result could not have been
achieved.

Paul Simon, lyric to 'I am a Rock' Course of treatment

John was aged 3 yrs 7 mths when he began treatment. At first
he came once a week, later three times, and finally five times a
week. On his first visit he was expressionless. He went past me

T
his lyric by Paul Simon was given to me by Jean, the
anorexic patient discussed in Chapters 12 and 13. She
said that it expressed how she felt. It illustrates the
similarity between the states experienced by an anorexic patient
and those of autistic children. Margaret, the patient who will be
discussed in this chapter, experienced the primal depression
which lies at the root of autism (see Chapter 4).
This was my first clinical paper, written in 1958. I was
treating autistic children when I was working with Margaret
but, at that tirne, I had not realized the connection between
anorexia and autism. However, it is implicit in the clinical
material as it unfolds. Here is the paper as it was published in
the British Journal of Medical Psychology (1958) 3 1 :184-200 ;
some minor editorial changes have been made.
as if I did not exist. The one moment when this was not so
occurred in the consulting-room when he pulled my hand
towards the humming top which I spun for him. At this, he
became very flushed, and leaned forward to watch it spin. As he
did so, he rotated his penis through his trousers whilst his other
hand played around his mouth in circular spinning movements.
This suggested to me that he made little differentiation between
the movements of the top and those of his own body. He exuded
a quality of passionate, sensuous excitement. It convinced me
of the importance of maintaining the analytic setting and
interpretative procedure if I was to be gradually distinguished
from his primitive illusions, and to do my work as a therapist
who would help him to come to terms with his sensuous
excitements and disillusionments. From now on, I kept to a
bare minimum my compliance with the actions he pressed me
to do. I made simple interpretations, interspersing them with
 T H E DEVELOPMENT OF PSYCHOGENIC AUTISM 71 236 A U T I S T I C B A R R I E B S I N N E U R O T I C P A T I E N T S
the few words the parents had told me he might understand. that there is an outer structure which helps them to bear what
These were 'John, Mummy, Daddy, Nina [his sister], pee-pee, had previously seemed unbearable. These unbearable sensa-
baby, potty, spin, spinning'. I repeated the interpretations in tions had seemed to gush out in an uncontrollable way which
several different ways, and occasionally used actions to sup- had undermined their self-confidence. As these are felt to be
plement my meaning - although I kept these to a minimum held and contained, the children begin to develop hopefulness
when I sensed that they were interpreted by him as seductive or and a sense of purpose.
threatening approaches. Clinical material was r!so presented to illustrate the dawning
The following are extracts from detailed notes which of an awareness that the actual body image is a cohesive entity
illustrate John's responses to interpretations. The first reported which has permanence in space and time. As the body image
session is one in which he used his first word with me. It begins to have more consonance with the actual body, a more
occurred after the Christmas holiday (he had begun treatment secure sense of existence an3 identity develops. T h e child
in November 1951.) John had no pronouns, so that this, and his begins to feel that he has a name and that he is an individual in
limited vocabulary, restricted what could be said in the his own right. All this is associatcd with becoming related to the
interpretations, although I had the impression that he un- therapist as the 'breast' of infancy. T h e development of mental
derstood much more than was implied by the restricted vo- imagery also contributes to the reassurance of the continuity of
cabulary he was reported as knowing. existence. Recollection, reverie and representation become
possible. Thus, the 'aloneness' and the isolating 'loneliness' of
Friday 10 Janua y 1952: Session 9 John now came three being an 'I' are assuaged.
times a week. This was his last session of the week. I quote
verbatim from my notes: 'As he had done since his second
session, he began by playing with the humming top. On the
basis of previous material, as well as the manner of his play in
this session, I interpreted that he was using his hand to spin the
Tustin top so that he could feel that John was Tustin and
Tustin was John. Thus he could feel that we were always
together.'
Immediately following this, he took out the mother doll and
handled the bead that joined the handbag to her hand with the
same circular movement with which he had handled his penis in
the incident with the humming top. After tapping the mother
doll he threw her to the ground, saying very plainly 'Gone'. (I
interpreted that John was spinning the mummy's bead as if it
were his pee-pee to feel he could go right inside the mummy
bag, but then he felt it made her into a 'gone' mummy.) He
immediately picked up the little girl doll, turned her round and
round and ground his teeth loudly. (I interpreted that John was
 THE DEVELOPMENT OF 'I-NESS' 235
Freud, the cotton reel incident and the mirror play occurred at
about the same time. For Antonio, there was a gap of one year
between the two incidents.
Jonathan Miller has observed that 'The body image is
laboriously constructed as we move our limbs.' As infants,
autistic children are very passive and do not move their limbs as
much as a normal infant. This may be one reason for the
elementary nature of their body image. Studying the stiff and
halting development of the body image and the sense of being
an 'I' of psychogenic autistic children cannot but impress us
with the complexity of the task achieved by normal infants
without their ever being aware that it is taking place.
Conclusion
In discussing the significance of the body image in the
development of a secure and authentic sense of 'I-ness', an at-
tempt has been made to write from the patient's point of view.
This has meant that this chapter has been an empathic rather
than a theoretical contribution. It has sought to show that
primordial states of sensation are of basic significance in the
development of the body image and of the sense of self. T h e
difficulty of communicating about such non-verbal states by
means of words has been recognized.
However, it has been felt that the needs of some of our
patients drive us to make the attempt, just as their needs drive
them to try to communicate about them to us. In an endeavour
to understand such communications, clinical material has been
presented to show that impulsivity, in these early states, seems
to be experienced in such terms as rushing water or explosive
bodily fluids and gases. In treatment, as the children encounter
the hardness of frustration in a sane and caring setting, and as
they feel that the uncontrollable 'waterfalls' and 'volcanoes' of
their impulsivity are received, processed and understood by
another being who has both sensitivity and robust common
sense, their body image begins to feel more substantial and
intact. They begin to feel that they have an inner structure, and
72 A U T I S T I C BARRIERS I N NEUROTIC P A T I E N T S
spinning into the mummy's bag to bite the girl baby, but then
he felt he made the girl 'gone' and the mummy 'gone'.)
He now took the baby doll and put it in the cot which he
turned upside down so that the baby fell out. (I interpreted that
he was spinning into the Tustin mummy bag to upset her babies
because he wanted to be her only baby.) Following this, he
worked the top inside the suitcase provided for his toys,
pressing the point into some soft plasticine strips in the bottom
of it. Once he touched the baby doll and said 'Baby' or '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 wandering so
that I was in danger of complying with some unspoken request
and thus behaving as if I were a part of his body or a toy, instead
of a mature, thinking person who was trying to help him to
come to terms with his feelings. Other workers have found that
this is a not infrequent occurrence with such 'atmospheric'
children. Later, I found it helpful to interpret to him that he felt
he spun inside my head to make my 'brain children' 'gone', so
that he could feel that I was a 'softie' with whom he could have
all his own way.)
In the above material, we see the beginning of his
disillusionment arising from the fact that I can be 'gone', both
in the sense of not attending to him, and in the actual bodily
sense of being separated from him. This meant that I was not
under his control. This was developed further four weeks later,
when he spoke two more words. Again it was in the last session
of the week.
Fn'day 9 February 1952 :Session 23 Mother and John had
rung several times before I could manage to get to the door to
open it. As they stood on the step they looked cold and frozen.
John had stopped rattling the letterbox; on previous occasions
I had had the impression that he felt he controlled me to come
to the door by doing this. He mournfully repeated 'Dirty' after
 T H E DEVELOPMENT OF PSYCHOGENIC AUTISM 73
his mother, as she looked into the orifice of his ear. In the
consulting-room he tried to spin the top on the soft carpet. It
would not spin. Violently thrusting his hand into mine, he tried
to use it as an appendage to his own hand to make it do so. It did
not. Spitting with rage and breathing heavily, he threw the
offending top to the ceiling. It just missed the electric light.
With a crash it fell to the ground and broke into two halves. The
inside fell out. Shocked, he went to it and said 'Broken!' and
'Oh dear!' in a grief-stricken way. He spent the rest of the
session hopelessly trying to mend it. It seemed that depressing
realities were penetrating the autism.
There now followed a confused period in the analysis
(February - April 1952). During this there was the attempt to
make people and things behave in a way,which ran counter to
their real nature, as in the incident with the humming top. The
toys and myself seemed to be manipulated as if they were his
excreta or parts of his own body. During this time he spent most
of the sessions lying on the couch playing with his penis, and
with his own faeces and occasional bits of plasticine, which
hardly seemed to be differentiated from faeces. There was also
nose-picking and spitting.
This ceased after the three-week Easter holiday in April.
This was his second long break in treatment. He now developed
an obsessional habit of tapping a button on a cushion and saying
'Daddy!', 'Daddy!' (his father was away from home during this
time). This, and the toy he called 'the red daddy bus', played a
large part in the analysis during this period. There were
tantrums when he realized that they were not part of him and so
could go away and leave him. Following this, he would say
'Broken!' 'Gone!' 'Oh dear!' very dolefully (May- June 1952)
His first use of the personal pronoun came after he had broken
the 'red daddy bus' in such a tantrum. He said, 'I mend it! I
mend it!' (Session 118).
Monday 26 November 1952 : Session 130 One day, after
changes in the routine of bringing him, he was distressed when
234 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
the delusion of encapsulation which shuts out stimulation;
schizophrenic-type children do it by seeming to enfold
themselves inside the mother and other objects; some deprived
children develop a precocious use of words, and others an
intellectual precocity (James, 1960).
Autistic children are full of terrors and misconceptions. T h e
misconceptions concern their body image and do not help to
alleviate the terrors. This hampers the development of a normal
sense of self. In his vivid way Jonathan Miller (1981) speaks of
the normal body image as being 'the translucent glove of the
possibility of self'. His BBC television series was based on
findings from work with patients who had had bodily
amputations or neurological surgery, as was Paul Schilder's
fascinating The Image and Appearance of the Human Body
(1935). This chapter has been based on findings from children
whose psyche had been damaged, either by being exposed to
reality too harshly and too early, or by being over-protected
from it so that, in everyday parlance, they were 'spoiled'.
For all these children, their body image seemed damaged.
This meant that their sense of self was damaged also. It
is encouraging to find that, with insightful and dedicated
work, this damage can be remedied, at least in certain young
psychogenic autistic children. With treatment which is
appropriate to their needs, they can be enabled to work over
body image processes which should have taken place in infancy.
However, they do this in a somewhat different way from the
normal infant. In the clinical situation, developments can be
observed taking place in a slow and stilted way which occur
much more rapidly and at a much earlier age in the normal
infant. For example, eight-year-old Antonio's play with the toy
sheep which he makes come and go is similar to the play of the
eighteen-month-old baby recorded by Freud in Beyond the
Pleasure Principle (1920), who made a cotton reel appear and
disappear over the side of his cot. Also, nine-year-old Antonio's
play with his image in the mirror is similar to the play of Freud's
eighteen-month-old infant. However, in the infant observed by
 TIiE D E V E L O P M E N T OF 'I-NESS' 233
around this time that Antonio began to refer to himself as '1'. He
had begun to have a sense of self. He was no longer autistic.
The clez!elopment of mental imagery It seems tenable to
assume that Antonio's body image was beginning to have more
consonance with the appearance of his actual body. He was
also realizing that through memory, recollection and
representation, objects (of which he is one) can have continuity
of existence, even though they may not be present to be seen,
touched and handled. Things that have been seen and cnjoyed
can, in Wordsworth's words, 'flash upon that inward eye which
is the bliss of solitude'. T h e 'aloneness' of being an 'I' can begin
to be tbierated. Individuality begins to become established.
Later, as the glaze of complacency begins to crack and bland
assumptions are given up, self-acceptance gradually becomes a
possibility. But this is another story.
The development of 'I-ness' in normal
and autistic children
T o continue with the theme of this chapter, Margaret Mahler
uses the metaphor of 'psychological birth' to denote the
dawning of a sense of self. In terms of normal development,
she sees this as beginning in early infancy, and as going on
throughout life. Antonio had to wait until he was eight years old
to begin this important process, a necessary condition for which
is the feeling that impulses experienced as dangerous fluids and
gases can seem to be received, contained, recycled, regulated
and appropriately directed, so that spontaneity is not damaged.
Thus, 'waterfalls', 'volcanoes', and suchlike uncontrollable
'overflows' do not break the creative healing flow between
caregivers and child. There are channels of expression for
them. Emotional attachment becomes established. Emotional
and co-operative relationships can begill. Until this takes
place, the attempt is made to control these dangerous 'over-
flows' by various ineffectual means. Autistic children do it by
74 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
his father, who had now returned home, nearly missed his
footing on the front steps as he was waving goodbye to John
after leaving him for his session. During this session, John
seemed to be trying to maintain that the movements of his body
could keep his father alive. (For example, he jumped up and
down on the couch, saying 'Daddy mended! Daddy mended!'.)
At the end of the session, when he found that his mother, not
his father, was waiting for him, he screamed 'Daddy! Daddy
gone! Daddy broken!' Following this incident he had a severe
nocturnal screaming fit. It was reported to me that in it he had
said such things as, 'I don't want it! Fell down! Button broken!
Don't let it bite! Don't let it bump!'
With hindsight, I realized that these nightmare screams
expressed infantile terrors which had been active in relation to
the father, the red toy bus, and the button on the cushion, all of
which had been felt to be identical with each other. They were
not symbols for the father, they were felt to be the father who
was undifferentiated from his bodily parts (Hanna Segal(1957)
has written of such symbolic equations). But as long as the
terrors were scattered in this way, I could not sufficiently un-
derstand them to help him to come to terms with them.
A session which occurred fifteen months after treatment
began will now be reported in detail. In this session terrors
which had been adumbrated in previous sessions were brought
together, and John was able to use representations by means of
words and toys to tell me about them. He could do this because
people were now being distinguished as people instead of being
used like inanimate objects, such as toy buses, buttons and the
like. Thus the autism was much diminished and representa-
tional activities were beginning,
25Januavy 1953 : Session 153 (Before giving this session, I
should say that in December John had seen a baby feeding at
the breast and had shown great interest. I had not used the word
'breast', not knowing whether he knew it. It now came into his
material.) He carefully arranged four pencil crayons in the form
 THE DEVELOPMENT OF PSYCHOGENIC AUTISM 75
of a cross and said 'Breast!' Touching his own mouth, he'said
'Button in the middle!' (I interpreted baby John's desire to
make up a breast for himself out of his own body.) He then put
out more pencils in a hasty careless fashion to make a
ramshackle extension to the cross. T o this he said, 'Make a
bigger breast! Make a bigger breast!' (These children feel called
upon to be extra-ordinary, and so they feel they need an extra-
ordinary breast. In the session I interpreted baby John's desire
to have a bigger breast than really existed.) He angrily knocked
all the pencils so that they spread in a higgledy-piggledy fashion
over the table. He said 'Broken breast!' (I interpreted his baby
anger that he could not have a breast as big as he wanted.) He
said, 'I fix it! I fix it! Hole gone! Button gone! Hole gone!
Button gone!' (I interpreted his baby desire to have a breast he
could make or break as he pleased.) He again angrily pushed the
pencils all over the table and said, 'Broken!' He then opened
and shut a wooden box with ear-splitting bangs. (1 interpreted
his baby anger that he couldn't have a breast with which he
could do as he liked.)
He said 'Broken' again and went to the umbrella stand which
is in the consulting-room; he put his hand into the glove cavity
which is in dark shadow. He shuddered and said, 'No good
breast! Button gone!' (I interpreted that he felt that his anger
with the breast that would not behave exactly as he wanted it to
do made him feel he had a 'no-good breast' with a hole instead
of a button.) He went to the case and fetched a piece of dirty
grey cardboard and a crocodile. He put them on the chest he
had banged. He pointed to the Sellotape round the edge of the
cardboard and said 'Icy! Icy!' Then he said, 'No good breast!
Button broken!' He slid the crocodile around the cardboard as
if it were slithering on ice. His face went cold and pinched. ( I
took up his feeling that breaking the breast made an icy no-good
breast which was no comfort to him when he was on his own.)
Now that the infantile transference was well established and
the anxieties were 'contained' in the analysis, his behaviour
outside showed great improvement. He was eager to come to
232 . \ U T I S T l C B A R R I E R S I N N E U R O T I C P A T I E N T S
The representation of himselfand other objects In recognizing
the mirror image and the photograph as representations of
himself, Antonio was moving towards the notion of 'self-
representation'. Related to this, important new developments
took place in his sessions with Maiello. Antonio showed that he
was realizing that if he were to make a representation of an
object, the image he had in his mind had to have some
consonance with the external appearance of the object, even
though his representation was in a different medium. In a
beautifully detailed piece of observation Maiello records this
important step of progress as follows.
Suddenly with great determination, Antonio fetches a sheet
of paper and the scissors, and begins to cut the paper. I feel
that he is cutting out something, the image of which he has in
his mind. He cuts a strip of paper and then cuts it into four
rectangles. He is sitting on the floor with his legs wide apart
and puts the rectangles in a line in front of himself between
his legs. Then he looks at the chest of drawers and copies the
arrangement of its drawers, two on top and two underneath.
He repeatedly looks at the original until his reproduction is
perfect.
Then he starts cutting more rectangles, always four from a
strip. If there happen to be five of them, he throws away the
fifth one. On his left-hand side, he makes other copies of the
chest of drawers, with the paper rectangles. When doing the
first two copies, he looks at the prototype between his legs to
check that it is correct, but he never returns to looking at the
actual chest of drawers to check the correctness of his
representation. Finally, the other copies are done without
looking at the actual chest of drawers or at the prototype
between his legs. He does these last ones 'by heart' - 'from
memory'.
Maiello says that it was as if he had a central 'matrix'. It was
 THE DEVELOPMENT OF 'I-NESS' 231
Antonio's play at home, and also from his activities in later
sessions. The parents' information concerned Antonio's
interest in the external appearance of his body, as distinct from
his subjective proprioceptive image of it.
The external appearance of the body The parents reported
that Antonio would play for hours looking at his image in a long
mirror and then obliterating it with soapy water. He would then
wipe the mirror clean so that his image reappeared again. At
first Antonio may have thought that it was another boy who
appeared in the mirror, but since the parents also reported that
during this period of mirror play he had recognized a
photograph of himself, he must have come to realize that the
mirror image was of his body. Mirrors are very magical things
to children. In the world of 'through the looking-glass' all sorts
of impossible things seem possible. By covering his mirror
image with soapy water, Antonio could break it up and make it
'gone'; on cleaning the mirror, the image would reappear again
as a whole object. Perhaps he felt that he could do the magic
which Maiello had done with the concertina lion. Certainly,
through this play, he could again feel in control of things being
'there', and of things being 'gone'.
However, there were also reality gains from his mirror image
activity. It must have been reassuring for him to find that
although the mirror image became obliterated, his actual body
remained. He was becoming aware of the actuality of his body,
which had continuity of existence in time and space. He was
realizing that he had an actual body which was different from
his subjective body image. This body image was insubstantial
as compared with the solid reality of his actual' body. In
Kleinian terms, as well as 'unconscious phantasies' about his
body, he was realizing that he had an actual, substantial body.
He was developing the notion that he was a real live, substantial
boy, of whose mirror image and photograph he could say 'That
is me.' He was beginning to feel that he existed as an '1'.
76 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
analysis and made good progress in spite of family illness,
changes in the routine of bringing him, and family be-
reavements. He began to admit his dependence and help-
lessness, and would say of things that were beyond his powers,
'I can't do it! Please help me!' This progress was maintained
when his mother and younger sister went abroad and he was left
with his father. An unfortunate break now occurred in the
'holding situation' (Winnicott, 1958, p.268).
Friday 5 April 1953 :Session 194 I showed him, by means of
a diagram, the day he would come back to analysis after the two-
week Easter holiday. Family circumstances made it impossible
for his father to bring him back until one week later. In ad-
dition, he had been left for one week with the aunt with whom
they lived. When he came back I was appalled. He seemed
traumatized and frozen. He had a stiff-legged mechanical gait.
What speech he had left was stammered. He was indeed in the
grip of the 'icy, no-good breast'. This had provided no comfort
for 'poor little baby John left all alone on an island', as he put it
later.
As the bodily tensions relaxed, the night-time screaming fits
became such a regular occurrence that the referring psychiatrist
prescribed a sleeping draught. During the screaming fits he
would hallucinate birds in various parts of the bedroom, and
say some of the phrases he had used in his first screaming fit.
The birds threatened to peck him and were a great source of
terror.
However, he gradually began to bring the infantile terrors
back into the analysis. He again proceeded with the dif-
ferentiations he had been making ever since his first word of
'Gone!' He continued to relate to his father in a more real way,
and less in terms of a 'thing' like a button that could be broken.
He accepted that space and time separated him from me. He
put experiences into categories such as 'nice' and 'nasty', and
people were classified as 'naughty' or 'sensible' according to
whether they did what he wanted them to do. There was the
 THE DEVELOPMENT OF PSYCHOGENIC AUTISM 77
beginning of the differentiation between fact and fantasy. He
would sometimes say 'It's a story', or 'It's not really true'. He
now told me in more detail the illusory terrors that had given
rise to the cryptic phrases in the screaming fits.
He began to associate the misuse of objects with their being
broken. For example, of the humming top he said :'It's broken!
Tops don't go on the carpet.' At the end of sessions he some-
times hinted that he felt I left him because he had a part
missing, or because he was a 'stinky little goat'. Sometimes he
would make as if to break off his 'stinkers' (his word for the
hard faeces that hurt his anus), and pretend - a significant
development - to drop them down the front of my dress.
Sometimes he got rid of his own feelings of silliness by calling
his father 'silly' and 'naughty', and to his sister, Nina, as to me,
were assigned all the nasty experiences he did not want himself.
Thus he demonstrated clearly the fantasy of breaking off
unacceptable parts of himself and thrusting them into other
people.
Tuesday 28 January 1954 : Session 360 The effect on his
psychic development of having his projections contained by
understanding was again shown by his use of the pencil crayons
which he arranged to make a 'breast'. This was the first time he
had done this since the previous occasion eight months earlier,
before the unfortunate separation experiences. He pointed to
the carefully arranged pencils and said 'Breast!'Then, touching
his own mouth, he said, 'Button in the middle!' Then he st009
a pencil in the middle and said 'Rocket!' He called the whole
thing a 'firework breast'. This linked with the drawing of a
dome-shaped object with brown and red 'stinkers' coming out
of it which he afterwards called 'fireworks'. (This had been
drawn following a tantrum when I would not let him use my
hand as if it were his own.) Holding his mouth as if it hurt, he
said, 'Prick in my mouth!' Then, 'Falls down!', 'Button
broken!', 'Nasty black hole in my mouth!' Then in an alarmed
way, he held his penis and said, 'Pee-pee still there?' as if he
230 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
realizing that there was the possibility of having a cohesive
outside body which could be a whole object with characteristic
form and shape and a name which distinguished him from other
objects. However, this material poses many questions. Was
Antonio realizing that two things could look alike, and could
even have the same name, but could be different in certain
ways? (The concertina lion was different from the play material
lion.) Was he feeling that with Maiello he could feel that he was
a whole boy -because she held and understood his explosive fit
of temper - whereas at home he still felt that he fell apart when
he was angry, and then felt that he was put together in the
wrong way? (It will be remembered that the concertiria lion was
from home and the other lion belonged to the play material
provided by Maiello.)
Why could he not look at Maiello's efforts to reassemble the
concertina lion? Was it that he felt that it was a much more
complicated task than making the paper tunnel and that he
could not bear to look at the complication because it brought
home to him his dependency on Maiello? Was it that he wanted
to bluff himself that he had done it himself and, if he watched
her, his bluff would be called? Was he envious of her capacity
to be constructive, and wanted to negate her efforts? Did he not
look because he was feeling that the concertina lion was akin to
his body image, which could not be seen and could seem to
be dismantled? Was the more intact lion akin to the outward
appearance of his body? Was he feeling that there was a
discrepancy between the illusory 'private phantom' formed
from bodily sensations, which was more ephemeral than the
substantial reality of his 'public body', to use Jonathan Miller's
terms? T o put it in another way, was he realizing that his 'felt-
self' was different from his outside body, which seemed more
intact and more permanent? Was a deeper idea of his bodily
separateness developing? Was he beginning to distinguish more
clearly between inner and outer reality?
Following the lion material, the answers to some of these
questions were provided by information from the parents about
 THE DEVELOPMENT OF 'I-NESS' 229
The development of a more cohesive body image When he was
eight years old, and in a fit of temper due to some frustration,
Antonio dismantled a toy lion which he had brought from
home. This lion was made of plastic sticks assembled in such a
way that it could be stretched and shortened like an accord-
ion. After an interpretation from Maiello, based on Donald
Meltzer's concept of 'dismantling' ( Meltzer et al., 1975),
Antonio tried to put the lion together again. But he did it in such
a haphazard way that it became 'a bizarre object' (Bion, 1962b).
In the next session, Antonio took the ill-assembled lion
to pieces and, collecting the parts together, put them into
Dr Maiello's lap. Since he was obviously asking for help, she
proceeded to put the lion together in the proper way so that it
looked like a lion. However, whereas he had been able to look at
Maiello making the paper tunnel through which the toy sheep
had gone back and forth, Antonio could not watch her putting
the concertina lion together again. He turned his back and went
into a far corner of the room whilst she did it. When it was
finished, he examined the put-together lion and then fetched
another toy lion, which was part of the play material Maiello
had provided for him, and which could not be taken to pieces.
He compared it with the concertina lion and then gave it the
name 'lion'.
Maiello comments: 'I felt that Antonio took it as a sort of
proof that an object which has been dismantled and has fal-
len to pieces can become a whole object again that functions
properly, and can look like other objects of the same species;
and furthermore that, being a whole object, it could have a
name.' In fact in the following session, Antonio took the key of
his drawer and detached the label which was hanging on it. He
then proceeded to write his surname and Christian name on this
label. However, although he said his name correctly, it was
w ~ t t e nin a haphazard jumble of the letters of his name similar
to the ill-assembled lion.
Discussion of the lion material Antonio was obviously
78. A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
thought it was not. (In the session which followed, he said of
the broken humming top, 'Broken top! Nasty peoples coming
out to blow me up!')
Wednesday 29 January 1954 : Session 361 Material then
came about his 'stinkers' burning and piercing the button and
making 'a black hole in my mouth'. I asked him about the black
hole. He answered simply, 'When naughty things are burned
they go black.' Following this he said sadly, 'My nice dreams
turn into nasty dreams', and then, brightening up, 'I have my
nasty dreams with Tustin.' One day the screaming fits, the
cryptic phrases and some of the previous fantasies all came
together into one session.
Thursday 6 February 1954 : Session 367 H e was in a
screaming tantrum when I opened the front door because he
had fallen and bumped his head. There was no sign of damage,
but he seemed panicistricken as well as enraged. When he
stopped crying I took him to the consulting-room. Without
taking anything from the case of toys, he went to the table to talk
to me. He said, 'Red button gone! It fell with a bump!' H e then
indicated both his shoulders with a semi-circular movement
and said, 'I've got a good head on my shoulders. Can't fall off.
Grows on my shoulders.' He then said, 'It was the naughty
pavement, it hit me.' (I said I thought that he was trying to tell
me about his fears when he fell down just now.) Touching his
own mouth, he said, 'Nina's got a black hole. She had a prick in
her mouth. Button broken! Nasty black hole!' (I should have
interpreted here that these were his own nasty experiences of
which he was ridding himself by attributing them to Nina, but
I birked it.)
He took the plastic tractor, which was a toy he had attacked
remorselessly. He touched the plastic axle, which is not in
reality sharp. However, he touched it, gave a huge shudder and
said, 'Nasty hard tractor, it pricks.' He spat as though spitting
out something that was repugnant. He then screwed himself up
 T H E DEVELOPMENT OF PSYCHOGENIC AUTISM 79
and screamed loudly. (I reproached myself for not having
attempted to put his feelings into words, and so possibly spared
him from having to express them in violent action.) In his
screaming he pushed away flying beaks. I was afraid that
he would fall off his chair, so I took him on my knee and
interpreted through the shrieks, The interpretations concerned
his feeling that the button was part of his mouth and the
destructive feelings he had when he found that this was not so.
He then felt he had a 'black hole' and a 'nasty prick' instead of a
nice button. He felt he spat the nasty thing into the girl baby
whom he felt had taken the button away from him. But then he
felt that she tried to spit it back at him and her nasty mouth
seemed like flying birds. (We had had material where he had
equated the flying birds with mouths.) Without the 'button' he
felt that they could hurt him. He was afraid that he might lose
his head or his penis, as he felt he had lost his button.
For two sessions after this he was afraid of certain objects in
the consulting-room: one was the dark glove cavity, another
was a penis-like pipe near the ceiling, a third was the 'dirty
water bucket'. (This room had no water plumbed in, so there
was a jug of water and a bucket for dirty water.) After these
sessions the night-time screaming stopped. (It came back after
a particularly worrying holiday, and when the question of
ending treatment was being discussed.) The hallucinations
subsided and did not, so far as I know, trouble him after this:
Closure note Treatment came to an end when John was aged
6 yrs 5 mths. This was earlier and more sudden than I would
have liked, but the parents were urging that he finish,
particularly as his need for psychotherapy was not now so ob-
vious. He attended a school for normal children. He was
making friends, enjoyed school, and was learning avidly. He
had a vocabulary beyond that of most children of his age, but
this was not surprising since his parents were both intelligent
people.
He was still a 'finicky' eater. In times of stress he was inclined
228 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
the French psychoanalyst mentioned earlier. Dr Maufras
records: 'Louise had in her hands a little tube. She put her left
index finger into the hole of the tube and then into her left ear-
hole with a thoughtful expression upon her face. Immediately
after that, she put her right index finger into the hole of the tube
and then into her right ear-hole.' It seems tenable that Louise
was wondering whether her ear-holes led to tubes in her head,
similar to the tube in her hand.
In an original and interesting paper, 'The notion of a
psychotic body image in neurotic and psychotic patients', an
Argentinian psychoanalyst, Dr David Rosenfeld, brought con-
vincing material from adult patients to show that, in very
regressed states, their body image was a system of tubes which
were felt to control the flow of body fluids. Dr Rosenfeld (1981)
suggests that this seeming containment of body fluids by the
body image as a system of pipes is a more elementary body
image than that described by Dr Esther Bick, who has written
(1968) of the containing function of the skin. Dr Didier Anzieu,
a French psychoanalyst, has also written of the containing
function of the skin in the development of the sense of self, and
coined the phrase 'moi-peau', the 'me-skin' (Anzieu, 1974). My
own clinical work confirms that the body image as a system of
pipes is more elementary than the image of the whole body
being contained by the skin. However, the 'system of pipes'
body image implies awareness of 'insides', and also awareness
of outside situations and identification with them. It is a
movement away from undifferentiated autism to a transition-
al awareness of 'me' and 'not-me'. Transitional activities are
becoming possible. However, Maiello's patient was also
moving from his body image as a system of pipes, to a
proprioceptive awareness that his body had cohesive form and
shape bounded by a skin which gave it an outline. He began to
realize that his body was one object amongst other objects
which had identifiable forms and shapes and distinguishing
names.
 THE DEVELOPMENT OF 'I-NESS' 227
Indeed, 'tunnel' was his first word. On one occasion, he used
the carpet as a tunnel and crawled through it several times, as
Maiello says, 'with great involvement and concentration'.
When he came out of the carpet tunnel into the light after the
long crawling in the dark, there was 'an expression of deep
surprise on his face'. Later in treatment he did the same thing
with a small toy sheep which he made go through a paper tun-
nel. As it emerged he greeted it with an exclamation of 'Here it
is!' in a tone of both 'relief and confirmation of an expected
event'. Antonio was obviously gaining reassurance that both he
and the toy sheep could still exist even though they were out of
sight and were not being looked at.
His Berkeleyan notions were being modified. He was
realizing that things had continuity of existence apart from
being seen by him. The horrors and despair of non-existence
were being dealt with. Thus, hope was becoming a possibility.
These developments took place partly as the result of reality
testing, but also through Antonio's feeling that through play, he
had control over the comings and goings of things - of things
being 'there' - and of things being 'gone'. A few sessions later,
play developed in which he showed that he was beginning to
realize that things could be out of his control, but could still
exist. This concerned his interest in the water pipes.
The body image as a system of pipes Antonio became very
interested in the water flowing out of the outlet hole in the
wash-basin down the outlet pipe and under a grating in the
floor. He also put his ear to the pipe which channelled the rush
of water when the toilet was flushed. The existence of the water
in these pipes could be inferred, but it could not be seen nor
directly controlled by him. There were also indications con-
cerning the nature of his body image during this period. As he
was washing his foot he asked 'What is in my foot?', as if it
seemed a logical inference that it too might have water pipes.
A similar comparison seemed to be being made by a nine-
month-old infant described by Dr Anik Maufras de ChBtellier,
80 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
to stammer and to have sleeping difficulties. These remaining
symptoms made me want to continue, but since there were
signs that he was moving into latency, and since I felt that the
parents very much wanted to have John to themselves, I agreed
to the cessation of treatment, with the proviso that it might be
advisable to seek further help in adolescence.
Follow-up It has only been possible to get information about
John in a somewhat roundabout way. T h e parents of
encapsulated autistic children seem to want to forget the whole
experience once it is over. This is in marked contrast to the
attitude of parents of symbiotic (entangled) children, who keep
contact with the therapist. John's parents did not seek further
help. 1 have heard that John attended public day school at the
normal age and did well. Later he obtained a good university
degree. He has developed into a sensitive young man who is
very musical.
Discussion
John's experience of pi'ef' Such a child's descriptions
are probably the closest we can get to crucial, panic-stricken
experiences concerned with grief about the loss of a vital object,
which John called the 'button'. This was his experience of the
nipple of the breast which he had taken for granted, and indeed
had not known that it existed, until he discovered that it was not
always there. When he became aware that it was not there,
overwhelming feelings of disillusionment were aroused, the
essence of this grief-provoking situation being partly expressed
in his first words of 'Gone!', 'Broken!', 'Oh dear!'. These
ejaculations expressed evocations from his infancy, when the
loss and seeming destruction of the 'button' had been felt to
leave a 'black hole with a nasty prick'. This was John's pre-
sent day formulation for the previously undifferentiated,
unformulated, insufferable experience of sensuous loss which
had precipitated the autism. Seeing the baby feeding at the
breast had evoked the whole system of illusion which had set
 THE DEVELOPMENT OF PSYCHOGENIC AUTISM 81
John's autistic reactions in train. He was now able to get
sufficiently in touch with this experience to put me in touch
with it also. Being preverbal, it is difficult to discuss in words;
evocative rather than theoretical language seems most
appropriate to describe it.
Recalling the two sessions in which he represented the breast
with coloured pencils (Sessions 156 and 360) it will be remem-
bered that the 'no-good breast' with the hole becomes the
'firework breast' with 'stinker' rockets discharged into it by him-
self. T h e firework, rocket-like discharges had been felt to go
into a 'hole' - into a nothingness - instead of being received by
a human presence who responded to them in an appropriate
way and helped him to manage them. These are very early
infantile experiences, in which 'feelings' are experienced in a
bodily tactile way as sensations of various kinds. When the 'but-
ton' will not stay in John's mouth to be under his control and to
be available just whenever, and however, he wants it, he
becomes discombobulated. I n panic and rage, the aggravat-
ingly 'naughty' 'button' is felt to be discharged from his body
like spit or faeces. It seems to leave a 'hole' in the breast where
the 'button' had been. Since his mouth had been undifferen-
tiated from the breast, it leaves a 'hole' in his mouth also. T h e
burning sensations of rage make it into a 'black hole'. (As John
says, 'When naughty things are burned they turn black.') Put-
ting these preverbal experiences into words distorts their origi-
nal nature, but both John and I felt that it had to be done, if we
were to come to terms with them. 'Acting out' is often the first
way in which such primal dramas find expression. But follow-
ing this way of dramatizing them in psychotherapy, words are
necessary if the impulsive discharges are to be contained by
thinking about them. As this is done the patient feels that a part
of himself, which had previously reacted impulsively in terms
of powerful illusions, is being brought within the orbit of
thoughtful attention and understanding care.
Autistic patients like John have felt assailed by nameless
dangers, some of which will be discussed in later chapters. In
226 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
jects. He practically did not speak, but produced some
inarticulate sounds every now and then, and did not usually
react to my interpretations.'
In the fluid, gaseous, floating state which has been described
in the first part of this chapter, Antonio climbed to quite high
up, using the wooden frames of the door and windows to do
this. He was extremely skilful and fearless in so doing. A change
came when Antonio became afraid of flying birds with whom he
obviously felt equated. In various ways he showed Dr Maiello
that he wanted her to put them (him) in a cage, because he was
afraid that they (he) would fly higher and higher and be gone.
Maiello records, 'It seemed to him that it was important to
remain down and inside the room where I was,' Maiello did not
put her patient into a cage but, by her dedicated attentiveness,
consistent behaviour and relatively unchanging setting, held
him in her attention. This prevented him from slipping away
from her like the flying birds. As the result of this, rewarding
changes began to take place. One of these was the development
of imagination and fantasy.
The development of imagination As Antonio experienced
being held firmly but understandingly, he virtually stopped
climbing. He became aware that although he was restricted by
the boundaries to the room, he was also held safely by them. He
also became aware that there were closed doors to rooms into
which he could not enter. This frustration stimulated the
development of imagination. Sometimes he imagined that there
were wonderful Maiello things in the closed rooms; at other
times, there were threatening things. The development of
imagination is a necessary prerequisite for the secure establish-
ment of a body image from the early flux of uncoordinated
sensations. This, and the development of memory, helps to
establish the feeling that there is continuity of existence.
The continuity of existence Antonio showed the development
of this realization by some interesting activities with tunnels.
 T H E DEVELOPMENT OF 'I-NESS' 225
disillusionment of the Fall from the seeming perfection of
continuous, silky smoothness into the broken gritty darkness of
lack of perfect satisfaction in the exact terms they desire. But for
some infants, for a variety of reasons, this fall from grace has
been experienced as a catastrophe. This can be due to con-
stitutional factors in the infant, or to environmental ones, or to
a mixture of both. Interchanges seem to break down. T h e
seamless robe of perfect perfection seems rent with holes. In
neurotic children, in the terms of this chapter, the development
of a sense of 'I-ness' has been disturbed, in psychogenic autistic
children it has been stopped, by catastrophic happenings to the
'felt-self'.
In psychoanalytic treatment we have to set these trans-
forming interchanges going again. Dr Genevitve Haag, a
French psychoanalyst, has shown us that the children indicate
that these remedial interchanges are beginning to take place by
drawing a cross in which two lines of equal lengths intersect
each other. It is ,her finding that when they draw this, the
autistic children are beginning to have a body image which has
a supporting, inner bony structure (Haag, 1983).
The early body sense has been illustrated by Jean's and
Pierre's material. Clinical work with another psychogenic
autistic child will now be presented to illustrate the working
through of these states, and the more secure establishment of
the body image. With this comes the development of a sense of
personal identity and the use of the pronoun '1'.
Clinical example 3
Antonio is currently being treated by Dr Suzanne Maiello, who
works in Italy and who discusses her work with me from time to
time. Antonio was referred to her when he was five-and-a-half
years old, and is being seen three times a week. Antonio's was
obviously a severe case of psychogenic autism; Maiello records
that when she first started working with him, he was completely
closed up in an autistic state (1982). She writes :'His large green
eyes seemed not to see, and to slip away from me and from ob-
82 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
order to feel that these dangers were kept at bay, they have
needed to feel in control of what happened to them. When they
find that they are not in control but, in reality, are weak and
helpless, they are devastated. This is well illustrated in Session
367, in which the 'naughty' pavement got out of control and 'hit'
John. In this session it was clear that he felt he had lost a part
of his body. In his relatively undifferentiated state, he was not
sure which part had 'gone'. Was it his head? His penis? Or was
it that sensuously exciting 'button'? I had the impression that he
experienced his screams as solid, piercing tangible objects; his
mouth emitting them as a round black hole. In later sessions,
not presented here, he told me that he avoided looking at
people's eyes, 'because of the black hole in the middle'. As these
agonies and terrors about the 'black hole' were worked over in
the analysis, John began to look at people's faces in the way a
normal child will do.
T h e material presented implies that in the relatively
undifferentiated state, phallic and anal sensations were drawn
into the primary oral experience, which seemed to affect every
orifice of the boy's body. His body, fretted with sore black
holes, seemed to face an outside world which was pitted with
similar black holes. Empathic identification with John put me
in touch with the wordless elemental dramas which had pro-
voked the psychogenic autism. These illusory dramas arose
from sensations in his body, the 'button' being the product of
these bodily sensations.
Let me now discuss this 'button' and the role it played in the
development of John's psychogenic autism.
The button It is obvious, in terms of John's early sensuous
experience, that the 'button' was something more than the
actual nipple of the breast or teat of the bottle. Other objects
which had similar shapes, or aroused similar sensations, had
accreted to it. It was an illusion which could be different things
at different times. T h e core of the sensation experience was a
 T H E DEVELOPMENT O F PSYCHOGENIC AUTISM 83
'teat-tongue' combination. This arose from the lack of clear
differentiation of his mouth from the breast. (You will
remember that in the referral notes John was reported as
confusing his mother's mouth with his own.) Later his penis,
his head, his 'stinkers', a toy red bus, a button on a cushion
and even his 'Daddy' were all drawn into this 'teat-tongue'
combination, probably on the basis of their common sensation
of hardness. I t is difficult for us, as differentiated individuals,
to get in touch with such undifferentiated modes of operation.
In these states objects which, in sensuous terms, have a rough-
and-ready 'clang' similarity with each other are grouped
together and treated as if they were the same.
In undifferentiated states, the tendency is to be aware of
similarities rather than differences. Thus, objects which, to our
more differentiated awareness, seem very unlike are ex-
perienced by the relatively undifferentiated child as being the
same. T o a young child, a boiling kettle and a steam train may
seem to be the same as each other, because the thing that is
important to him is the steam. For John, I suspect hardness was
what was important to him, because hardness could protect him
from the terrible dangers by which he felt threatened. Thus the
nipple, his penis, his head, his stinkers, a pipe in the therapy
room, a button on a cushion, the toy red bus, and his 'Daddy'
all evoked the same reactions.
It is not that they are similar and so can be used to represent
each other. They are felt to be the same. In John's un-
differentiated state the button on the cushion and the toy red
bus evoke the same sensations as Daddy does. They did not
represent Daddy, they were felt to be Daddy because they
evoked the same hard sensuous in~pressionas Daddy did
(Session 130), hardness being the trigger sensation. But, so far
as John is concerned, these objects had another thing in
common as well as hardness - they could all be broken. T h e fact
that they were not unbreakable, in spite of being hard, fills John
with grief and despair. His desperate efforts to keep himself
224 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
these deep levels, it becomes evident how much the homely
sayings of everyday speech have been influenced by them.)
Autistic children often walk on their toes and seem to float
rather than walk. In this floating state they feel that they can
perform remarkable feats such as flying, climbing to great
heights, or walking on a tightrope high above the ground.
Indeed, they often do some of these things. For example, An-
tonio, whose clinical material is to be presented later in this
chapter, did some very skilful climbing to considerable heights
in the early days of his treatment. Also, when I worked at the
Putnam Center in Boston, Massachusetts, there was a little
autistic girl who walked on a very high tightrope. Such autistic
children perform these hazardous feats without any realistic
sense of danger.
Paradoxically, however, they are beset by fantastic, illusory
terrors. For example, in their fluid, gaseous states they are
afraid that they will explode or be spilled through holes. Being
spilled or exploded means emptiness, extinction, nothingness.
The delusions associated with autistic objects are very operative
at this stage. One function of these is to seem to block up holes
through which 'me-ness' can spill or erupt. The slippery
smoothness of the fluid state can seem threatened by floods,
waterfalls, whirlpools, eruptions and the like, which arouse
primitive terror.
Elsewhere (Tustin, 1972, 1981) attention has been drawn to
processes which I have called 'flowing-over-at-oneness'. These
processes are seen as contributing to the sense of 'primal unity'
described by Freud. Two Italian workers with psychogenic
autistic children, De Astis and Giannotti (1980), have shown
that these early interchanges between mother and infant heal
the rupture of the caesura of birth.
Winnicott (1958) has pointed out that, in early infancy,
interchange is based on illusion. The illusion seems to be of a
continuous, rhythmical ebb and flow. In infancy this healing,
cleansing flow between mother and baby can seem to be broken
in a violent and catastrophic way. All infants suffer the
 T H E DEVELOPMENT OF 'I-NESS' 223
series in 1981, 'The Human Body', Jonathan Miller expressed
the idea that 'the felt image is a fiction - an imaginary space -
rather like a jelly mould.' T h e outside world is cast in this
mould. Building with bricks in the middle of the waiting-room
indicated that Pierre felt that his body had something solid
inside it so he could face the terrors of the lava-filled passage
leading to the consulting-room. Thus, he did not need to flop
down. He was beginning to feel that he had an inner structure
which could support him and, as a result of his analyst's
firmness and consistency, could feel that there was also an
outside structure which could do this. T h e Tennyson verses
quoted at the head of this chgpter implied that this was ne-
cessary for the sense of being an '1'. It was also necessary to
avoid madness or the wrong, terrible kind of 'isolation'.
Both pieces of clinical material indicate that Jean's and
Pierre's impulsivity was coming under control. They were
beginning to become psychologically toilet-trained. This meant
that they could communicate about their terrors. Because he
had a more secure sense of his existence, Pierre could begin to
feel that he had a secure body image. Previously, he had felt that
he could dissolve and be 'gone'. He had been a mass of body
sensations with no feeling of solidity and substantiality.
The signifkance of the early body sensations
T h e thesis which is being developed is that at first, the 'felt-self'
is experienced in terms of fluids and gases. This is not
surprising, since the newly born infant has emerged from a
fluid medium and his early food and excretions are associated
with fluids and gas. As Spitz (1960) has pointed out, the
neonate has to adjust from being a water creature to being a
dweller on dry land. This is quite a big adjustment, and it is to
be expected that sensations associated with floating in a fluid
medium will linger on to become part of the early body image.
Autistic children often show that they feel that they are
floating. For them, getting in touch with reality is felt quite
literally as 'coming down to earth'. (When we become aware of
84 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
absolutely safe have failed. None of us likes broken things, but
to the hypersensitized autistic child a broken thing is not merely
a mishap, it is a catastrophe.
John's behaviour is not puzzling when we realize that the
primary mode of organizing our experience is by means of
classification. We sort things in terms of the characteristics they
have in common. John's method of classification is strange to us
because he sees things as being the same which, to our more
differentiated awareness, are very different. For him, objects
are sorted in terms of their hardness or softness. Looked at from
this point of view, John's behaviour becomes more under-
standable. In terms of his sensuous reactions, there is logic to
his seemingly strange behaviour and puzzling statements. We
need to try to think as he does, if we are to begin to understand
him.
This classifying of objects and experiences in terms of
sensuous,!y significant features which they have in common also
seems to be responsible for the relatively undifferentiated
autistic child's confusion of the configurations of nipple-in-
mouth, stool-in-bottom and penis-in-vagina. In these children,
due to the lack of an adequate capacity for differentiation, as
well as to the precocious arousal of auto-erotism, oral, anal and
phallic constellations become confused with each other in a
polymorphous way. This results in the homosexual tendencies
of untreated autistic children. An important part of psy-
chotherapy is the sorting out of such confusions.
In. studying autism we find that we are studying the
beginnings of perception. The phenomenon of the 'button'
seems to arise from inborn nipple-seeking patterns of response
which take shape again in treatment. It is obvious that such a
nipple-seeking pattern will promote breast - or bottle feeding.
Piaget's observations of his own babies complement and
confirm inferences derived from psychoanalytic work in respect
of this (Piaget, 1954). For example, when Piaget hid a feeding
bottle or a toy stork with different parts of the body left
showing, he found that it was only when the teat of the bottle or
 T H E DEVELOPMENT O F PSYCHOGENIC AUTISM 85
the beak of the toy stork were left exposed that the young infant
would search for the object; that is, nipple-like objects
promoted his response. Clinical work has made me think that
such inborn responses are like 'feelers' which reach out into the
outside world to mould, and be moulded by, it. In my first book
Autism and Childhood Psychosis (1972) 1 suggested the term
'innate forms' to describe them. The 'button' is the result of
such an innate form.
Innate fonns These will also be discussed in Chapter 9. They
seem to be flexible sensuous moulds into which, at an elemental
level of psychic development, experience is cast, and which are
modified by the experience so cast. When an innate form seems
to coincide with a correspondence in the outside world, the
child has the illusion that everything is synonymous and con-
tinuous with his own body stuff. In primitive states, pat-
ternseeking tendencies are active but, since discrimination is
minimal, any one part of the subject's own body, or other
people's bodies, or objects in the environment, can seem to be
the same. Thus the nipple can be felt to be part of John's body
because fingers can be equated with the innate form of nipple;
the knob of the humming top could match this form; penis,
tongue, 'stinkers', and so on could all be equated with it and
with each other. Such unmodified equivalents led to bodily
confusions which presaged later mental ones. In this state, live
and inanimate objects were treated in almost the same way: for
example, the father could be a button on a cushion and the same
things could happen to him. In the confused period of the
material presented, it seemed that John used parts of his body
- and outside objects as if they were parts of body stuff - for the
manipulation of what later could become abstracted as mental
concepts; much as a child uses fingers or sticks to do
arithmetical processes which he later becomes able 'to do in his
head'.
In these early days, when the fact of his separateness from me
was forced upon him, words seemed to be experienced by John
222 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
that he was building with bricks in the middle of the waiting-
room floor, Previously, he had either been flitting around the
room in a floating sort of fashion, or sitting quite still beside the
person who had accompanied him to the clinic. Also, unlike on
other occasions, he now walked purposefully down the corridor
to the consulting-room with an upright back as if he had
the sensation of having a hard backbone to support him. On
previous occasions, he had always flopped down outside the
waiting-room door and had had to be supported or half-carried
to the consulting-room (see Alvarez,, Anne, 1980).
On this day, Pierre also did an unusual thing in the
consulting-room. With great intent, he drew something on the
paper Dr Maufras had provided for him. He said that it was a
volcano. This 'volcano' had a passage-like space down the
middle of it through which, he said, the lava erupted. There
was also anxiety about some sugar which he saw dissolving in
water. Pierre was now able to tell D r Maufras about feelings
which had previously been inexpressible. T h e tension of
waiting for her to come, and the excitement to get to her room,
seemed to him as if his body passages were full of lava-like fluids
he could not hold in.
In previous sessions this lava had seemed to erupt and to
make him feel 'gone', so he flopped to the ground. In this state,
his sense of existence (of 'being') was tenuous. He feared that he
could dissolve away and be 'gone' like the sugar. Today, he had
been able to play with the hard bricks, which had enabled him
to wait and to make him feel stronger. He had been able to feel
that he had a hard backbone to support him. He had been able
to hold the lava-like sensations in check, to wait to represent
them on paper so that he could share thern with D r Maufras. He
felt held in her attentive awareness so that his overflow could be
anticipated and contained. He was less afraid of erupting like a
volcano and of becoming 'gone'. He was developing the sense of
having a firm body image.
Autistic children 'rubber-stamp' the outside world in terms
of their body image - their 'felt-self'. In his BBC television
 T H E DEVELOPMENT OF 'I-NESS' 221
possibility of developing relationships with other people is
emerging.
This half-way 'transitional stage' (Winnicott, 1958) will now
be illustrated by clinical material which demonstrates that
awareness of solid objects as separate from the body is a
necessary prelude to moving on from a predominantly fluid
'felt-self' to 'transitional' states. In such states there are felt to be
inner and outer structures which can contain and control
the fluids which overflow and become out of control. Lacking
such regulating structures, autistic children feel that they can
be trodden underfoot like an insect, as in Kafka's story
'Metamorphosis' which clearly described Kafka's own terrors.
Kafka's preoccupation with 'the Law' demonstrates the
psychotic's need for, but lack of, inner structure. Psychogehic
autistic children have tried to compensate for lack of this by the
delusion of hard external encapsulation. But they have become
entrapped by their autistic devices. Reactions which developed
to control the 'overflow' have resulted in damage to their
capacity to relate to others. With the establishment of inner
regulating and stabilizing structures, tension begins to be
sustained, and actions delayed until appropriate means of
expression are available. In such a situation, intentionality and
purpose begin to be manifested. The child begins to feel that he
has something solid and reliable to hold on to and to push
against.
Clinical example 2
Clinical material will now be presented to illustrate the be-
ginnings of a movement towards having an inner structure
which 'contains' and transforms raw impulses. A session is
taken from the therapy of a five-year-old psychogenic autistic
boy who is being treated by a French psychoanalyst, Dr Anik
Maufras de Chltellier, who discusses her work with me from
time to time. On the day in question, when D r Maufras went to
fetch Pierre from the waiting-room, she was surprised to find
86 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
as solid objects. When he was told about the ends of sessions, or
breaks in the treatment due to holidays, he winced as if
something had been stuck into him. These separations seemed
to be experienced quite concretely as broken things which
pierced his body. It is difficult to know how to discuss such
states, in which the singular feature is that feelings seem to be
experienced as physical entities. Absence was 'goneness' -
'goneness' was a broken thing - 'a black hole' full of a 'nasty
prick'. T h e observer might speak of 'depression', but for John
this was a 'black hole'; 'persecution' was a'nasty prick'; 'despair'
was felt as taking into his irreparably broken body an object felt
to be broken beyond repair. H e did not 'think' about these
things; he felt he took them into his body. When the all-
powerful, controlling 'button' was gone, uncontrollable dan-
gers rushed in in an uncontrollably painful way. These dangers
were experienced as tangible things. Also, the pain of pre-
verbal, preconceptual loss was experienced as bodily rather
than mental pain.
The 'black hole' This illusion was the significant element
which had set John's autistic reactions in train. This was what
was felt to be left when the 'button', and all that it signified, was
'gone'. T h e patient can only tell us about this experience when
it is over. When it is happening, he is frozen by it. It was re-
evoked for John when he saw the baby feeding at the breast.
This enabled him to work over his reactions to his breastfeeding
experiences. In so doing, he showed me the multiple sig-
nificances of the 'button'. Absence of the 'button' was not just
the absence of 'nice' things which we might intellectually expect
it to he, but it was a nasty physical presence - a 'black hole'.
When I asked John about this, he said: 'When naughty things
are burned they go black.' T h e uncontrollable 'button' was a
'naughty' button which had been burned away and turned
black, by the flames of his impulsive rage which he had never
been helped to manage appropriately. These children have
 THE DEVELOPMENT OF PSYCHOGENIC AUTISM 87
never become toilet-trained in either the psychological or the
physiological sense.
As well as being associated with feelings that John has not
been able to control, the 'button' is also associated with things
that will not be controlled by him, and so arouse his un-
controllable rage. It is associated with the top that will not spin,
my hand that will not spin it, the 'button' that will not remain
part of his body. These children lack sufficient experience of
hard 'Daddy' discipline being married to comfortable 'Mummy'
softness. They have been left alone to manage their outbursts of
temper aroused by frustration. In the outburst in which they
unburden themselves, they feel that they explode away a vital
bodily part. In their undifferentiated state they are not sure
which part it is, or whether it is theirs or another's. Thus as
John's fiery rage burned the 'naughty' object that would not do
as it was told, he felt that a bodily part was 'blacked out' also.
Was it his penis? Was it his head? Was it that sensuous 'titbit',
the 'button'? Was it broken off like his 'stinkers'? Was it the hard
'Daddy' bit? In his hypersensitized state, in which everything
was exaggerated, the results of his unheld tantrums were
experienced as 'catastrophe'. Bion (1962b) has shown that the
critical decision for psychic development is whether frustration
is avoided, or whether the attempt is made to come to terms
with it. Winnicott's transitional area of skills, 'let's pretend'
play, humour and aesthetic activities come into being when
depression about this catastrophe is experienced, and the
attempt is made to control the feelings aroused by frustration.
The child learns to sustain tension and to delay action.
In the clinical material presented here, we see John's at-
tempts to avoid frustration by explosive projection. On the
other hand, his first words of 'Gone!', 'Broken!', 'Oh dear!'
show that as soon as he developed even a limited capacity to be
in touch with the 'black hole', he began to develop speech
(Session 23). Later he was able to re-present his emotional
situation (Sessions 153 and 360). Such representation required
220 . 4 U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S
self-confident and self-reliant. She developed more initiative:
for one thing, she formed a relationship with a very suitable
young man. The terror of being at the mercy of her un-
controlled 'waterfall' feelings seemed to have been alleviated to
some extent. In a subsequent session, she told me that
'nowadays' she felt as if she 'had something solid to hold on to'.
Discussion of Jean's material I felt that in this session we
became in touch with a part of Jean's early experience which
had been sealed off but had continued to give her trouble. In the
depths, she felt fretted with terror and uncertainty. In this state
she felt as if she were a flux of sensations which were not
bounded or controlled. She had little sense of having a body
which contained them. In this state, unrelieved panic and
terror were experienced as being turgid with fluids which
overflowed in an uncontrollable, waterfall-like fashion. From
our adult point of view, the children are tense and impulse-
dominated. The child's experience is of being massively spilled
and overflowing in a rushing, uncontrollable way. It is the
essence of madness. With this capsule of madness at the base
of her being, Jean's sense of 'I-ness' was very impaired. She
had intense feelings of unworth. She felt 'no good', a 'non-
entity' - a 'nobody'. In the depths she feared extinction and
'nothingness'. In such a state she felt that she had a 'hole'.
Autistic objects - in this case, the inconsequential chatter -
seemed to plug the hole (see Chapter 6).
Later, when she talks about Alfred's reactions to being in
hospital, she begins to feel like a flesh-and-blood person who
can use a transitional object - the teddy bear - to solace her
loneliness and help her to feel held together and attached to
something. The development of this transitional area provided
an important half-way house between feeling that she was a
mass of fluids, which could slip or be taken away from her to
make her 'gone', and the sense of having a secure body image
and a sense of self which had continuity of existence. The
 THE DEVELOPMENT OF 'I-NESS' 219
she had looked after when she worked as a mother's help to a
family in her village, was now four years old. He had had to go
into hospital and was very depressed and would not speak to
anyone; he would only talk to his teddy bear. She said that she
had a similar teddy bear. I suggested that she was telling me
that long gaps in being away from me, as the mother to the baby
parts of herself, seemed like being in hospital seemed to Alfred.
She felt angry and depressed; she was feeling like this now; she
didn't want to speak to me and could only talk to her teddy bear.
However, I suggested that she had moved on from feeling like
a waterfall - a 'thing' - completely out of control, with no
boundaries and no solidity. She now felt that she was more of a
flesh-and-blood person with solid things to cling to, like a teddy
bear. But she wanted to ignore me, just as Alfred ignored
everybody. By so doing she felt that she could make me 'gone'.
In the baby depths, 'looking' was felt to make me exist, 'not
looking' was felt to make me 'gone'. She wanted to make me
'gone' because she felt that there was a fixed amount of the water
of existence and only one of us could have it in our jug. She felt
that we were in deadly rivalry for this vital thing. If she could
stop me from having it, she could have it. I went on to say that
these early baby feelings got in the way of co-operating with me
as a person from whom she wanted help, and to whom she felt
grateful.
All the way through this girl's analysis, predatory rivalry
(Gaddini, E., 1969) constituted the biggest hazard to the
establishment of a secure sense of self. Phantasms formed from
these unacknowledged, savage feelings 'dogged' each step of
progress as it seemed imminent. However, on this particular
day, after the above interpretation, the atmosphere relaxed, as
if - for the time being, at any rate - we had sufficiently worked
over the intense feelings aroused by the unduly long holiday.
Her next association concerned conflicts we had been working
on before the holiday.
It is significant that after this session there was a marked
change in Jean. She began to sleep better. She became more
88 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S
that his impulsivity should be beginning to be held in check,
and that he should be beginning to have some capacity to
tolerate his separateness.
T h e 'black hole' was John's experience .of 'primal' or
'psychotic depression'. As we shall see in Chapter 14, getting in
touch with and working over this depression was a crucial
situation for the anorexic girl's recovery. Getting in touch with
this depression is crucial in the amelioration of autistic states.
As one adult patient expressed it, 'You held me firmly so that I
did not "break out" and so my "breakdown" became a
"breakthrough".' Work with autistic children has brought home
to me that such patients need to be held in a firm but
understanding 'holding situation' (Winnicott, 1958, p.268).
The 'holding situation' I n earliest infancy, the coincidence of
innate forms with matching correspondences in the outside
world is the first 'holding situation'. Winnicott expresses this
when he says 'The mother places the actual breast just where
the infant is ready to create and at the right moment'
(Winnicott, 1958, p.238). Bion expresses the same idea when
he says 'A preconception mates with a realization' (Bion,
1962b). Mother and baby, teat and tongue, work together to
produce the illusion of continuity and to confirm it. T h e
'button' illusion seems to 'button' mother and child together,
and also to enable each of them to feel 'all buttoned-up'; falling
apart being an existential dread.
Both Winnicott (1958, p.238) and Milner (1956, p. 100) have
stressed the importance of ample opportunities for such illusion
in early infancy, and the dangers of a disastrous impingement of
awareness of bodily separateness. But coincidences cannot al-
ways be exact, nor can they always be forthcoming, and Bion
has increased our understanding of this early situation by
delineating the role of the mother as a 'container' for her infant's
burning rage, which is experienced as bodily discharge.
Lacking an adequate 'conta~ner',the f~erypass~ons of the
autlstic chlld have been covered by the ~ c cap
e nf a ~ ? ~ 9m~ !.c h
 T H E DE\'ELOPRIENT OF PSYCHOGENIC AUTISM 89
a child is like a volcano waiting to erupt. When an autistic child
starts having tantrums he is beginning to recover. How he is
held through these tantrums is important if the recovery is to be
sustained. He must never be left alone with them. We must 'talk
him through' them. Thus 'held', tantrums can be the
beginnings of creative responses. In the North of England, it is
common for a mother to describe her child's tantrums by
saying, 'He created something terrible!' What a common-sense
way to react to tantrums!
In early infancy the infant's lack of discrimination, and the
mother's adaptation arising from empathic identification with
him in the form of 'reverie' (Bion, 1962a, p.309), serve to
minimize the explosion-producing gap between primitive
illusions and actuality. This empathic reciprocity at first fosters
the illusion of bodily continuity, and then gradually ac-
climatizes the nursing couple to the dimly apprehended fact of
separateness. It enables the mother to support her infant
through the turbulence arising from awareness of separateness;
separateness which seems to be experienced as a break in bodily
continuity - as a loss of a part of the body. Changes of state, for
example, from 'button-in-mouth' to 'button-gone', inevitably
bring tensions, tensions experienced as bodily turgor, to be
relieved by bodily discharges. A mother with unbearable,
unformulated infantile insecurities, and little support in
bearing them, finds it difficult to.take such projections from her
infant. I n a way, both mother and child are too alike in their
reactions.
Such a mother easily succumbs to attacks on her capacity to
pay attention to her infant -to hold him in her awareness. Such
attacks may come from her own infantile 'privations', or from
outside events and people, or from her infant's atmospheric
reactions; it is usually a combination of these. They mean that
her attention is gone, her mind wanders just as mine tended to
do in one of the reported sessions (Session 9). It seems that if a
mother, through no fault of her own, is absent-minded, the
'holding' situation' (Winnicott, 1958, p.268) is broken just as
218 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
she lost all sense of having a body- of existing. She said that this
interpretation had been very meaningful to her. I pointed out to
her that the fear that she would lose her existence was even
worse than being afraid that she would die from bleeding to
death. If she died, at least she would leave her body behind, but
if she stopped existing, it would be complete annihilation,
nothing would be left. She would be a no-body - a non-entity.
After a short pause, she reminded me of a remark she had
made in the first phase of her analysis about something which
we had both recognized to be an illusion. She had said, 'I know
it's an illusion but the terror is real.' 1 replied that I thought this
applied to the terror of losing her existence - of becoming a 'no-
body'. She knew that it was an illusion but the terror was real.
However, realizing that it was an illusion could help to mitigate
the terror to some degree. There was silence whilst I felt that we
both thought about this; I broke the silence to ask her what she
was thinking. She said that she was thinking of the hymn,
Time like an ever-rolling stream
Bears all its sons away
They fly forgotten as a dream
Dies at the opening day.
Jean came from a religious background, so I said that to think
about a hymn was often comforting in states of terror. I went on
to say I had noticed, in this session, that we had both kept
referring to the previous phase of her analysis, before she went
to boarding school. Perhaps the unduly long Christmas holiday
had re-evoked the feelings she had had between the ending of
that first phase and her return to analysis now. She had told me
that during the time when she was at boarding school, and
afterwards, she had been afraid that I would forget her and that
she would forget me. She was showing me that, in the depths,
'forgetting' was the feeling of everything being spilled out of her
and out of me. She experienced this as losing her sense of
existence - of feeling 'gone'.
After a pause Jean went on to tell me that Alfred, the baby
 T H E DEVELOPMENT OF 'I-NESS' 217
The neurotic adult patient whose material is about to be
presented had to use images from her later, speaking ex-
periences to try to communicate about these primordial, non-
verbal, bodily states. The images indicated the fluid nature of
her early body experiences. They also expressed the un-
controllable nameless terrors of being 'gone' - of not existing -
which had been associated with these fluid states. Being
nameless and inexpressible, they had seemed to be the un-
stoppable. The terror of the unstoppable had interfered with
the development of a secure and normal body image, and thus
of a secure sense of identity.
Clinical example I
Jean was discussed in the last chapter, and you will remember
that at thirteen she had been severely anorexic but had re-
sponded well to psychotherapy. However, at the age of twenty-
one she had returned to psychotherapy because she had fits of
depression.
You may also remember that Jean said that she felt that we
were two jugs pouring water into each other, but that her jug
had a hole in it and water spilled out of it. She also said that she
felt as if 'deep down' she were a 'waterfall'; 'falling and falling
out of control' into a bottomless abyss, into boundless space,
into nothingness. She emphasized that it was the feeling of
being out of control, as much as the falling, which was so
frightening. Significantly, she added, 'I'm afraid I shall lose
myself.' (At this point I was reminded of an old lady whom I
used to visit in an old people's home, who always referred to her
afternoon nap as 'losing myself'; for example, 'I just lost myself
for ten minutes.' When she was in a confused state after being
moved into hospital, she said, 'I'm afraid I'm losing the image
of myself. ')
I responded to Jean by saying that I thought that 'deep down'
referred to experiences she had had very early in her life. She
seemed to be saying that in the beginning of her life she had felt
her body to be composed of fluids which could be spilled so that
90 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
much as by a traumatic geographical separation between
mother and baby. It is feasible that this 'holding situation' is
affected by the parents' relationship with each other, in that this
will affect the mother's responses to the infant who is the
outcome of that relationship.
A breakdown in the 'holding situation' means that the naive
infant is left to bear intolerable feelings alone. These seem to be
discharged into a void to come back at him with renewed force.
T h u s stresses and strains accumulate. Continuing to use his
own body as if it were another's body, and part of another's
body as if it were a lifeless part of his own, means that he
remains undifferentiated and cut off from alive human beings
who can help him with his troubles. Instead other people are
experienced as inanimate things to be manipulated in terms of
his needs and caprices. Thus John became more and more
enmeshed in the terrors and sufferings associated with the
illusion of the 'black hole'. T h e realistic fear of dying pales by
comparison with these illusory agonies and terrors.
T h e autism had been a reaction to deal with John's explosive
feelings in relation to loss of the 'button', for which he felt that
no help was forthcoming from the people around him. They
seemed to be as frightened of them as he was. But John had cut
himself off from such help as was there. In colloquial terms he
had 'cut off his nose to spite his face'. This had landed him in
serious trouble. As his autism broke down, these impetuous
outbursts, experienced as bodily discharges, were released
from their autistic wraps. As they were released, other elements
in the 'black hole' depressive situation were revealed. These
were mourning feelings.
Mourning feelings When I first encountered these feelings, I
found it difficult to believe that they could be possible at such a
primitive level of psychic development. Finally, however, the
evidence was so compelling that I had to face the fact, and help
John to face the fact, that he was mourning the loss of the ultra-
special 'button' which could never exist in reality. It was an
 THE DEVELOPMENT OF PSYCHOGENIC AUTIShl 91
illusion, but an important one. H e felt bereft of a very vital
thing. It was like a bereavement. When I was introduced to
Margaret Mahler's paper 'On sadness and grief in infancy and
childhood: loss and restoration of the symbiotic love object'
(1961), I was reassured that I was not reading feelings into the
child that were not there. I realized that the 'button' was John's
'symbiotic love object', the loss of which had rendered him
numb and dumb. As we worked this over together, we realized
that his 'crow-black' sulk about this loss had prevented him
from working over the disillusionment that the 'button',
conceived in his terms, was not available in the outside world.
Another type of baby would have reacted d#erently. As he
relinquished his unrealistic hopes of finding the superlatively
perfect 'button' in the outside world, it became established as a
psychic construct in his mind. This seemed to be the basis for
a more trusting relationship with me, based on more realistic
expectations. T h e therapeutic 'holding situation' seemed to
provide a 'cradle', in which John's baby self could go over early
unresolved psychic situations, and modify his unrealistic,
perfectionist, exacting demands, both of himself and other
people.
Conclusion
On superficial observation, organic and psychogenic autistic
disorders can look the same. However, on careful investigation,
it becomes clear that organic autism arises from gross damage
to the brain, whereas in the present state of our knowledge,
psychogenic autism seems to arise mainly from damage to the
psyche. In my view, psychic damage needs to be investigated as
meticulously as the neurophysiologists are investigating brain
damage. Global understandings in terms of unresponsive
mothers and unresponsive babies just will not do. If we are to
be able to help children with the handicap of psychogenic
autism, we need to have detailed insight into its nature. In
studying this, we find that we are studying the elemental
emotions associated with the beginnings of perception, and of
216 A U T I S T I C B A R R I E R S IN N E U R O T I C P A T I E N T S
investigation it becomes clear that their sense of existing as a
person is tenuous. In such patients, cognitive and affective
development seems to have taken place by bypassing a 'blind
spot' of arrested development which then becomes a capsule of
autism in the depths of their personality. In this capsule, as
in the overall encapsulation of autistic children, there are all the
potentialities for the development of self, but secure and
authentic self-representation has never been satisfactorily
achieved.
These neurotic patients can often put into words the
primordial non-verbal states in which the development of a
sense of self had been grossly impeded or impaired. Of course,
in this verbalization the nature of these non-verbal experiences
is somewhat changed. But patients are very motivated to try to
find words to express these non-verbal states as evocatively
and precisely as possible, and what they tell us (and what the
poets can tell us) is probably as close as we can get to a
description of such experiences. (The psychosomatic illnesses
of such patients are also often an attempt to give overt
expression to these body-centred experiences.)
Thus, the first clinical example to be used to develop the
theme of this paper will be taken from work with a neurotic
adult patient. It indicates the fluid nature of the early pro-
prioceptive body image and the part that these sensations play
in the establishment of a sense of existence, which is basic to a
sense of self. The term 'image' for these early states is, however,
somewhat of a misnomer since the child, at this stage, is
incapable of 'imaging' in the precise meaning of the word.
These early states seem to be a repertoire of relatively un-
coordinated sensations which are sensed rather than imaged.
And yet the best way for us to communicate about them is by
means of evocative imagery. In an interesting television
programme on the body image, Dr Jonathan Miller (1981)
coined some telling phrases, one of which, the 'felt-self',
describes the early situation very well. Of this, he said: 'The
felt-self is a private phantom housed in a public body.'

CHAPTER THIRTEEN
The development of 'I-ness'
The baby new to earth and sky,
What time his tender palm is prest
Against the circle of the breast,
Has never thought that 'this is I :'
But as he grows he gathers much,
And learns the use of 'I', and 'me',
And finds 'I am not what I see,
And other than the things I touch.'
So rounds he to a separate mind
From whence clear memory may begin
As thro' the frame that binds him in
His isolation grows defined.
Tennyson, In Memonam, X L I ~
n another form this was a paper published in Winnicott
Studies (1985) 1 : 3 6 4 8 . Its starting point was the fact that
a definitive characteristic of psychogenic autistic children
is the speaking children's non-use of the personal pronoun, and
the mute children's obvious lack,of personal identity. T h e
paper sought to study the impediments to their sense of being
an 'I,, and to illustrate some of the steps whereby this process
takes place during the course of psychoanalytic treatment.
Illustrative case material from the treatment of psychogenic
autistic children was presented to demonstrate the importance
of the body image in the process of becoming an '1'.
.Veurotic patients with a capsule of autisnt
Certain neurotic patients have much in common with autistic
children (Klein, S., 1980; Tustin, 1978). Such patients feel
that they are unreal and that 'life is just a dream'. On deep
92 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S
the ways in which perception can become blocked and
distorted. John's revelations give us some insight into this.
Later chapters will carry this understanding further.
Psychotherap-v with psychogenic autistn An understanding of
psychogenic autism is complicated by the fact that in the
elemental, relatively undifferentiated state in which psychic
damage occurred, such psychic damage is experienced as bodily
damage. Since subject and object are scarcely differentiated
from each other, the damage seems to happen to both child and
object. Both mother and child are felt to lose the vital 'Daddy
button' which holds them together. John, a young child
suffering from psychogenic autism, showed us the details of
this psychic damage. Such a child is in shock. H e feels
damaged, weak and helpless. T h e reaction, to counteract this,
has been to develop practices which give him the illusion that he
is impenetrable, invulnerable and in absolute control. Al-
though they look so passive, such children are little tyrants. In
colloquial terms, they are 'too big for their boots'. They need
firm but understanding 'containment', mixed with compassion
and common sense. They welcome this, for they are as unhappy
about their state as are the concerned people around them.
From what she told me, I had the impression that John's
mother was stunned by the beautiful baby whom she felt she
had lost, as part of herself, by giving birth to him. He was not
a real live baby to her, but a precious piece of Dresden china.
How hurting it would have been to her, and how far from the
truth, if she had been told by an 'expert' that she had a 'death
wish' towards her child, and that this was the cause of his
troubles. Some of the psychodynamicists have made grave
mistakes in their approach to autism. This chapter has been an
attempt to bring in evidence which corrects some of these
mistaken notions.
It has also been an attempt to get in touch with the elemental
feelings which have provoked the psychogenic autism. In
reality, what happened to the children was in the nature of
 T H E DEVELOPMENT OF PSYCHOGENIC AUTISM 93
a sensuous mishap, but in the hypersensitized, illusion-
dominated state of early infancy, it had become exaggerated to
seem like a catastrophe. But the feelings associated with this
illusion had been traumatizing. As one patient said to me, I
know it's an illusion, but the terror is real. I have found that
this early, seemingly catastrophic damage can be healed by a
form of psychotherapy which is realistic about the nature of the
disorder being treated. I have also found that insights gathered
from such psychotherapy have thrown light on the autistic
barriers encountered in certain neurotic patients.
214 .4UTlSTlC BARRIERS IN NEUROTIC P.4TlENTS
the connecting pieces such as the neck intact and in place.
His bodily movements became more co-ordinated, and his
speech more coherent. Steve was obviously well on the way to
achieving a cohesive sense of self. At which point we will leave
him in the capable hands of Madame Cauquil. Like Odysseus,
Steve is almost home to Ithaca where the faithful Penelope,
who understands the importance of weaving, waits for the
solitary traveller to return from his voyage of self-discovery.
This chapter has sought to show how seemingly inaccessible
patients can be helped to feel less immobilized by fears of
spilling and dissolving. Insights about these fears have been
culled from work with psychogenic autistic children. Work
with such children leads us to think about such ultimate things
as 'existence' and 'non-existence'. T h e children themselves are
not metaphysical philosophers but, if we are to help them, and
if we are to survive their onslaught upon our sanity, we have to
work within the framework of a developed philosophy, using a
kind of poetic science.
 SPILLING A N D DISSOLVING 213
CHAPTER FIVE
After this, Steve moved on to trying to find a more effective
way of managing his ungovernable feelings. He began to feel
connected to his therapist as if she were a washing machine. Situations which may
This went on for some time until finally, in a session before the
Easter separation, Steve drew a pipe on the blackboard such as
precipitate psychogenic autism
would connect the washing machine to the tap which supplied
the water. T h u s the cleansing 'washing machine Mummy' was So he took his birth-sneeze in one hand
connected to the 'Daddy tap'. But in his terrified state of And his death-chill in the other
anguished jealousy about the coming separation from his And let the spark scour him to ashes.
therapist, Steve erased the drawing of the connecting pipe so Ted Hughes, 'Crow Improvises', Crow
that the cleansing 'washing machine Mummy' was no longer
connected to the 'Daddy tap'. Unconnected to the Daddy tap,
the mother's capacity to function in a cleansing way was
destroyed. This meant that she could no longer function in this
way for Steve. His survival was at risk.
Fortunately, Madame Cauquil understood his fears suf-
ficiently to say to him: 'Are you afraid that you are gone, leaked
out, forgotten, when you know that we are to be separated for
Easter?' (You will notice that she has not harped upon the
destruction of the links, but has concentrated upon the fears utism is a pseudo-independent state in which the child
which led to their destruction.) Steve responded to this by
saying, 'And soap smells good.' Following this train of thought,
Madame Cauquil replied: 'Yes, that's true. T h e odour lasts and
A grimly and stubbornly goes his own eccentric way with
no attempt to adjust and adapt to other people's ways.
Parents' reports indicate that this is partly because the mother's
afterwards we can remember it.' confidence was being undermined in the baby's early infancy.
Wrapped around by the network of associations, mean- Thus it had been easy for the child to treat her as a manipulable,
ings and understandings that he and his therapist were weav- lifeless object who was a part of his body. Also, the father's
ing together, Steve no longer needed Madame Cauquil to influence, in many cases, was absent or excluded. Now let me
accompany him down the corridor which led from the instance a few situations which have caused the mothers of the
consulting-room to the waiting-room. His need to cling to her, autistic children I have treated to feel underconfident.
as a physica.1 object to protect him from spilling or floating
away in either water or air, was being moderated by the Undemttning situations for the mothers
establishment of fragrant memories which linked them together A large number of the mothers have reported that they were
in times of absence from each other. The space between them tlepressed before o r attcr the tlmc of the baby's b ~ r t h .
was beginning to be tolerated and connections could be made 5.ornctrrncs the fathcr had to be away d u r ~ n gthc tlme ot the
across this space. b ~ r t hand the nlottler had telt unsupported. In other cases there
In this period Steve drew a cohesive human body with all
 PRECIPITANTS OF PSYCHOGENIC AUTISM 95
were interfering relatives who undermined the mother's
confidence. Sometimes the parents had moved house around
the time of the baby's birth. In others, the mother was not living
in her native country and felt lonely and uncertain. In other
cases, mother and father were of different religious per-
suasions. Some mothers report the death of an earlier baby, or
have had a previous miscarriage, the emotional effects of which
were still being felt when the later, autistic child was in the
womb and was born. Other mothers reported that an
emotionally important person had died around the time of the
child's birth. In an underconfident and distressed state such a
mother is called upon to cope with an infant who, for various
reasons, needs especially firm and confident handling. The
situations which have just been described are not uncommon,
and do not usually lead to autism in the child. For autism to
develop, a special concatenation of circumstances has to occur.
The primary caregiver's state of mind and that of the rest of
the family will affect the developing mind of the baby. A
mother who feels lonely and unsupported may be unable to
respond adequately to her baby. She will not be able to absorb
the inevitable shocks which impinge upon him, such as finding
that the nipple is not a part of his mouth; changes from one
biological state to another, such as teething; or environmental
changes such as removal from one house to another, changes of
babysitters, etc. One recovering autistic child spoke of his
autism as a 'shock-proof habitat'. This prevented the im-
pingement of shocks and kept him safe, 'safe' being the
operative word. Autism is a reaction to promote a feeling of
safety when the infant feels that this is not forthcoming from
the outside world.
As we know, the newly born infant needs extra-special
attention. Winnicott (1958) has formulated this in his concept
of 'maternal preoccupation'. Bion (1962a) has enshrined it in
his notion of maternal 'reverie'. Masud Khan (1964) speaks of
the 'protective shield'. This special kind of attention can be
affected in various ways. Depression or harassment in the
212 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
Steve's uncontrolled and inarticulate outburst of panic and
rage about the frustration associated with anything which
prevented immediate and ever-ready direct access to the
mother disturbed the fundamental relationship he had been
establishing with 'girlie-Cauquil'. Fortunately, Madame Cau-
quil understood this desperate situation of terrified, possessive
jealousy well enough to help him with it for, apropos his play
with a fireman's truck, she said to Steve, 'Waiting for me to
come when I am with others is like a fire in the head.'
You will remember that in the poem quoted earlier, James
Greene wrote 'Whose brain is racked1And under fire ...' In
short, Steve felt possessed by passionate, fiery feelings about
the frustrations inherent in human relationships. These have to
become regulated if his 'thereness' is to be securely established
so that he no longer suffers the threat of dissolution and 'non-
being' which is not under his control. In an autistic state, if he
cannot feel fused with the mother, he would rather feel fused
with the thunder, as James Greene expressed it; even if, as in
the case of Semele who was destroyed by Zeus, it should lead to
extinction. We saw from Jean and from Louis MacNeice that
destruction brought about by themselves is preferable to ex-
periencing the uncontrollable, overwhelming terrors about
spilling away associated with bodily separateness from the
mot her.
Steve now showed his therapist how ineffectual his autistic
attempts to regulate his passionate feelings had been. At the
same time as he drew a body with a torso like a tube marked with
a graduated measuring scale, Steve filled a glass tube with his
spit which he called 'fuel'. This tube also had a graduated
measuring scale to check the level of the fuel. After a while, he
-said 'Tube broken'. Steve seemed to be aware that a rigid,
inflexible, self-made tube was not strong enough to bear the
violent ups and downs of his turbulent emotions, experienced
in terms of bodily fluids. He was also realizing that these
emotions were imporiant in that they 'fuelled' his activities, and
that to do this they must be regulated in an appropriate way.
 SPILLING AND DISSOLVING 21 1
Like many autistic children, Steve had had a depressed
mother in early infancy. He must often have felt that her
empathic, responsive connections with him were absent or
sagging. He must have feared that he would slip out of the focus
of her attention, and be gone forever. In his panic he clung to
inanimate objects and to his mother as an inanimate object. All
this was being repeated with Madame Cauquil. With no
separateness between them he cannot think or hold her in his
memory. Without memory he cannot develop a belief in the
continuity of existence, his own and other people's, and that of
objects in the outside world. Thus, he can never feel safe.
Without such 'basic trust' (Erikson, 1951) the painful im-
pingement of cutting his first teeth must have been a terrifying
event. Something was happening to him over which he had no
control. It sent him into convulsive fits of panic and rage. His
jumbled volcanic explosion of speech in the session before the
summer holiday now becomes more understandable.
It seems likely that Steve had been reliving, through the
medium of the transference, the cutting of his first teeth. In
present-day terms he felt that 'girlie-Cauquil' was 'bitten' and
'eaten' like 'meat', and then he felt that she was 'broken' and
'leaking'. He was afaid that she would leak away from him and
be 'gone'. In his state of fused undifferentiation from her, he
felt that he would leak away also. He felt that his solidity and his
'thereness' were evaporating. He was slipping away and losing
his grip on solid and secure reality. In his terror, everything
became jumbled together on the basis of rough-and-ready
similarities. Thus, I suspect that the long sausage-like thing
seems to Steve to be a 'mishmash' of 'red car - red nipple -
sausage - penis - Daddy -tongue', etc., all of which are felt to
be broken. It is similar to John's undifferentiated reactions to
the red button, the button on a cushion, car, Daddy, etc. T h e
important process of becoming 'rooted' which leads to the
capacity to make differentiations, and to become established as
a differentiated entity in their own right, has been interrupted
and muddled in these patients.
96 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
mother will affect the fantasies she has about her child both
before and after birth. The baby may not seem to measure up
to her expectations, or may seem to be the monster or
handicapped creature she had feared she would produce, or
may be idealized to such an extent that the mother feels that she
is inadequate for such a wonderful being. Mothers with recent
bereavements may be communing with departed spirits more
than with their alive, human baby. This is bewildering to the
child, who is called upon to comprehend something which is
outside his comprehension. All these are inevitable human
reactions on the part of both mother and child. We need to try
to understand them rather than make moral judgements. If, in
such circumstances, the child has autistic tendencies, the stage
is set for mother and child to become cut off from each other. In
some cases, something upsetting has also happened to the child
which has set autistic reactions in train. Once these have been
set going, they are difficult to reverse. Thus, he is a difficult
child to rear.
Now, having discussed distressing situations for the mother,
let me turn to disturbing situations for the child which, when
combined with other circumstances, may lead to autism.
Disturbing situations for the child
In some cases, autism has arisen after or during a debilitating
illness, or surgical intervention in infancy, especially if the
limbs have been immobilized (Olin, 1975). But obviously there
are many children who have suffered such experiences and who
have not become autistic. It is clear that for autistic reactions
to become established, a special combination of circumstances
has to coincide. Important factors in this are the child's own
constitutional tendencies and the emotional climate of the
family in which he is reared.
Also, it'seems that in situations of biological change the
pangs of bodily separateness are likely to be reactivated, and
thus may call forth autistic reactions. For example, De Astis
and Giannotti (1985) report that they have had several cases
 PRECIPITANTS OF PSYCHOGENIC AUTISM 97
where autism became manifest at the onset of teething,
although they suspect that there had been some fragility in the
mother-child relationship before then. An interesting, as yet
unpublished detailed observation of an infant by psychologist
Shirley Gault (1983) has brought confirmation of the part that
the advent of teething can sometimes play in provoking autistic
reactions in a somewhat insecure nursing situation. This
carefully documented observation shows how a seemingly
normal baby met a mother who, due to various external cir-
cumstances, gradually became depressed. At weaning, and
with the advent of dentition, it seemed as if the child were
destined to be autistic. Many specialists were seen, and
eventually deafness was diagnosed (wrongly, as it turned out
later).
This sent the already depressed mother into a downward
spiral of increased depression. The baby resorted to inanimate
objects, such as; leaves and a piece of muslin cloth, instead of
responding to people. However, the encouraging fact about this
sequence of observations, which covered the baby's first year of
life, is that he was rescued from the downward slide into autism
by his own resilience and by the vitality of his father and elder
brother. Mother and baby again began to attend to each other,
the baby no longer seemed deaf, and all now seems to augur well
for the normal development of this baby. It has seemed to me
that amongst other precocious developments caused by the
trauma of bodily separateness, biting has developed pre-
maturely in the infant who becomes autistic. For a variety of
reasons, these children seem to become afraid of their savage
biting impulses, and this may, in part, account for their
restricted sucking.
In a book as yet to be published, Josephine Klein has sug-
gested another possible conjunction of factors which could
contribute to the initiation of autism in a child. She suggests
that a baby may be born with its sensory apparatus not yet ready
for out-of-womb existence but which, over the first few days, or
even over weeks and months, gradually matures to a normal
210 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
watery medium of the womb linger on to create a kind of post-
natal womb. As Freud (1926) reminded us, 'There is much
more continuity between intra-uterine life and earliest infancy
than the impressive caesura of the act of birth allows us to be-
lieve.' This continuity would seem to be a necessary interim
period during which the newborn infant makes the adjustment
from being a water creature to the frustrations and labours of
living on dry land. In the womb-like communal medium of the
'water bath' situation, Steve feels that he and his mother1
therapist flow around and into each other to make a sheltered
situation in which they can begin to forge affectionate and
sensuous links with each other. He can begin to experience his
separateness from her in a situation in which he is encircled by
the safety and warmth of her understanding. Shared meanings
develop between them. In this situation he can begin to get
emotionally 'rooted' in the earthy mother, who acts as what
Madame Cauquil called a 'mother sponge', to mop up and give
meaning to his bewildering and bewildered overflows. Before
he could re-experience this early state, the autistic shell had to
be scaled away.
This rooting process has something in common with the
'bonding' or 'attachment' described by the ethologists, but
there are human features to it. It is inaccurate to extrapolate
simplistically from animals to man. This rooting would seem to
be a prerequisite for object relations as described by the psy-
choanalysts. There is nothing mystical about this process. It is
mediated through the psychophysical capacities for empathy
and imitation which are inherent in the nature of human beings,
and which, as observations of babies by non-psychoanalytic
observers are showing, begin to develop in the first few days of
the infant's life. But for Steve, as for all autistic children, the
shelter for this important rooting process was always being
disturbed. T h e link with the primordial mother was always
being broken. This 'axis wrench', to use Plath's phrase, meant
that Steve was constantly threatened with dissolution and
extinction.
 SPILLING AND DISSOLVING 209
kneaded the plasticine, actively masticated it, and then
mumbled several words as if they were jumbled and stuck
together: 'Girlie - Cauquil- eaten - bitten - all-meat - broken
- it's leaking.'
Madame Cauquil was quick to understand his jumbled
outpourings well enough, for she said to him, 'When we are
going to be separated for several weeks you feel you want to
stick to me and have 'girlie-Cauquil' all to yourself. You are so
unhappy about not being able to do this, and soaangryabout our
separateness that you are afraid that you have bitten and broken
me, and that I will leak out of you and be gone.' Following this
interpretation Steve took the pieces of plasticine out of his
mouth and, showing Madame Cauquil a broken, sausage-like
thing made from the plasticine, said 'Glue-hole'. When she
offered him Scotch tape, he said 'Cut', and taped the plasticine
by himself, 'to reconstitute the long sausage-like thing, winding
the tape specially round the broken part'.
On his return from the summer holiday, Steve carried his
work concerning the long sausage-like thing still further. The
father element now came into the picture of his world that Steve
was creating with the help of his therapist. Until the
disciplining father element becomes an active presence, the
threat of dissolution remains. The father brings into focus the
reality that sharing is an inevitable part of life. It now became
clear that Steve felt that the father had come between him and
'girlie-Cauquil' during the holiday. Angrily pushing a red toy
car out of the way, Steve said 'Red car broken'. This is rem-
iniscent of John in Chapter 4 who, in similar circumstances,
said 'Red button broken'.
Steve was now confronted with what I have found to be the
critical situation for the ailtistic child. In his concern about
the long sausage-like thing, Steve showed us his present-day
version of the painful situation which provoked his self-
enclosure by the autism. Let me go into this in some detail.
In the 'water bath' situation Steve seems to have been re-
enacting a very early state in which sensations of being in the
98 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
state. She suggests that by the time this maturation has oc-
curred, the mother's confidence may have become so under-
mined by her baby's strange unresponsiveness that mother
and baby never get together.
Other autistic children seem to have suffered disturbances in
utem, and so are born prone to be autistic even from birth.
Grotstein (1983) has suggested that, as the result of the
mother's depression, some of them may have suffered a
'biochemical assault in the amniotic bath'. Rubinfine (1962) has
suggested that there could be excessive 'proprioceptive
stimulation' in the womb or just after birth. Of course, the
mother's fantasies about her unborn child will profoundly
affect the developing foetus. The fact that disturbances in utem
can lead to autistic-type reactions after birth was brought home
to me by a case I supervised recently. This was a little girl who,
at three years, was referred for psychotherapy because she had
transitory autistic-like episodes in which she went stiff as if with
terror, and was impervious to what was going on around her.
The significant facts in her early history were that the mother
became distressed towards the end of the pregnancy, and that
the infant, when near to term, whilst still in the womb, had
started to breathe and to defecate, behaviour which denoted
foetal distress. Obviously, such a child will be difficult to rear
after (s)he is born.
A variety of situations can lead to autism. In the past,
psychogenic hypotheses have been too simplistic and
judgemental. It is clear that several different combinations of
factors can result in an autistic picture of varying degrees of
intensity. However, in all cases, the autism is an attempt to deal
with intense elemental terror. The child freezes like a
frightened animal. In every case, the crux of the situation is that
mother and child have been prevented from getting together
because the mother and child's interest in, and attention to,
each other had been disturbed by factors such as have been
described. Let me now discuss some of the consequences of this
failure of mother and child to meet each other.
 PRECIPITANTS O F PSYCHOGENIC AUTISM 99
Consequences of the fuilure to meet
Several writers have written of the way in which a happy
mother and her responsive newborn baby heal each other from
the caesura of birth by their sensuous interactions with each
other (De Astis and Giannotti, 1980). But for a variety of
reasons they may not experience that special psychological
ambience, which is probably just as important for the mother as
for the baby. If it is lacking it is a tragic situation for both of
them; as also for the father, who plays his part in promoting this
psychological healing and protection. All the tiny details of
family life and infant care generate a healing atmosphere, and
lack of it means that the child remains emotionally unattached
to his parents. He does not grow emotional roots. Thus he
suffers the loneliness of self-incarceration. He is cut off from all
those responsive interactions which promote psychic growth.
In infancy, the relevant interactions are activities such as
sucking, eye-to-eye meetings, playful encounters and caresses.
These are the physical bases for that communion between
mother and baby which is the first form of communication.
Without this the child remains uncouth and unnurtured. His
psychic life is curtailed. Lacking adequate memories, he is left
in the grip of agonizing terrors about losing his sense of
existence - his 'going-on-being', as Winnicott has so aptly
called it.
Some of these terrors accrete around the basic inbuilt fear of
falling. There is the terror of being 'dropped', of 'falling
infinitely' (as Winnicott puts it), of 'falling apart', of 'falling to
bits', of falling with a damaging bump. There are others such
as spilling or dissolving away, or exploding away, or of losing
the sense ofphysical continuity with an everlasting entity who is
felt to guarantee the infant's existence. These 'nameless
dreads', as Bion called them, will be discussed later in the book.
For these children, also, the unhealed primary wound of
bodily separation from the mother is again laid bare whenever
further separation experiences impinge upon them; for ex-
ample, when they become aware that the nipple of the breast (or
208 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
undifferentiated bodily fusion with the mother in order to avoid
the threat of dissolution, which came as soon as he was assailed
by the realization of his lack of bodily continuity with her.
In his poem 'Flash-back' James Greene, (1980, p.9) ex-
pressed these terror-struck states of separation very vividly. He
writes :
If I cannot suck
My thumbs,
If like lightning I all-but crack -
A minus, non-plussed -
Will you hold me - criss-cross - in your arms,
A gentle straitjacket? . . .
Oh fuse me with the surplus of the thunder
Whose brain is racked
And under fire . . .
T h e words 'all-but' and ' - criss-cross - in your arms' are
hyphenated as if to suggest the reactive states of fusion caused
by panic about bodily separateness. In Steve's developmental
history it was reported that, in his convulsive episodes as an
infant, he could only be calmed by being held in his father's
arms. As infants, autistic children do not suck their fingers or
thumbs, but resort to autistic objects and autistic shapes for the
relief of tension. These self-generated protections and comforts
distract their attention away from the terror of 'spilling' or
'leaking' away and of disappearing altogether. In using the
phrase 'A minus, non-plussed' Greene. expressed the
arithmetical exactitude of these children, and their Sartrean
horror of becoming a 'nothingness' (Sartre, 1957). Greene's
mention of a 'straitjacket' implies that the unthinkable,
uncontrollable overspill which seems to threaten dissolution is
what we call 'madness'. Autism is a defence against this
madness. T h e autistic self-generated practices make rigid
'straitjackets' to prevent dissolution. T h e therapist becomes the
child's 'gentle straitjacket' replacing the autistic object which is
mcrcilesely constricting. On the day that Madame Cauquil told
Steve about the dates of the coming summer holiday, Steve
 SPILLING AND DISSOLVING 207
stances. In this state of oblivion he was cut off from human
sympathy and human care. Madame Cauquil also sensed that
Steve felt 'glued' to the window by his spit. It is possible that in
his panic at the disappearance of his mother, Steve clung to
something solid in order to feel that he was 'there' and not
'gone'. His spit was like the trail made by a snail.
After one-and-a-half years of therapy, Steve drew a red oval
containing two shapes, a smaller oval and a circle. Madame
Cauquil felt (and I agree with her) that the two contain-
ers within a larger container indicated that Steve felt that he and
his therapist were held within a shared ambience. He was
beginning to realize that there could be bodily separateness
between two people who were held together within a context of
'togetherness' of a non-physical kind. Within this context of
mental 'togetherness' Steve could begin to 'think', for as he
drew the containers he said, 'It made a lot of noise when ...
thought Cauquil.'
He probably left out the personal pronoun 'I' because his
sense of personal identity, as also his capacity to think, was
dependent upon his 'togetherness' with Madame Cauquil. In
Kleinian terms this was an instance of projective identification,
which Bion has demonstrated as being instrumental to the
beginning of thinking (Bion, 1962a). However, Steve's sense of
bodily separateness within a context of mental 'togetherness'
did not feel secure. Following the 'container' session he said in
panic, 'It's leaking ... everywhere .., you ... put ... kaka,'
meanwhile defecating into his pants.
From then on 'the wet', as Steve called it, became very
important for him. In Madame Cauquil's words, 'It is as if
we both share the same liquid bath which offsets the worry ab-
out physical discontinuity.' However, this encirclement by the
communal flow of non-verbal communion was disturbed by the
threat of the summer holiday. Steve was not able to feel that
their bodily separateness from each other could be bridged by
his, as yet, insecure capacity to reflect, to think, to remem-
ber, to communicate. In terror, he reverted to the delusion of
100 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
its substitute) is not a permanent part of their mouth - witness
John's experience, cited in chapter 4. In the absence of healing,
these traumatic wounds are 'scabbed' over by autistic practices
which drive the child further and further away from the healing
and humanizing influences of his family and his culture. As
David Rosenfeld (1981) has shown, autism 'preserves the
traumatic experiences so that they can be dealt with when
propitious circumstances arise for doing so, but it does not
promote integration. The child is left in a crude, unintegrated
state. He does not develop a working simulation of reality which
is effective for coping with the exigencies of the outside world
in an ongoing way, nor with his own inner states. Let me
discuss this further.
The representation of reality
As we know, we can never be in touch with ultimate reality. We
make a kind of analogue which helps us to function effectively.
An important part of cognitive and emotional development is
the creation of more and more effective working simulations of
reality. In relatively normal development, on the basis of his
own constitutional 'blueprint', the child absorbs the construc-
tions of his family and of the culture in which he lives. In the
first place, this absorption comes from interactions with the
primary caregivers through all the tiny details of infant care.
Thus the infant's state of mind, and that of the caregiver, are of
paramount importance if progressive and effective working
simulations are to develop. Due to a variety of combinations of
unfortunate circumstances autistic children have become stuck
in crude simulations arising from their inbuilt gestalts and their
own bodily processes. Their behaviour becomes automatic and
mechanical.
I have also come to realize that this can happen in an isolated
part of more normal individuals as well.
The autistic part in neurotic patients
I share Dr Sydney Klein's findings that many neurotic patients
 PRECIPITANTS OF PSYCHOGENIC AUTISM 101
have an autistic split-off part to their personality. When they get
in touch with this, the unhealed psychic wounds of primal
separateness are exposed. These have driven them along the
road of psychogenic autism, but in a less total way than is
the case with the autistic child. Perhaps, even in normal
development, such psychic wounds are never totally healed,
but throughout life creative interactions promote their healing,
to prepare the individual for the ultimate separation of death.
Glazing over the wounds with autistic shapes and plugging
them with autistic objects prevent this natural healing, because
such manipulative activities impede the necessary creative
interactions. Neurotic patients with such autistic barriers will
be discussed and illustrated in Part Two of this book. In
conclusion, let me say a few hopeful words about psy-
chotherapy with psychogenic autistic states.
Psychotherapy with psychogenic autism
The events and circumstances which have been outlined as
contributing to the development of psychogenic autism are only
important in so far as they have affected the psychic situation of
the patient. They are in the past. We cannot do anything about
them. However, we may be able to do something about the
patient's psyche. I have come to the conclusion that for the type
of autism which has developed to deal with the unhealed
psychic wounds of early infancy, psychotherapy is just what is
needed. But this must be psychotherapy which is based on a
thorough understanding of the nature of psychogenic autism,
and its possible origins. In psychotherapy with such autistic
states, be they partial or more total, a Pandora's Box opens up
before us. If both patient and therapist have the courage to look
into its depths, and if they have the resilience and patience to
generate the necessary insights, it has been my experience that
hope usually emerges from its inner darkness.
206 AIJTISTIC BARRIERS IN NEUROTIC PXTIENTS
first tooth appeared. ( D r Guilianna de Astis and Professor
Giannotti (1985) have found that the advent of dentition
precipitated the first signs of autism in some of the autistic
children seen by them in the Psychotherapy Unit of Rome
University's Institute of Childhood Neuropsychiatry.) Steve
was not toilet-trained until he was four years old, because until
then he had been afraid of being put on his potty. His mother
described him in this situation as appearing 'terrorized as if he
might fall.'
At three years of age Steve began to fall in actual fact,
'contracting his foot and toe without any organic cause'. At
four, as he became toilet-trained, Steve began to utter a few
words - 'Mummy', 'Daddy', 'car' - but he never used the
personal pronouns 'I' or 'you'. When he was first seen at the
clinic, Steve ate only with his hands and drank ten to twenty
bottles of fluid a day. He had stereotyped gestures, he rocked,
he bit his hands and hit his forehead on the floor. He handled
objects without really playing with them. ( I n my terms, they
would be autistic objects.) T h e clinic team thought the mother
seemed 'depressive, fragile and rather undifferentiated from
her son'. T h e father would not be involved in the treatment, but
he did not oppose it.
The course of treatment It would make this chapter too long if
I gave you the detailed account which Madame Cauquil
presented to me; I can pick out only the significant features. In
his first session Steve demonstrated one of the means by which
he dealt with being separated from his mother. After his mother
left the consulting-room, he turned his back on Madame
Cauquil, and with his spit made so many whorls and scribbles
on the window-pane that it became impossible to see through it.
Madame Cauquil felt him to be completely inaccessible
because, in her words, 'He seemed to be wrapped in a wet
universe which he himself secreted.' Steve had distracted his
attention away from his mother's departure by resorting to idio-
syncratic, unshared shapes made from his own body sub-
 SPILLING AND DISSOLVING
excesses of stimulation are moderated and transformations can
take place (see Anzieu, 1974; Bick, 1968; Freud, 1911).
Biven describes a neurotic woman patient who told him that
she literally felt that she had no skin sometimes. In this state she
described herself as 'being hidden and little, inside a walnut
shell' (Biven, 1982). I call autistic children 'shell-type' or
'encapsulated' children. Jean did not open the 'walnut shell' of
her autistic enclave until the second phase of her analysis. As
well as being afraid that they will 'spill away', their lack of the
sense of being anchored to a caring and cared-for nurturing
object makes such patients fear that they will float away and be
'gone'. This increases their desperate autistic manoeuvring to
maintain the illusion of controlling their surges of passion by
self-enclosure.
Let us now follow the odyssey of a five-year-old autistic boy,
Steve, on the 'wine-dark sea' of personal development in the
ship of psychoanalysis. You will remember that on his arduous
journey back to his home base of Ithaca, as Odysseus was often
buffeted by storms and waves. Homer describes how as Odysseus
lay exhausted on some forlorn island shore, his limbs were
'loosened', and his body 'ran like water'. He was threatened
with dissolution and extinction.
Steve's journey away from the threat of impending
dissolution to the security of caring connections within the con-
text of a human family, in which he could learn to manage his
tempestuous feelings, was presented for my supervision in
Paris by a talented psychotherapist called Madame Cauquil.
(We met Steve and Madame Cauquil briefly in Chapter 8.) The
significance of her name, having a clang similarity to la coquille
(a shell), played its part in the psychotherapy.
Stee~e
Steve was referred to Madame Cauquil at five and a half for
'repetitive convulsive episodes without any precise medical
explanation'. The convulsions started at six months, when his
205
CHAPTER SIX
Autistic objects
Once upon a time there was a person
Almost a person.
Somehow he could not quite see
Somehow he could not quite hear
He could not quite think
Somehow his body, for instance,
Was intermittent.
Ted Hughes, 'A Bedtime Story', Crow
T
he chapter that follows is a considerably revised
version of a paper which was originally pub-
lished in the International Review of Psycho-Analysis
(1980) 7:27-39. I n working with autistic children I have be-
come aware of their perseverative use of certain objects, pe-
culiar to each individual child, in sensation-dominated ways
which impede mental and emotional development. These will
be referred to as autistic objects.
Autistic objects
Two clinical illustrations will now be given which exemplify the
nature of autistic objects:
At the beginning of treatment, an autistic ten-year-old boy
called David used to bring a dinky car to every session. This car
was clasped so tightly in the hollow of his hand that it left a deep
impression when he took it out, In working with him it became
 AUTISTIC OBJECTS 103
clear that the dinky car was felt to have magical properties to
protect him from danger. As such, it was like a talisman or
amulet. The difference between David's car and a talisman was
that he felt that by pressing it hard into the hollow of his hand
it became a hard extra bit to his body. Even if he placed it on the
table, the deeply imprinted sensation remained, so that it was as
if the car were still a part of his body to keep him safe.
Another autistic child called Peter who was six years old at
the beginning of treatment used to bring to his sessions a large
keyring with over fifty keys on it. It became clear that he felt
that this was a hard extra bit of his body.
However, during the period when these children felt pro-
tected by their autistic objects they were impenetrable to my
attempts to help them. Thus it seemed important to understand
the nature of these objects and the possible origin of their use.
The nature of autistic objects
An outstanding characteristic of autistic objects is that they are
not used in terms of the function for which they were intended.
Instead they are used in ways which are idiosyncratic to each
child. For example, David did not push his dinky car along the
table or play with it on the floor as a normal or neurotic child
would have done. Peter did not use the keys to open cupboards
or doors. He just carried them around. From a realistic point of
view they were used in a way which was useless and mean-
ingless; from the child's point of view it became obvious that
they were absolutely essential.
The hard metal trains and cars which some autistic children
take to bed with them to put under their pillows are similarly
not used in terms of their intended function as playthings. Nor
can it be said that they are used for fantasy purposes. There is
a 'let's pretend' quality in fantasy play and a realization of bodily
separateness from the object which are lacking in the autistic
child's use of his autistic objects. They have a bizarre and
ritualistic quality and the child has a rigidly intense pre-
occupation with them, which is not a feature of fantasy play.
204 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
of autism often describe to us, and which Graham Greene has
described, in A Sort of Life, as being characteristic of some
writers. 'There is a splinter of ice in the heart of a writer.' T h e
icy clarity of 'I am I' as expressed by Plath seems to indicate that
her sense of identity is precarious and tenuous. After struggling
for years to cope with her fears of dissolution, Sylvia Plath
finally took her own life- possibly, in part, to get away from this
threat.
In the passage which was quoted above, Sylvia Plath might
have been writing about the onset of autism. But because she
experienced the pain of the 'axis wrench' and the 'polar chill' at
a later time of life than do autistic children, for whom they
occur in early infancy, she did not become massively autistic.
She was able to catch the torrential overflows of her undigested,
passionate feelings within the context of her poems. However,
throughout her life she obviously experienced the autistic
backward 'drag' to her ongoing development which one of my
patients has described as the 'undertow'.
Biven tells us that Sylvia Plath felt her skin to be an artificial
barrier that had to be 'penetrated', 'peeled away' or 'melted'.
Autistic children feel like this also. When they experienced the
'axis wrench' and 'polar chill' they reacted by callusing
themselves with hard autistic objects, or by wrapping
themselves in softly soothing autistic shapes. These delusions
make them feel that they have an artificial, inert barrier rather
than a living, breathing human skin. This barrier keeps at bay
the 'nameless dread' that they could liquefy and spill away.
They have made their own containment. But this rigid en-
capsulation has prevented them from using the more adaptable
containment of human relationships. T h e longer they stay in
their rigid, self-enclosed state, the more they remain in the grip
of 'nameless dreads'; and the more difficult it is to get in touch
with them to help them to develop the sense of having an
adaptable physblogical and psychological 'skin'. This, as a
permeable membrane, would filter their experience so that
 SPILLING AND DISSOLVING 203
of the skin in early psychological development, D r Biven, a
psychoanalyst from Ann Arbor, Michigan, has studied the
poems and writings of Sylvia Plath, as well as Alvarez's bio-
graphy of her, in order to get in touch with her struggles to
preserve her 'entirety' against the floods of feelings which
threatened to submerge her (Alvarez, Al, 1963; Biven, 1982).
As with Jean, it seems likely that Sylvia Plath, as an infant and
small child, had been unduly merged with her mother, and then
experienced her bodily separateness before she had sufficientky
emerged to a state in which she could cope with feelings about
individual identity and separateness. For example, Plath writes
as follows about her feelings when she learned at the age of two
and a half that her mother would soon be home with a new
baby :
I hated babies. I, who for two-and-a-half years had been the
centre of a tender universe, felt the axis wrench and polar
.
chill immobilize my bones .. Hugging my grudge, ugly and
prickly, and sad sea-urchin, I trudged off on my own, in the
opposite direction towards the forbidding prison. As from a
star I saw, coldly and soberly, the separateness of everything.
I felt the wall of my skin; I am I. That stone is a stone. My
beautiful fusion with the things of the world was over.
(quoted in Biven, 1982)
Obviously, Sylvia and her mother had been in an undue state
of fusion with each other, so that the birth of a new baby
was a terrible shock. In such a situation of fusion the child
would seem to use the mother as an autistic object or as an
autistic shape - that is, the mother is experienced as a sensation
part of the child's body. When sudden awareness of bod-
ily separateness is forced upon the child, he or she feels wren-
ched apart from the mother. Without having had sufficient pre-
paration for this, such.a child is plunged into intense emotional
states about bodily separateness. Sylvia Plath experienced that
stark icy coldness and loneliness which patients with a capsule
104 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
The objects which some autistic children spin obsessively have
a similar quality.
This brings me to another characteristic feature of autistic
objects as used by autistic children. They have no fantasy
associated with them. Psychogenic autism is a sensation-
dominated state, and autistic objects are sensation-dominated
objects. As a result of the lack of fantasy, they are used in an
extremely canalized and repetitive fashion. They are static and
do not have the open-ended qualities which would lead to the
development of new networks of association. They are the
result of, and result in, repetitive circles of activity which
become entrenched.
Another typical feature of autistic objects is the seeming
'promiscuity' of their use. The keyring that Peter carried
around with him had many keys on it. If one were lost, there
was always another to replace it. David did not bring the same
dinky car each time. At the beginning of his treatment, it was
the hard sensation in the hollow of his hand which was
important to him . Many dinky cars could give him the same
sensation. Thus it did not matter which one he used. If one
dinky car were not to be found, another one would do. Some
autistic children have one autistic object which is used for a time
in a stereotyped and ritualized way. It is then discarded, to be
replaced by another which is used similarly. Thus over a period
of time, there may be a succession of objects which have been
used in turn, with an intensity which shuts out awareness of
anything else. They are used, discarded and replaced by
another one. If an autistic object is gone, the child is distressed
as if he had lost a part of his body, but the object is soon replaced
by another one which is experienced as being the same.
However, it is important to realize that the autistic child's
inability to tolerate the fact of loss comes from his having
experienced excruciating distress about the seeming loss of an
instinctually significant part of the nursing mother which had
been felt to be part of his body (Winnicott, 1958; Mahler, 1961 ;
Tustin, 1972). This loss was experienced as a loss of part of his
 AUTISTIC OBJECTS 105
body and not'as the loss of the mother and her breast. It is this
situation which has led to the obsessive use of objects which are
experienced as if they are bodily parts.
The foregoing discussion hints at another characteristic fea-
ture of autistic objects. The sensation-dominated state of the
autistic child means that such children live in a globally
apprehended world. This is very different from ours. We
distinguish objects from each other by more than the mere
sensation of their shape. We use other clues. Autistic children
do not. Their responses are solely on the basis of contour and
outline: meaning and function are not taken into account.
Thus, at one time, Peter thought that the word 'boiler' was 'boy'
with an extra bit to his body. This was not a bit of fun. He was
very serious about what, to us, is an amusing misconception.
Segal(1957) describes an adult schizophrenic patient who was
also operating on this basis of meaningless 'clang' similarities.
T o this patient, the piece of furniture called a 'stool' and his
faecal 'stool' were equated because the same word was used for
both.
Another factor which comes into this discussion is that in
autistic children the sensory modalities are not always clearly
differentiated from each other. Thus, seeing and hearing are
often experienced by the child in a tactile way as being touched
by the object. Written words which have roughly the same
shape are felt to be the same. This applies also to objects,
pictures and sounds. This leads to what the observer designates
as the concrete nature of the autistic child's experience.
As his treatment proceeded David brought evidence of
misconceptions which arose from the imprecise, tactile ap-
prehension of the shapes of words. For example, an Aston
Martin dinky car was felt to have in it the essence of the.village
where he lived which was called Martin. An Austin car was felt
to have in it the essence of Tustin. T o those people who have
not worked with autistic children this might seem to be an
example of rhyming or punning. But these are developed forms
of expression when the individual has a sense of his bodily
202 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
After there had been a change of therapy room, for example,
a little girl being treated by Verena Crick said, 'I'm afraid I'm
losing my characteristics.' Her characteristics seemed to
threaten to spill out of her to be lost. She was 'forgetting' who
she was. She feared that she could dissolve away and be gone.
Of course, Ted Hughes was not overthrown and submerged by
this situation of flux, as is the autistic child. He was sufficiently
secure in his own identity to be able tp empathize with such
states of non-identity, and then to re-experience his own
identity with a strengthened capacity for compassion. He
seemed to be experiencing our ignorance about the ultimate
nature of things, alongside echoes of the earlier bewilderment
felt by the' small child who is surrounded by a sea of meaning
which, by its meaninglessness for him, has threatened to
overwhelm him.
Like Louis MacNeice in 'Prayer Before Birth', patients such
as Jean prefer death to the feeling of being dissipated and spilled
away. In despair, Jean felt that death through starvation was
preferable to the unco~trollabledissolution which threatened
her. At least she would be in control, and her struggle to defend
her 'entirety' would be at an end. Louis MacNeice had managed
to enclose his waterfall feelings within the disciplined context of
a poem. Jean was also stimulated to keep her torrent of feelings
within the context of amateur dramatics and music, in both of
which activities she had considerable talent. But immense and
powerful feelings were always surging out of the confines of
these creative activities, bringing the terror of spilling away and
being 'gone'. The reaction to this threat was to 'seize up' and to
stop doing anything. Jean's enjoyment of life and of her un-
doubted capacities was continually being halted by this fear of
spilling away and losing herself. It was this depression which
had brought her back to me.
Sylvia Plath
Jean's fears have much in common with those of Sylvia Plath,
who was the first wife of Ted Hughes. Focusing on the function
 SPILLING AND DISSOLVING 201
Hughes' poem expresses very cogently the bewilderment
associated with states in which the sense of personal identity is
under threat and things are perceived as utterly discrete and
separate because there are no threads linking them together.
Connections have broken down or have not been established.
The threat of watery dissolution is in the air. Everything has to
be inspected carefully, and the works examined. Nothing can
be taken on trust. There is a vacuous sense of lack of purpose,
of understanding, of meaning. There is no coherent picture of
the world nor of the subject himself. He lives in a peripheral
world of vague guesses, conjectures and speculations which
have no basis in previous experience. There is a sort of
prehensile awareness. Like the monkey using his tail to swing
from branch to branch he apprehends one thing after another
but does not comprehend them. Indeed, spilling away can be
equated with loss of comprehension. This comes from lack of
the sense of being encircled by caring understanding and mean-
ing. There are no boundaries. It is a state of unfocused undif-
ferentiation. In part, Hughes makes this point by the lack of
punctuation in his poem.
For the autistic child who lacks this encirclement, the autistic
encapsulation has been a protection against the threat of
dissolving away. Every change of state or circumstance means
the recasting of previous formulations of experience. In his
rigid state of keeping dissolution at bay, this is a dangerous
threat to the psychogenic autistic child. Changes mean that
everything is thrown into the melting-pot; he is in a state of
flux which has to be borne if trans-formations are to occur.
This state of flux can only be tolerated if the child has experien-
ced lively reciprocal trans-actions with an adaptable nurturing
person. Without these, he lives in an 'all or nothing' state.
Formulations are either 'there' in their entirety, or they are
'gone'. The midway state of suspense in which they are grad-
ually transformed cannot be tolerated, because if rigid for-
mulations are threatened with change they seem hopelessly
shattered. The child no longer feels invulnerable. Vital sub-
stances threaten to spill away.
106 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
separateness from other objects and has a normal perception of
them. As he emerged from his autism, David was able to tell me
that he had felt that the words 'Tustin' and 'Austin' must be the
same because they were the same shape when they 'touched' his
ears or eyes.
In working with David, it was necessary to help him to
realize that bringing the Aston Martin dinky car did not mean
that he brought a bit of his village with him: nor did bringing
and taking home the Austin car mean that he could carry Tustin
around with him. A neurotic child would have used these cars
to represent his feelings about his village and about himself. For
David they did not represent his feelings. He felt them to be
actual bits of Martin and of Tustin. This realization means that
in the psychoanalytic situation we deal with such material very
differently from the way we would approach it with a neurotic
patient. Gradually, as David developed more sense of his
bodily separateness from the outside world, it was possible to
talk to him about his homesickness for Martin (he was in a small
boarding school for autistic children), and his craving to have
me always with him (quite literally in his pocket). T o have
talked to him about this in the early days would have been
meaningless to him because the dinky cars were autistic objects
which shut out any sense of missing Martin or myself.
An important part of modifying such children's pathological
use of their autistic objects seems to be the realization on the
part of people caring for the child that these objects are not
experienced by him as substitutes for longed-for people. For
him, they are that person because they give him the sensations
he desires, the sensation of an object being of pre-eminent
importance to him. Also, the desired sensation is not localized
in any specific part of his body. For example, if the car gave him
nice feelings in the hollow of his hand, it was the same as if it
were in his mouth. However, even to use the word 'desire' in
this context makes the communication inexact. Autistic chil-
dren cannot become aware of needs, wants or desires because
thky have little mental equipment to help them to bear the
 AUTISTIC OBJECTS 107
frustration these feelings entail. Instead they use autistic
objects. By these they avoid the suspense of waiting. The way
in which these children provoke others in their environment to
be as concerned as they are to have an autistic object readily
available is a striking illustration of their power to keep the
autism going and to get others to collude with it.
Autistic objects bring almost instant satisfaction, and pre-
vent the delay between anticipation and realization which, so
long as the suspense can be tolerated, leads on to such symbolic
activities as fantasies, memories and thoughts. Thus the
autistic child continues to live in a bodily way, but his mental
life is massively restricted. This is why many of these children
function as mental defectives when first seen for clinical
assessment. This pathological use of autistic objects results in
the autistic child's lack of motivation and his lack of basic trust
in the 'facilitating environment'. It is only when insightful
caring gets through to him that he is able to begin to give them
UP.
'Hardness' is a characteristic feature of most autistic objects.
This gives the child the feeling that they keep him safe. Autistic
chilren, because they lack experience of civilizing relationships
with other human beings, feel constantly threatened with being
attacked and hurt. They feel that their helpless bodies are a
target for savage and brutal attacks. They particularly feel that
the projecting parts of their bodies will be bitten off in very
barbarous ways. The castration anxiety of neurotic children is
mild as compared with the perils that autistic children feel they
have to face. The main purpose of autistic objects (that is,
objects used as part of the body to give reassuring and diverting
sensations) is to shut out menaces which threaten bodily attack
and ultimate annihilation. Hardness helps the soft and
vulnerable child to feel safe in a world which seems fraught with
unspeakable dangers, and about which he feels unutterable
terror. These objects help to prevent the realization of bodily
separateness, and to promote the delusion that impingements
from the outside world are obstructed. One of the ways in
200 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S
Before Birth', quoted at the head of this chapter, Louis
MacNeice described such fears of dissolving away and being
'gone'.
I n his poem 'Wodwo', T e d Hughes (1970) also evokes for us
the feelings of bewilderment and amorphous lack of individual
identity associated with such rootless states.* T h e whole poem
needs to be quoted to get the atmospheric sense of watery
bewilderment which it conveys. 'Wodwo' would seem to be a
nonsense word. T h e therapist finds the sense in nonsense
(Milner, 1956).
What am I ? Nosing here, turning leaves over
Following a faint stain on the air to the river's edge
I enter water. What am I to split
The glassy grain of water looking upward I see the bed
Of the river above me upside down very clear
What am I doing here in mid-air? Why do I find
this frog so interesting as I inspect its most secret
interior and make it my own? Do these weeds
know me and name me to each other have they
seen me before, do I fit in their world? I seem
separate from the ground and not rooted but dropped
out of nothing casually I've no threads
fastening me to anything I can go anywhere
I seem to have been given the freedom
of this place what am I then? And picking
bits of bark off this rotten stump gives me
no pleasure and it's no use so why do I do it
me and doing that have coincided very queerly
But what shall I be called am I the first
have I an owner what shape am I what
shape am I am I huge if I go
to the end on this way past these trees and past these trees
till I get tired that's touching one wall of me
for the moment if I sit still how everything
stops to watch me I suppose I am the exact centre
but there's all this what is it roots
roots roots roots and here's the water
again very queer but I'll go on looking.
*I would like to thank Jeanne hlpgilana for iiltroducing me to this poem.
 SPILLING AND DISSOLVING 199
This understanding led her to showing me that, in these
states, 'spilling' was equated with 'forgetting'. In long absences
from me (as the mother of her infancy), she felt that I was
spilled out of her and she was spilled out of me. Memory traces
had been dissolved and she feared that we no longer existcd.
After this session with Jean, I was introduced to a paper by
Michael Whan called 'Lethe, time and forgetting' (1980). In
this Whan says that in Greek mythology Lethe, as well as being
the 'Spring of Forgetfulness' in the Underworld, was also 'a
condition of the soul which was likened to a leaky pitcher', and
that this 'leaking' was associated with forgetting. I was struck by
the relevance of this to Jean's material. Forgetting is felt to be
lethal.
From babyhood Jean had had an unduly close association
with her mother, partly because she was her mother's last child,
and partly because her father was often abroad due to his work.
For Jean, her mother had not become sufficiently differentiated
as a person who could seem to catch the torrential overflows of
feelings about bodily separateness and absence. T h e fact that
her mother died when she was eight years old added to Jean's
feeling that there was no alert and alive person to catch the
overflows of her powerful feelings about identity and sep-
arateness. All this explains why Jean felt that the waterfall of
her anguished and panic-stricken feelings about the long
absence from me seemed to spill into a 'bottomless abyss', into
'nothingness', and she with them. Since we were not clearly
differentiated as separate persons, I was also spilled and 'gone'.
Jean felt that vital substances, both hers and mine, had
liquefied and been spilled away. T h e word 'dissolution' has in
it the notion of change from a solid to a liquid state like, as it
were, glass changing into water. In discussing such wordless
elemental states it is important to find tltose words which evoke
images which are as close as possible to the actual experiences.
T h e word 'dissolution' seems to do this. For example, one
autistic child feared that he could disappear like some sugar he
saw dissolving in water. In the last verse of the poem 'Prayer
108 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
which they do this is by focusing attention on familiar bodily
sensations rather than the strange 'not-me' outside world.
But this is the sophisticated view of the observer and, in
order to bring clarity to a discussion of undifferentiated states
through the differentiated medium of words, it is necessary to
distinguish the experience of the observer from the very
different experience of the relatively undifferentiated child.
For the child, an autistic object is primarily a sensation. But the
observer is aware of the object which provokes the sensation.
The observer distinguishes differences in objects which all
seem to be the same to the child, who only distinguishes them
in terms of the sensations they give him as they seem to touch
his body.
The pseudo-protection of autistic objects (or sensation ob-
jects) prevents the child from using and developing more gen-
uine means of protection. In particular, it prevents him from
getting in touch with the caring human beings around him who
would help to modify his terrors. It keeps him trapped in a
bereft state beset with fantastic terrors with no authentic means
for these to be alleviated and modified.
I have always been puzzled by the fact that some psychogenic
psychotic children are reported as having been withdrawn from
birth. Whilst writing this paper, it has occurred to me that these
children may have chanced upon autistic objects very early in
life and have thus been diverted from turning to the suckling
mother. A depressed or underconfident mother would not be
able to muster sufficient firmness and resilience to attract her
infant away from the illusory delights of his sensation objects to
the real enjoyments of her breast, which he gradually learns to
use as separate from his body. In such a situation the use of
autistic objects could become entrenched and pathological.
The on'gzns of pathological autistic objects
Our understanding of the origins of autistic objects is helped if
we realize that, at first, it is not the milk which is significant to
the nursing infant, but the cluster of sensations experienced as
 AUTISTIC OBJECTS 109
'mouth-encircled-nipple'. Nature baits the hook, as it were, and
ensures that a lifegiving instinctual activity is also pleasurable.
But things can go wrong here for many and varied reasons,
which can be in different constellations in each nursing couple.
The infant is then driven to obtain almost constant trance-
inducing ecstasy from his own body to distract his attention
from the unutterable pain of the outside world.
Clinical work indicates that pathological autistic objects have
their origin in hidden auto-sensuous activities which began in
infancy. Autistic children often bite their compressed tongue,
or the bunched-up pads of their cheeks. Or they wriggle their
bottoms to feel the faeces in their anus. All these observations
have been culled from the psychoanalytic situation, in which
children demonstrate to the therapist what they are doing, or,
when they can talk, they will tell her. The children may do
other things to which I have not been alerted. As a rule, the
caring adults are relatively unaware of these activities because
they do not see them. This means that these auto-sensuous ac-
tivities become more and more deviant and perverse, since
outside agencies cannot modify them because they are un-
observed. The infants who practise such activities become in-
creasingly odd and eccentric. The autistic objects which such
children use later, as if they are part of their bodies, seem to
arise from this earlier pathology. This accounts for the idio-
syncratic nature of pathological autistic objects.
The need to shut out the outside world to the massive degree
characteristic of the autistic child arises from a wide variety of
situations, all of which seem to occur in infancy. According to
my observations, a very common precipitating infantile sit-
uation for psychogenic childhood autism is a situation in which
a particularly vulnerable child experiences a series of shocks at
a time when his neuromental apparatus is not sufficiently
developed to stand the strain. These occur in a nurturing
situation which, at that particular time, for a variety of reasons,
cannot help him to handle it, or cannot handle it for him. A sad
situation which often seems to be the starting place for autistic
198 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
are relevant to the present theme. The patient will be called
Jean.
Jean
Jean came to see me as a thirteen-year-old girl and as such a
severe case of anorexia nervosa that it was feared that she would
die. She responded well to intensive psychoanalytic treatment
but it was terminated earlier than I thought advisable when, at
fifteen years of age, she went to boarding school. She returned
to me aged twenty-one, of her own volition and paying her own
fees, because she had fits of depression.
The summarized material is taken from a sesqion of this
second period of Jean's analysis, when the Pandora's Box of her
autistic enclave was opened and she revealed to me the terrors
which had been shut away there. These revelations came after
there had been an unduly extended Christmas holiday due to
heavy snowfalls. She came back from this over-long holiday
telling me how 'empty' she felt. She went or; to say that she
often felt that we were two jugs pouring water into each other,
and falling out of control into a bottomless abyss, into
spilled out and left her 'empty'. She went on to say that 'deep
down, hidden away', she felt as if she were 'a waterfall falling
and fal-ling out of control into a bottomless abyss, into
boundless space, into nothingness'. She explained to me that it
was the feeling of being out of control as much as the falling
which was so frightening. Significantly, she said 'I'm afraid I
shall lose myself.' She added, 'I know it's an illusion but
the terror is real.' It seemed very meaningful to Jean when I
reminded her of the time when she had been suffering from
anorexia nervosa and she had told me how relieved she had been
when her periods had stopped because she had been afraid of
bleeding to death. I suggested that the 'waterfall' fear was even
worse. If she bled to death, at least she would leave her body
behind. But if she were a waterfall which spilled into bottomless
nothingness, nothing would be left; she would be a 'no-body, a
non-entity'.
 110 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S
CHAPTER TWELVE withdrawal is a mother and baby who experience bodily
separateness from each other as being torn violently apart and
Spilling and dissolving wounded (Bick, 1968). Autistic objects seem to plug the gap
between the couple so that bodily separateness is not
experienced. Unhappily, these delusions prevent a healing,
I am not yet born; 0 fill me
With strength ... against all those reciprocal relationship between the couple from developing.
Who would dissipate my entirety, would They have meant that the child had sensation-dominated,
Blow me like thistledown hither and inanimate artefacts which blocked his approach to the outside
Thither or thither and hither world, instead of human beings who facilitated the gradual
Like water held in the development of a differentiated and differentiatingmedium for
Hands will spill me. communication and interpretation.
Let them not make a stone and let them not spill me.
Otherwise kill me. The deleterious effects of the use of autistic objects
Erikson (195 1) is trying to convey the notion of the deleterious
Louise MacNeice, 'Prayer Before Birth' effects of deviant auto-sensuousness when he writes that the
infant 'will find his thumb and damn the world'. But this notion
is not relevant to autistic chidren. In normal development, as
Winnicott (1958) has shown, finding the thumb leads to ex-
ploration and enjoyment of the world outside the child's own
body. Sucking the thumb or the fingers becomes associated

T
his is a revised version of a paper prepared for presen-
with rich fantasies and ideas which enable the child to wait until
tation, under the title of 'The dread of dissolution', at a
more appropriate and authentic satisfaction comes. This is not
conference arranged by the California Institute of the
the case with the infant who shows signs of psychogenic autism,
Arts in March 1985. I t sought to study the fears of spilling away
in whom sucking has been virtually replaced by the clutching of
and dissolving experienced by autistic children, and by
hard autistic objects.
neurotic patients who have a capsule of autism. Insight into
Perpetual recourse to autistic objects means that autistic
these fears increases our capacity to empathize with these
children have remained in a raw, unnurtured state relatively
seemingly inaccessible patients in such a way that their sense of
unmodified by the disciplining and humanizing elements of
identity becomes established and they feel more intact and co-
the nursing situation. They are at the mercy of elemental
ordinated.
inbuilt patterns which are stereotyped and unmodified by
First of all, clinical material from an articulate neurotic
experience. These are unregulated and have not been co-
patient will be presented. This young woman was the first
ordinated in the normal way. They also seem to be affected by
patient to focus my attention upon these terrors about spilling
atavistic elements. Such children feel threatened by predatory
away - terrors which are deeply buried and difficult of access.
mouths and creatures. They feel they can be trodden underfoot
In the next chapter this patient's clinical material will be quoted
like insects. They feel they are jostling with other creatures in a
in more detail. Here I shall summarize those aspects of it which
desperate effort to survive. It is rivalry 'red in tooth and claw'
 AUTISTIC OBJECTS 111 196 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
and the hard autistic objects seem to be extensions of nails and mother's body, is devastating. The autistic situation of illusion
teeth. is much more excruciating than Dave's reaction to an actual
The constant use of autistic objects means that the autistic situation, although that had an element of illusion in it also.
child has little possibility of learning to tolerate frustration. One of the reactions to the threat of falling is to try to grasp
When frustration impinges, tantrums pound through muscle something. It is very terrifying if it seems to break away from
and vein and cause the child to fear total annihilation. T o the individual's grasp, and a piece falling can seem to be just
counteract this deadly terror he clutches a hard autistic object. that.
This means he never learns to deal with frustration in a The disposition to cling on to something in such a precarious
considered, thinking way. situation is seen in patients in autistic states. In describing
Such a child has also missed the 'practising' stage of normal neurotic patients with a capsule of autism, Sydney Klein (1980,
infancy which takes place during the mother's absences. For p. 395) writes that autism manifests itself 'by a rather desperate
example, when studying the language development of autistic and tenacious clinging to the analyst as the sole source of life,
children, Ricks (1975) found that many of them had missed the accompanied by an underlying pervasive feeling of mistrust.'
lalling and babbling stage of normal infancy. My own ob- This will be illustrated by the patients who are described in the
servations have shown that many of them have missed the chapters which follow.
normal sucking and mouthing stage when the child creates a
working simulation of the breast. This simulation enables him
to develop a more skilful and efficient use of the actual breast
when it comes. In short, they have missed the early learning
experiences associated with play. Such a child expects to do
everything at the first attempt without any practice away from
the actual situation. When he fails to do this, he desists from
effort. This seems to be an important component in the
passivity and lack of confidence of autistic children. They have
missed the creative work of adjusting illusions, and developing
fantasies which Winnicott's (1958) work on the transitional
object and transitional phenomena has shown are a bridge to
reality. Instead they use pathological autistic objects, which are
a barrier to it. They block the apprehension of a reality which
can be shared with other human beings in his culture. Nothing
can get in but, more important still, nothing can get out.
Such objects are the result of primary creativity having gone
wrong. Such children's premature and shocking dis-
illusionment means that they have had insufficient op-
portunities for illusion. Felt needs which are tolerable provoke
anticipatory pictures (normal hallucinations) which prepare
 FALLING 195
described so well by William Blake in the poem quoted at the
head of Chapter 1. In their preternaturally hypersensitized
state in which, because of their lack of experience of the outside
world, illusion holds sway, any minor mishap is exaggerated
into a catastrophe. They react to this in a similarly extreme way.
The almost complete retraction of 'feelers' is one of these
extreme reactions. Being cut off from experience of the outside
world perpetuates their hothouse hypersensitivity. The trouble
with psychogenic autism is that once it is started, it is self-
perpetuating. Psychotherapeutic intervention has to be firm,
appropriate and decisive.
As we saw from John's clinical material, the tantrum with
which he unburdened himself was felt to leave him with a part
missing: this was the wonderful, vital 'button'. In his relatively
undifferentiated state, John experienced this as becoming
detached from his mother's body, as well as from his own.
Popular colloquialisms catch up the essence of elemental
human states. For example, people often say of such children,
'He is not all there9, 'He has a screw loose.' Neurotic patients
with a capsule of autism feel that they are defective in some way.
One adult patient referred to herself as 'damaged goods'.
John made clear that the seeming catastrophe of losing the
'button' was the pebble which had provoked the landslide into
autism. It seems to me to be not insignificant that Dave's
traumatized state was intensified by his dislodging a piece
of rock, and hearing it rattle on to the scree below. In an
unconceptualized way it probably evoked the feeling that he
could fall and be 'gone', in just the same way as that in-
significant piece of rock, Similarly, in the quotation at the head
of this chapter, Pincher Martin gulps with horror when he
realizes that a lump has fallen out of the cliff. The feeling of
being alone in a precariously balanced situation with nothing to
hold on to is intensified if something actually falls. As they
begin to speak, autistic children talk of 'wobbly feelings' and of
'whirly feelings'. In such a precariously balanced state, to seem
to lose a vital bodily part, which is also a vital part of the
112 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
the infant for what is to come. This is the beginning of hope.
Instead of creating a valid working simulation of the breast
which enables them to use it when it comes, autistic children
have developed fake artefacts which replace the breast and for
which they do not have to wait. (In neurotic development a
rubber 'comforter', if over-used in an obsessive way, long past
the time when it is usually given up, can become such a
pathological autistic object.)
Winnicott writes: 'The mother places the actual briast just
where the infant is ready to create, and at the right moment'
(Winnicott, 1958). However, as Winnicott well realizes, the
'good-enough mother' inevitably fails in this feat of adaptation
to her infant. For the child who is developing normally, these
'failures' on the part of the mother are his opportunity for 'crea-
ting' anticipatory pictures and new responses to the mother. As
in her absences, so in the times when she does not perfectly
understand and meet his needs, he has opportunities for
adjusting his anticipatory pictures and adapting to his changing
perceptions of her. He learns to wait. H e learns to control his
impulsiveness. H e begins to create ideas which are a substitute
for the mother, but which do not obliterate his need for her, or
inhibit his instinctual responses to her. H e begins to relate and
respond to people and situations when they are not actually
present. Thus, imagining and thinking develop.
T h e frustration of unbearable disappointment means that
instead of the creation of healthy illusions and hallucinations
which lead on to dreams, fantasies and ideas, the infant begins
to manipulate autistic objects in an excessive way. These, being
tangible, sensation-dominated and ever-present, keep the child
stuck at a primitive level of over-concretized mental func-
tioning. Material objects become unduly important because
they stimulate entrancing bodily sensations. Autistic objects
develop to deal with unbearable frustration, but they prevent
the development of thoughts, memorics and imaginations
which, in normal development, in some measure, compensate
for the inevitable lack of complete satisfaction w h ~ c hbeing a
 AUTISTIC OBJECTS 113
human being entails. Another result is that the children
themselves are vulnerable to being manipulated as autistic
objects instead of being treated as human beings. The
echopraxia of some psychotic children is an extreme example of
this.
Echolalia is a manipulation of words and sounds as if they are
tangible physical objects in order to make them into 'me'. Thus,
words can be autistic objects. This echolalic behaviour is often
reinforced by the adults around them who, because of the
children's non-responsiveness, repeat what they say to the
children many times in an effort to attract their attention. This
is a good illustration of the effect that such children have on
their environment. As Stroh (1974) puts it, 'The parents are
forced into walking the child's autistic way.' If, as therapists, we
do this and unduly collude with the child's pathological, autistic
use of objects, we leave him in the grip of his pathology with no
possibility for developing genuine relationships characterized
by effort and co-operation.
If mother and child become autistic objects for each other,
they live in a sensation-dominated cocoon in which they seem to
fit each other predictably and perfectly. They become each
other's ecstasy. Some autistic children come into treatment
with a history of such an idyllic infancy. But the benefits from
such an infancy are spurious. A beneficial feature of the
bearable lack of fit of the 'good-enough mother' is that it
provides a space in which chance happenings can occur. Such
chance happenings are agents of transformation and change.
The mother and child who become entrancing autistic objects
for each other, so that they fit each other perfectly, prevent the
possibility of such a space. This means that the child's mental
development is massively stunted and goes awry, because
agents of change are shut out. In my experience, the father in
the family has an important part to play in supporting the
nursing couple through the pains and tribulations aroused by
the lack of perfect fit with each other, and the realization that
they cannot absolutely control each other.
194 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
weekends and vacations, are not experienced by such patients
as a rejection, as they would be by patients in a neurotic state of
response, but as actual physical breaks in a substratum which
they have experienced as supporting them. Quite literally and
physically, they feel 'let down'. The ground seems to have
opened beneath their feet, and they feel on the edge of a chasm
which opens before them.
In these states, they draw or talk about such things
as 'bottomless pits', 'black holes', 'chasms' and 'precipices'.
Their early experience of bodily separateness from the mother
is being repeated through the medium of the infantile trans-
ference to the therapist. This experience has been unthinkable,
partly because it was encountered in an immature psychic state,
but also because at the time they had no one 'to talk them
through it'. Feeling unheld and unsupported, they were caught
in the grip of the illusion that they could fall with nothing to
break their fall, and with nothing to hold on to. In this state, the
patients often talk about having feelings of vertigo.
It might be thought that these patients' references to phe-
nomena such as black holes and bottomless pits were metaphors
to enable them to talk about preverbal experiences. Autistic
children are not capable of such symbolic activities. The
original experience had been such as we describe when we say
we have a sinking feeling in the pit of the stomach. In their
elemental state of psychic development, they had felt that they
were falling in to (and had) a void with nothing to catch them
or to break a fall. Of course, the original experience, which was
preverbal, is distorted by the use of words, but it is the nearest
that both patient and therapist can come to it.
In a metaphorical way, on a more sophisticated level of
functioning, all of us go through the experience of the Fall from
the pleasures of the Garden of Eden, into the disillusionment of
the reality which is our common human lot. But I have the
impression that people who are prone to autistic states were
sensitive infants to rear. They seem to be more prone than a less
sensuous type of infant would have been to the 'primal sulk'
 FALLING 193
parallels with autistic behaviour. He was in the grip of an
automatic reaction which had caused his normal functioning to
be temporarily suspended. The autistic patient is in a similar
state, but there are significant differences. For one thing, it is a
much more long-term state. For another, unlike Dave's
behaviour, which was activated by an actual situation of
unconceptualized danger, that of the patient in an autistic state
is a reaction to illusory, though similarly unconceptualized
danger. Also, the state of autism arises from a more comp-
licated, interwoven set of factors than did Dave's temporary
paralysis on the crags. Inborn patterns associated with falling
turn in on themselves, and become intertwined with others
which intensify the paralysis, and make emergence from it dif-
ficult. Let me now outline some of the elemental psychic factors
which give rise to psychogenic autism.
Failure of attachment We are now realizing the importance of
the newborn infant's innate disposition to become emotionally
attached to the mother, and the serious consequences which are
set in train if this does not occur. As we have seen in other
chapters, in autistic children this innate disposition has been
thwarted by unbuffered awareness of bodily separateness.
Unbuffered awareness of bodily separateness As infants, such
patients have become aware of bodily separateness from the
mother in an immature state of psychic organization, and in a
family situation which could not help them with it. This means
that they feel unheld, unsupported and unprotected. Such
patients seem to have the constant illusion that they are on the
brink of being dropped - of falling. This is another important
factor in their autism.
Threat of falling In psychotherapy, as patients emerge from
autism, they show very clearly that they feel on the brink of
'falling' or of being 'dropped'. For example, breaks in the
continuity of the physical presence of the analyst, such as
114 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
Such a child never experiences 'missing'. In his concretized
mode of experience, absence of a needed person is experienced
as a 'hole', which can be filled immediately with an autistic
object. He experiences 'emptiness' and 'nothingness', which are
different from missing a needed person. T h e persistent re-
petitiveness of some autistic children in psychotherapy may be
the result of our undue collusion with their use of autistic
objects. Also, if the analyst is unduly passive and malleable, he
can become used as an autistic object. It is progress in the
analysis of an autistic child when he begins to miss the analyst.
Until this occurs, he has replaced the absent analyst with
autistic objects which block any sense of lack and the
consequent development of memories which compensate for
this lack.
Another deleterious effect of the undue use of autistic objects
is that in times of extreme crisis hard autistic objects are liable
to break under the strain, and to let the child down. This is due
to their inflexible, rigid nature, which makes them brittle. It
also comes from their being inanimate obects. Alive people can
grow and change and be healed. They can recover from states
in which they failed the child. Inanimate, inflexible autistic
objects can seem to break irreparably. Also, autistic objects are
cast in the mould of innate dispositions and in their formation
have not been wrought by experience as, for example, the
transitional object has been. T h u s they are more liable to snap
and break. Such an irreparable breakdown is the source of the
autistic child's despair.
T h e autistic child (or the autistic child in all of us) is always
trying to rubber-stamp the world in terms of rigid systems
which seem to be safe. I n doing this, an endless succession of
autistic objects is manipulated and these hamper genuine
change and growth. Thus it is obvious that the study of autistic
objects has implications far beyond the study of the serious
mental illnesses of childhood which bring such tragedy to the
families in which they occur. They can also bring tragedy to the
societies in which we live. However, these wider implications -
 AUTISTICOBJECTS 115
such as the part they play in bigotry and fanaticism - cannot be
developed in this chapter, which is concerned with the
development of autistic pathology in children.
Therapeutic implications of these understandings
Firstly, in the therapeutic situation, this replacement of needed
people by autistic objects which help the child to feel im-
penetrable and safe leads to behaviour on the part of the child
which, to the outside observer, appears idiotic, but to the child
seems essential. It is only by finding what such behaviour
means to the child, and by entering and understanding his
world, that we can help him. If we stand outside and merely
describe it, we shall try to manoeuvre and manipulate him into
our more normal ways of behaving. This will leave untouched
and unmodified the rages and panics which give rise to his
peculiar state. Also, if we ruthlessly deprive him of his autistic
objects we shall expose a hypervulnerable child to unbearable
terrors. T o cope with these he may develop an even more
entrenched form of autism. Thus, the handling of the transition
from the undue use of autistic objects to developing feelings of
trust in the alive human beings around him needs consummate
tact, patience and skill. It cannot be done in a hasty, mechanical
way. We need to wait patiently for the appropriate moments
when we can demonstrate to him that human beings, in spite of
their unpredictability and mortality, give more long-term and
effective support than these objects imbued with excessive
auto-sensuousness.
Secondly, the foregoing understandings concerning the
nature, origins and functions of autistic objects enable us to take
a compassionate but unsentimental view of psychogenic
childhood autism. Those workers in the psychological and psy-
chiatric field who propose inhumane methods for the treat-
ment of these children may begin to realize that, behind such
children's seeming lack of fear, there is a terror so great that it
cannot be expressed. This needs to be put into words by the
therapist who supports the child in experiencing it. This does
192 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
musical. For example, an Italian psychotherapist described an
emergent psychogenic autistic child as 'speaking in poetry'.
Thus, in the process of bringing them 'down to earth', it is
important not to destroy their aesthetic capacities, as some
methods of treatment seem to do.
On the other hand, we must be realistic about the state of
psychogenic autistic children if left in their autistic state. Some
workers have idealized these children, to the point of equating
them with Contemplatives and even Buddhas. Others have
seen them as being engrossed in a world of wonderful fantasy.
Neither of these ideas fits the facts. In fact, autistic children
are so mentally retarded that they have not developed fantasies
or thoughts. They are so undifferentiated from the outside
world that they are incapable of imagination and empathic
identification with other people (Frith, 1985; Hobson, 1986).
Their capacity for symbolization is rudimentary. Theirs is a
world based almost entirely on their own bodily sensations,
through which they experience a very different world from that
which we apprehend by our more developed perceptions. It is
very arid as compared with the richness of the world of the
normally developing child who can play and use 'let's pretend',
neither of these resources being available to the autistic child at
the beginning of treatment.
However, as we become more closely in touch with such
children, we begin to feel an affinity with them. We begin to
realize that they are reacting in terms of inbuilt predispositions
which are the basis for all human activities. It is for this reason
that Dave's account of a state which has parallels with that of a
psychogenic autistic child has been presented. But there is
another reason for presenting Dave's experiences: in psycho-
genic autism, automatic reactions to upsetting experiences
which seem to carry the threat of being dropped or of falling are
very significant. Let me now discuss such experiences.
Psychogenic autism as a state of being bnpped silly' As we
have seen, Dave's behaviour on the crags has some striking
 FALLING 191
the neurotic patients with a hidden capsule of autism. As they
face their terrors, the autistic scales fall from their eyes; their
perceptions become sharper and clearer. T h e psychotherapist
helps them to bear this enlarged perception. These aesthetic
experiences enrich and enlarge their enjoyment of the ordinary
world and ordinary people. Dave implies this when he writes:
As we dropped into the valley with its farms and warm
evening lights, so our spirits settled to the tolerable level of
conversation and laughter. And back in camp we said we'd
had a good day and listened to the stories of the other groups,
whilst I smoked a pipe and browsed in the rich contentment
of my own secrets.
But to reach this state, as in the Sagas, the individual has to go
through testing ordeals which need to be faced with heroic
courage. T h e patient who remains 'gripped silly' by terrors has
avoided them by the autistic manoeuvres discussed in previous
chapters. T h e psychotherapist's job is to help such patients to
face their terrors which, unlike Dave's actual experiences, are
illusory ones. In doing this, both therapist and patient come to
realize that they are part of a process which is larger than
themselves. As the men in the Sagas used to say, 'Men die,
cattle die, you die, but the world story does not die.'
Dave felt that he became part of a 'vast orchestral pattern', in
which he played his part not in a slavish imitation of Alan,
the experienced leader, but - important point - with his 'own
inevitable variations'. Facing his terrors had enabled him to be
enriched by them.
It is a state which we hope some psychogenic autistic
children, and some neurotic patients with a capsule of autism,
can achieve. But this is not an easy task, either for patient or for
therapist. Psychotherapy which is closely in touch with the
nature of their disorder is essential. It seems to me to be
appropriate that poets and artists have been enlisted to help us
in this journey into the mind of a psychogenic autistic child, for
some of these children (though not all) are poetic, artistic or
116 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
not mean that unbridled abreaction is the order of the day.
On the other hand, those educationists who are unduly
permissive in their approach to these children may change some
of their attitudes. Both they, and some psychoanalytic ther-
apists, may become more active and rigorous in discouraging
and even stopping pathological activities. Some objects may
even have to be taken away from the child, so that he can
develop more appropriate ways of relieving tension. Or, we
may be more strict than we are with neurotic children about
whether we allow a child to take toys home with him, or to bring
toys from home to the consulting-room. However, any such
action on our part needs to be associated with interpretations
which show that we understand the meaning of such behaviour
to the child. As well as being both more disciplined and
disciplining in our technique in the consulting-room, rec-
ognition of the impeding efforts of autistic objects will modify
the ways in which we couch our interpretations. This should
make treatment more effective. As the child begins to feel held
in our awareness by our thought, care and concern for him, he
begins to hold experiences in his mind as thoughts, memories
and imaginations. The undue use of autistic objects begins to
wane. As Bion (1962a) has pointed out, the mother mediates
sanity to the nursling as well as nourishing milk. By their
sensible attention and behaviour, therapists can convey such
sanity also. The feeling-tone of the therapeutic setting is of
especial importance to autistic children.
Thirdly, it has been my experience that an autistic object is
often mistaken for Winnicott's transitional object. These
understandings concerning the nature of autistic objects should
help to prevent this. Confusion between autistic objects and the
transitional object leads to mismanagement in both education
and psychotherapy, in that the caring person colludes with the
use of autistic objects instead of patiently and gently weaning
the child from using them so inappropriately, by giving him
more authentic means of protection. In terms of Winnicott's
(1958) definition of the transitional object as 'the child's first
 AUTISTIC OBJECTS 117
not-me possession', it can be said that autistic objects are
elemental 'me-possessions'. They are not companionable
objects as is the transitional object; their role being that of
protection and escape from danger. Also, autistic objects are
peculiar to each individual child, transitional objects such as
teddy bears and comforting pieces of cloth being objects the
like of which many other children use. That is, they have
communality in their use (Winnicott, 1958; Gaddini, R.,
1978).
Fourthly, understanding the nature and function of autistic
objects enables us to have a deeper understanding of the ways in
which the development of the mental life of autistic children has
been impeded. For example, we begin to realize that the autistic
child's eccentric and impatient way of relieving himself by the
persistent and pathological use of autistic objects has prevented
him from learning the appropriate skills and techniques which
he can share with other human beings in his culture. Thus, an
educational setting in which, as autistic objects are given up,
the child can begin to learn from experience and be'helped to
make the basic distinctions and integrations which, in normal
development, are taken for granted is a valuable adjunct to
psychoanalytic therapy.
In psychotherapy, we shall be more aware of such children's
lack of, or shaky capacity for, symbol formation. Symbol
formation is based on the capacity to use substitutes for actual
things and situations. It is also based on the capacity to feel
separate from the outside world and thus to use abstractions.
The use of material objects which are felt to be part of his body
and permanently to replace the real thing has prevented the
autistic child from doing this. Thus, we shall not read into his
behaviour the complicated fantasies and ideas which are
encountered in neurotic children, but which are not possible for
him. We shall realize that the complicated and esoteric in-
terpretations which are sometimes given to autistic children do
not convey to them the meaning they have for us, although they
will probably feel 'touched' (quite physically) by our care and
190 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
hills and sky seemed near and in sharp focus, their beauty
almost painful.'
His aesthetic vision had been released from numbing terror.
When they get out and about again, people who have been
confined to hed for a long time through physical illness often
describe such intense responses to the beauty of the outside
world. As they are released from their autistic capsule, some
neurotic adult patients describe aesthetic experiences similar to
those of Dave. Anne Bronte expressed this state poignantly for
us when she wrote in 'On Becoming':
Oh dreadful is the check - intense the agony -
When the ear begins to hear, and the eye begins to see;
When the pulse begins to throb, the brain to think again;
The soul to feel the flesh, the flesh to feel the chain.
Anne Bronte describes something like the experience of 'hot-
aches' when a limb is recovering from being frozen. It is the
state of some autistic patients as they emerge from the state of
'emotional cold storage'. It was the state of Elly in Chapter 6,
who could not talk about the beauty of the moon because of the
painful response it evoked. When one contrary becomes fused
with its opposite, it is a state of luscious pain, just as when one is
facing the edge of a precipice, and the dread of 'falling' becomes
fused with the fascination in doing so. Anne Bronte describes
this state of fusion of opposites: the return of feeling is an
agonizing pleasure, it is an excruciating rapture.
T h e study of psychogenic autism is the study of the
narrowing of perception through terror, but it is also the study
of the undifferentiated fusing of sensation, which gives the state
its unbearable poignancy. T h e autistic patient had felt that the
only thing to do was to mute this unbearable undifferentiated
responsiveness. Some poets seem to have gone through such
vibrant but harrowing experiences to emerge to a sharper
enriched perception, which, when they tell us about it, makes
life more vivid for the rest of us. They have needed great
courage to do this; as do the psychogenic autistic children, and

connection with the mourning he experienced on the untimely
death of his friend Hallam. He wrote:
I leave this mortal ark behind,
A weight of nerves without a mind,
And leave the cliffs, and haste away
In Memoriam, XII
Dave describes a state of what he calls 'emotional cold storage'.
This was a different state from that of the previous day when
the 'fright' had descended upon him unawares. He was reacting
in a way that would enable him to go on living. He watched
himself from the outside with crystal-clear clarity. A friend of
mine who was threatened by a fierce dog, in a situation in which
no help was forthcoming, described a similar situation of
thinking with unusual clarity about what she had to do to get to
safety.
At certain stages in their treatment, when they are re-
experiencing fundamental threats to their 'going-on-being' - of
which falling is one - autistic children go through 'out-of-the-
body' states in which they behave like a robot or a zombie going
through automatic motions. In these states they will say such
things as 'He will do this', or 'He will do that9,and not 'I will do
this or that.' In a paper as yet to be published, Mrs Enid Balint
has described a patient who, for a very long time, only spoke of
himself in this disembodied way. Such patients feel that,
having left their body, there is an armoured carcass which walks
around automatically, and is hollow and empty, like the Tin
Man in The U.'izard of Oz, or the hollow men in T.S. Eliot's
poem of that name.
But Dave's 'out-of-the-body' experiences were of short
duration. He writes: 'There was, in effect, a return to
consciousness, a consciousness which became aware of one
whole person, all of him - body and mind ...IThis state of
enlarged perception was associated with what Dave calls 'a
vibrant elation'. Of this state he writes: 'Whenever we rested,
118 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
interest. Paradoxically, a more sophisticated understanding
will simplify our approach to these children.
Fifthly, this understanding of the nature and origin of
pathological autistic objects would seem to throw light on the
perversions and also on the development of fetishistic objects.
There have been attempts to relate Winnicott's concept of the
transitional object to the development of fetishism (Greenacre,
1970), but findings from work with autistic children would
seem to indicate that fetishistic objects have more in common
with autistic objects than with transitional objects. T h e ob-
sessive quality in the use of autistic objects also indicates that
they could add to our understanding of the early beginnings of
obsessional neurosis.
Conclusion
In this chapter, human emotions such as love, hate, aggression,
envy and jealousy have not been emphasized as being the main
determinants of the child's behaviour. This is not because these
feelings are thought to be unimportant, but clinical work with
autistic children indicates that distress, panic, rage and
predatory rivalry (Gaddini, E., 1969) need to be talked about
with the child before interpretations about love, aggression,
envy and jealousy will be meaningful to him. There is much
evidence that autistic children have experienced an agony, of
consciousness in early infancy in which these more soph-
isticated feelings were experienced precociously and in a com-
pacted way. If we interpret these feelings too soon, before the
child has the primal basis to distinguish and bear them, we shall
reinforce the precocity which led to the development of an
empty fake. Our aim is to help a sincere but tactful child to
emerge from the artificial layers of autism with which he has felt
protected. T o do this, we have to be in touch with basic ele-
mental depths in ourselves.

CHAPTER SEVEN
Autistic shapes exemplified
in childhood psychopathology
Shape without form, shade without colour
Paralysed force, gesture without motion
T.S. Eliot, 'The Hollow Men', Collected Poems
T
his chapter is a revised version of a paper previously
published in the International Review of Psycho-
Analysis (1984) 11 :280-8. It seeks to study a
phenomenon which certain autistic children have called
'shapes'. T h e nature and function of these 'shapes' is in-
vestigated, and also the part they play in autistic pathology.
Finally, psychoanalytic therapy in which such 'shapes' play a
part is described.
'Shapes '
In the days when I was working as a psychoanalytic child
therapist with young autistic children, they would tell me, as
they began to talk, about their 'shapes'. I knew that shape was
important to such children because if they were testable at all
(and most of them were not), the psychological tests on which
they did best were those to do with the matching of shapes. But
188 A U T I S T I C B A R R I E R S I N NEUR(.)TIC P..ZTIENTS
help from a psychiatrist for the severe troubles that remained.
When asked by this psychiatrist what he remembered about
being autistic, he replied 'the terror'. The psychiatrist was
surprised because, as he said, autistic children do not look
terrified. This is quite true. The terror has been kept at bay by
their autistic practices. It is only as they emerge from autism
that they can tell us about it. Like the autistic child, Dave was
wellnigh struck dumb by 'vague forebodings' which flooded
over him and made him stand frozen and paralysed on the
crags. He says that he could only talk in monosyllables. 'There
was chatter but I could not join in.'
On the first day, when the horrifying experience had gripped
him, it had arrived unexpectedly. It was an unthought reaction
to an unconceptualized danger. The sense of danger and the
reaction to it were one. It was an automatic reaction over which
Dave had no control. In such a situation there is the reaction to
shrink away from the drop which looms ahead, and also the
need to clutch something solid. On the first day, Dave was
virtually struck numb and dumb by the elemental fright he
experienced.
The next day, Dave's reactions were different. He could
begin to marshal his reactions to cope with it. He feared that the
horrifying situation would return. As with the autistic children,
the reaction is to get rid of it. In their bodily mode of operation,
autistic children react by feeling that they sneeze, spit or
evacuate the upsetting experience away. Dave expresses
something similar, in that he feels that he has left it behind him
in the camp. It is an escape reaction. But it does not work for
long, for Dave says starkly, in a way which sends shivers down
the spine, 'it was there waiting for me at the crags.' He now
escapes from it in another way. In colloquial terms, he 'jumps
out of his skin with fright'. He says, 'This was not me standing
there. I became a detached observer of my own body.' He
watches himself climbing like an 'automaton'. 'I watched
myself coolly and steadily start to climb.'
Tennyson describes such a mindless, disembodied state in
 FALLING 187
Whenever we rested, hills and sky seemed near and in sharp
focus, their beauty almost painful. When we moved, nerve
and muscle resonated to each other and execution followed
wish with ease and clarity. One played one's perfect part in a
vast orchestral pattern.
Dave goes on to say that through this experience he acquired a
new humility, and that this hypersensitized, intensely personal
experience had enriched his participation in common human
experiences. Here is how he describes it:
As we dropped into the valley with its farms and warm
evening lights, so our spirits settled to the tolerable level of
conversation and laughter. And back in camp we said we'd
had a good day and listened to the stories of the other groups,
whilst I smoked a pipe and browsed in the rich contentment
of my own secrets.
Discussion
Parallels between Dave's experiences and those of autistic
patients Much of what Dave says about being 'gripped silly'
has many features in common with what we observe, or come to
realize, about autistic patients. When patients are
paralysed by the autism, they cannot tell us what it is like. It is
only as they are emerging from such states that, if we are
receptive, they can reveal to us something of its nature. Even
this is a matter of hindsight, but we get useful indications about
it. Let me remind you of some of Dave's comparable reactions.
For example: 'I was aware only of space and isolation and a
vague foreboding, which I could not, even to myself, call fear.'
This could be an emergent autistic child telling us what the
autism had been like. All such patients talk of the terror they felt
in that state. For example, Piggott (1979) describes a grown
man of twenty-five who had been diagnosed by Leo Kanner at
the age of four as s,uffering from early infantile autism, and who
had emerged from his autistic state sufficiently to be able to seek
120 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
I began to realize that the 'shapes' the autistic children were
talking about to me were not those objective geometrical shapes
which we all share. They were entirely personal shapes which
were idiosyncratic to them, and to them alone. They were not
the shapes of any particular object. They were just 'shapes', the
circle being an especially comforting one for all of them. I do
not know what other forms were covered by what they referred
to as 'shapes', but I do know that it was the bodily 'feel' of such
'shapes' which mattered to the child. These 'shapes' brought in
the rudiments of the notion of boundaries enclosing a space,
although they themselves were not located in external space
as are the shared geometrical forms to which we ordinarily give
the name 'shapes'.
As we shall see later, the feel of an object held loosely in the
hand could be a 'shape'. When it was used in this way, the
particular features which made it into a specific named object
were not differentiated or attended to. It was not the shape of a
specific object which existed in actuality; it was just a'shape'. I
inferred that it had arisen from inbuilt dispositions in the first
place. Later, we shall see that an autistic adolescent girl was
concerned to produce a bipartite 'shape' whose two sides were
symmetrical, whereas two shapes which exactly matched each
other were important to an autistic young man. It is
characteristic of autistic children that asymmetry, contraries,
differences and lack of fit to shapes are unpleasant and are
avoided.
With the younger children the 'shapes' of sound, smell, taste
and sight seemed to be 'felt' rather than heard, smelled, tasted
or seen. Such children's consciousness is very restricted be-
cause what they take in is so restricted; 'touch' being an avenue
of awareness which, in these younger autistic children, over-
rides other sense perceptions. Also, conscious and unconscious
levels of functioning are scarcely differentiated, although, at
times, these children can become agonizingly conscious as the
outside world impinges unexpectedly. The children struggled
to use words to tell me about these unverbalized experiences.
 CHILDHOOD PSYCHOPATHOLOGY 121 186 AUTISTlC BARRIERS IN NEUROTIC PATIENTS
It is a struggle for us to understand them. They seem so dif- body. There occurred a state of emotional cold storage, no
ferent from our own more differentiated experiences. How- excitement, no nervous clumsiness. And so it was that, when
ever, let me make an attempt to describe their nature still Alan called from the top of the first pitch, I watched myself
further. T o do this, autistic shapes must first be differentiated coolly and steadily start to climb. I was an automaton.
from those that can be inferred to be normal ones.
Following this facing of the terrifying situation, Dave describes
Normal shape-making activities It seems likely that the the gradual return of his morale and his confidence. Here it is,
normal human infant has an inbuilt disposition to form as he recorded it: 'Alan said, "Dave, move across to your right.
'shapes'. These primary 'shapes' are likely to be vague for- There are some good footholds at the edge, and the rock is quite
mations of sensation. They would tend to offset the random- dry".' Dave responds in the following way:
ness of the flux of sensation which constitutes the infant's early
These words came from the outside world. I had no idea how
sense of being. In the first place, these 'shapes' will occur
much time had passed or how I climbed. There was, in ef-
without the child's intervention. However, the child will soon
fect, a return to consciousness, a consciousness which
learn that he can make some 'shapes' recur Gy his own move-
became aware of one whole person, all of him - body and
ments. Thus, as well as arising spontaneously, they will become
mind - striving to climb well and climbing with enjoyment.
self-induced. These early shapes arise from the 'feel' of soft
bodily substances such as faeces, urine, snot, spit, the food in T h e enjoyment swelled to a confident and vibrant elation.
their mouths, and even vomit, some of these being elements for In a moving and vivid way, Dave describes his return to
repeated experiences. However, it is the 'shapes' rather than the normality. This needs to be quoted at length.
bodily substances which are important to the child. The bodily
Alan was in view for nearly the whole of the first pitch of the
substances are merely shape-producers, In normal de-
buttress, which we climbed with a steady, unhurried ease. As
velopment, this shape-making propensity will soon become
he moved from one stance to the next there was a harmony
associated with the actual shapes of actual objects. This will
and melodic quality in his pauses and progress without
result in the formation of percepts and concepts which facilitate
discord or jarring note. T h e pleasure of arrival at a good new
a working relationship with objects in the outside world which
stance in a climb has in it something of the pleasure of
can be shared with other people. Normal sensation shapes are
striking a new note which rings true, and in tune with others.
the basic rudiments for emotional, aesthetic and cognitive
Having played out his tune, Alan called, and I followed his
functioning. If things go wrong here, then dire trouble is in
theme with my own inevitable variations. I reached him and
store. This is what happened with autistic children.
paused, waiting for him to shift so that I could belay and he
move on again. But he glanced up the climb, then looked at
Austistic children's 'shapes' In autistic children, the shape-
me, and grinned, 'You lead through,' he said, 'I'll follow.'
making propensities have taken an atypical course which ser-
Surely, the tune which followed, the first I had ever com-
iously hampers ongoing psychological development. Because
posed myself, faltered and wavered. 1 have only a vague
their 'shapes' are unshared with other people, they become
memory of it, but the sense of playing it is clear, etched and
entirely personal and peculiar. They are much more contrived
enshrined.. . We climbed all day.
than those of normal children, their use of regurgitation of
 FALLING 185
stance to ease the cramp in my leg, that I dislodged a piece of
rock - perhaps the size of a cricket ball. I glanced down but
found I could no longer do so without dismay ... The very
faintness of the stone's final rattles as it joined the scree 400
feet below emphasized the quiet, the height, the space and
the isolation ... I was aware only of space and isolation and a
vague foreboding, which I could not, even to myself, call
fear. When Jean arrived I could only talk in n~onosyllables.I
muddled the rope as we changed positions for her to belay: I
started to climb again, clumsily and without iest.
Dave goes on to describe the rest of the climb, which he did so
badly and unskilfully that Alan, the leader, reproved him.
During the scramble down, and when they were back at camp,
Dave was uncommunicative. He couldn't think about the next
day's climbing, but he knew he had to do it.
He slept badly. He writes: 'imps of pain played hyde-and-
seek with lurking doubts amidst the shadows of my mind. I
rose neither refreshed nor reassured but dully resigned to see
the day through. I felt somehow detached from reality.' He then
describes his reactions as they walked to the next day's climb. 'I
had a sense of walking away from my problem, of having left it
in camp. But,' as he says chillingly, 'it was there waiting for me
at the crags.' He continues: 'There within the compass of one
gaze, was the whole climb. I knew from the first moment of gaz-
ing that all the misgivings of last night were with me still. I felt
rather sick . . . There was chatter, but I could not join in.'
Dave then describes how Alan suggested that perhaps some
of the party might like to walk rather than climb today. As Dave
says, 'This was clearly a moment for retreat with honour.' But
Dave knew that he must face his horror and not retreat from it,
so he opted to climb. He writes:
With the certainty of unwanted yet welcome decision, there
returned the early morning feeling of unreality, stronger and
sharper. I was involved, yet took no part. This was not me
standing there, I became a detached observer of my own
122 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
food, for example, being similar to that of infants suffering
from 'rumination' (Gaddini, R. and E., 1959). Their use of
contrivances gives their functioning a stilted, mechanical
quality.
When they first come into treatment, young autistic children
are usually not toilet-trained. At home some of them smear with
their faeces, presumably making 'shapes' on their skin. When
they become toilet-trained, they manipulate the faeces in their
anus to make 'shapes' on the skin surfaces there (outside and
inside of the body not being clearly differentiated). This is not
to imply that, at this stage, the child does anything as developed
as drawing a shape. It is the impression of a shape which these
young children obtain on body surfaces. Nor are the skin
surfaces differentiated clearly as such, they are merely the
medium upon which the impression of 'shapes' arises, some
surface media being more sensitive than others.
The young autistic children told me that they wriggled or
rocked their bodies to make 'shapes' from bodily substances.
Spinning and swinging also produced them. The children also
bubbled with the spit in their mouth or the snot in their nose.
These bubbles were experienced as the 'felt' sensation of a
circle, and not as a three-dimensional object located in external
space. 1 presume that all the 'shapes' had this two-dimensional
quality, although most of them would not have such a precise
shape as that of a circle. (In discussing such elemental pre-
image manifestations which arose in his pyschoanalytic work
with the psychosomatic disorders of adult patients, Eugenio
Gaddini (1982) makes especial reference to the circle.) '
These autistic 'shapes' were also produced by non-bodily
objects and processes experienced as if they were bodily ones.
The 'felt' shapes produced on the child's bodily surfaces by
these non-bodily objects and processes did 'not lead to their
being shared with other people, as is the case with more normal
children. The objects and processes were at the service of the
autistic child's entirely personal idiosyncratic purposes. Like
the bodily substances they were merely shape-producing
 CHILDHOOD PSYCHOPATHOLOGY 123
agents. They scarcely existed in their own right for the child.
Some young autistic children are so unaware of the actual
existence of objects that they try to walk through them as if they
did not exist. I n the same way, they listen to other people's
voices, not as a communication but as a self-envelopment by
lulling shapes. Thus they are often thought to be deaf before it
is recognized that they are autistic. The children are capable of
forming elementary percepts and concepts from their shape-
making propensities, but these are idiosyncratic to them, and
they are not very interested in them; they are so captivated by
'shapes'.
The non-bodily equivalents to bodily substances are such
things as mud, sand, plasticine, clay, water, paint, and so on.
As we shall see later, toys can also be used in this way. Also, we
shall meet a thirteen-year-old girl who used arithmetical no-
tation, and an eighteen-year-old young man who used the letters
of the alphabet as equivalents to bodily processes. The
necessary quality of these equivalents is that they lend
themselves to being manipulated as 'shapes'. These 'shapes' are
not the differentiated shapes of actual objects as we see and 'feel'
them. Nor were the arithmetical and alphabetical processes
used as we would use them. They were used as contrivances to
produce the 'shapes' that the child wanted. Autistic children are
'stuck' in this peculiar mode of functioning. Very little ongoing
psychological activity takes place.
There was another important way in which the autistic
child's 'shapes' were different from those of more normal
children. They were repetitive and unchanging. Metaphor-
ically speaking, they went round and round in an unbroken
sequence. Unexpected, spontaneous 'shapes' which popped up
out of the child's control were upsetting. They struggled
laboriously to shut out the unexpected 'shapes' by trying to
make the known and familiar ones recur again and again. They
felt that things must not get out of their control. T o the child,
bodily movements were felt to be all-powerful to produce
known and familiar 'shapes'. These 'shapes' were also felt to be
184 :\L:rISTIC BARRIERS IN NEUROTIC P.4TIENTS
completed, but, before he died, Dave gave me permission to
use the paper in any way I thought fit.
I>are's experience of being kripped sill>*'
Dave opens his paper by describing the somewhat high-and-
mighty state of mind in which he, as an inexperienced beginner,
started his first climb. Here is his first sentence: 'I remember
thinking, this rock-climbing's a piece of cake. There's really
nothing to it for anyone with a reasonable sense of balance. I'm
a rock monkey. I can soon pick this stuff up.' Dave then goes on
to describe the start of the climb in which, in this somewhat
inflated state, he climbed nonchalantly and watched the others
climbing. But then - as he says: 'there came a flatter moment -
a period of waiting whilst climber number 3 climbed the pitch
below .' T h e experienced climbers had gone on and were out of
sight. Jean, who was number 3, was a less experienced member
of the group.
Dave writes about this waiting time as follows:
T h e sun was well down and had been off the rock fall for
some time; it was cold in the evening wind. T h e sweat of the
afternoon's exertions was now damp and unwelcome. I
shivered, chilled by inactivity.
'Bless the girl, I wish she'd hurry up.' But Jean was calling,
asking me to let the rope out; she had to retreat from an
awkward position and start again.
Dave continues :
T h e other more experienced climbers were now well away
from the crags and just occasionally a faint voice came back
on the wind. Otherwise it was quiet; quiet and getting darker
and colder.
Jean started again and slipped. It was almost nothing - no
more than six inches - but the tension in my right leg, as I
braced to take the strain, would not go when Jean was
climbing again. It was some time later, when I shifted my

CHAPTER ELEVES
Falling
He edged forward and looked down. There was a sheer
almost unbroken descent on the left and then the cleft in
the middle of the cliff, and above that, the tunnel ... He
went on hands and knees to the edge and looked down.
The cliff was visible for a yard and then turned in and
hit itself ...
A lump has fallen out of the cliff.
William Golding, Pincher illartin
T
his chapter seeks to demonstrate that psychogenic
autistic children are in the grip of elemental terrors
which are part of the inborn lot of all of us, though not
to the same degree. I n particular, it will suggest that the
automatic reaction to the threat of falling is one which has
immobilized them, and one with which we can empathize. T o
d o this, I want to share with you some extracts from an at-
mospheric paper written by a late friend of mine who, in his
first experience of serious rock-climbing, was - in rock-
climbing jargon - 'gripped silly' by the terror and fascination of
falling.
Dave hlunrow was a very normal person. He was a fine
athlete, and head of a university department of physical
education. T h e paper from which extracts will be quoted
(Munrow, 1950) was to be a chapter in a book on the aesthetic
aspects of sporting activities. Unfortunately the book was never
124 A U T I S T I C BARRIERS I N N E U R O T I C PATIENTS
all-powerful in that they could make the child feel soothed and
comforted or, if they got out of control -for example, a loud and
unexpected noise hitting his ears - they could upset him.
'Shapes' had powerful effects upon his moods. He tyrannized
over them and they tyrannized over him. He was enthralled by
them. The child felt that the existence of the magical 'shapes'
depended upon his activities, and that he depended upon their
magical presence to give him a sense of 'being'.
Just as the philosopher Bishop Berkeley felt that his'looking'
created the world, so autistic children feel that their 'shapes' are
all-powerful to create it. With the younger autistic children,
these were primarily 'felt' shapes; with the older children sight
became important also. Of course, we all create our world in
that, in terms of our modes of perception, we construct a
working simulation which helps us to function in what we
quaintly call 'the real world'. We all share the experience of the
Scandinavian god Odin who, at the beginning of time, before
he could create the World, leaned over a bottomless chasm until
the swirling mists below formed themselves into shapes.
'Shapes' are the primary means by which we create both our
inner and our outer worlds. The trouble with autistic children
is that their 'creation' is unduly 'quirky'. They have used the
shape-making propensities of the human mind in their own,
idiosyncratic way. The evolution of their construction has not
been modified by co-operative interplay with other people. It is
also unduly suffused with crude auto-sensuousness. This
makes the children pick up the wrong cues for ongoing psy-
chological development. They becoae trapped in a vicious
circle from which they cannot escape. Only what they can
easily manipulate seems real. 'Shapes' are easier to manipulate
than actual objects used as actual objects, thus 'shapes' seem
more real.
This means that the activities of autistic children are mostly
asymbolic. They do not play, dream, fantasize or imagine to
any appreciable extent. It is progress when, in treatment, such
a child has visual hallucinations. (The 'shapes' may be a kind of
 CHILDHOOD PSYCHOPATHOLOGY 125
tactile hallucination.) They do not suck their fingers or their
thumbs. Nor does genital masturbation appear. It is progress
when they do these things. It is great progress when they begin
to play. Through lack of contact with other people's 'shapes',
which could change and transform their 'shapes' into common
coin, they are cut off from the enriching psychological
possibilities of everyday life with ordinary people. Their
thinking, if it can be called such, is restricted and meagre.
Imagination is completely lacking. Speech is either absent or
cripped by echolalia. Their emotional life is similarly muted,
except on the rare occasions when it bursts forth in an explosive
way which is terrifying to the child.
In Greek mythology Morpheus, the son of the god of sleep,
could change his shape at will. From this we get the term
'morphology'. Winnicott has suggested the term 'psychomor-
phology' for the study of psychological forms and shapes. This
chapter concerns an aspect of psychomorphology which is con-
cerned with non-objective shapes. We live in a world domin-
ated by words and by the shapes of actual objects. In studying
autistic children we have to try to enter a wordless world
dominated by self-induced, amorphous, unclassified, con-
cocted 'shapes'. Writing this chapter has brought home to me
how difficult it is to cross the threshold into this world. The
reader may be finding it as difficult as I did.
T o help you to understand it, try a little experiment. Forget
your chair. Instead, feel your seat pressing against the seat of
the chair. It will make a 'shape'. If you wriggle, the shape will
change. Those 'shapes' will be entirely personal to you. T h e
autistic child's attention becomes so focused upon these entirely
personal 'shapes' that the chair, as such, is not important to
him, although he may be vaguely aware of its existence and may
even know its name.
Perhaps this has made it a little clearer. It may become
clearer still when these 'shapes' are seen in action in actual
children.

PART TWO
Psychogenic autism
in neurotic patients
The sooner the analyst realizes the existence of this hidden
part of the patient the less the danger of the analysis
becoming an endless and meaningless intellectual
dialogue, and the greater the possibilities of the patient
achieving a relatively stable equilibrium. Although the
analyst has to live through a great deal of anxiety with the
patient, I feel ultimately the results make it worthwhile.
Sydney Klein, 1980, p,401
126 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
Autistic 'shapes' in action
T h e stereotypes which are so characteristic of autistic children
are an exhibition of the child's shape-producing activities. Mrs
Shirley Hoxter described a moving example of such a
stereotype when she wrote as follows:
On my way to the clinic, I drive past a couple who are slowly
making their way along the pavement - apparently a father
taking his twelve-year-old(?) daughter to school(?). Every
now and again the girl stops, obviously immovable, she holds
u p her hand, twists it and twiddles her fingers, gazing at it in
entranced joy. Nothing else in the world exists and certainly
there are not joys like this to be found elsewhere. Her father
stands by, patiently waiting for long minutes like someone
resigned to chronic, repeating spasms of pain. T h e eternity
of suspended time is over. They proceed on their way for a
few yards and then it is repeated. (personal communication)
As I read this account, I feel full of sadness that the girl could
not turn to her caring father for comfort and reassurance from
her terrors, instead of resorting to her concocted, self-induced
'shapes'. But at twelve years of age this is likely to have become
an established way of life. It would be very difficult to help her
to change it. However, it has been my experience that it is
possible to bring about changes if autistic children come into
psychotherapy at under seven years of age or thereabouts. If
such psychotherapy is to be tactful and sensitive, we need to
understand some of the functions that 'shapes' have for the
chidren. However, before discussing them, autistic 'shapes'
need to be differentiated from autistic 'objects'. This latter
phenomenon was described in a paper published in my book
Autistic States in Children (1981). Such 'objects' had been
hinted at in my earlier book Autism and Childhood Psychosis
(1972).
I understand them better now. As one lives with such
elemental phenomena they become better understood and their
 CHILDHOOD PSYCHOPATHOLOGY 127
critical importance to psychotherapy with autistic children
becomes realized. (I now prefer to call them 'auto-sensuous
objects', particularly in their normal manifestations; 'autistic'
can then be restricted to pathological ones.)
Autistic 'objects' Autistic 'objects' also arise from self-induced
bodily sensations. Like autistic 'shapes' they arise from auto-
sensuous activities. Their difference from 'shapes' is that they
are stimulated by hard bodily substances such as hard faeces,
hard snot, hard muscles, and hard bunched-up tongue or the
insides of the cheek. They are experienced as clusters of hard
sensations. In these instances the child's body is tight and taut.
Later, hard objects such as toy cars, toy trains, keys, etc., are
used as if they are part of the body to give the child the same
sensations as those aroused by the hard bodily substances. The
actual, detailed features of the objects are not attended to other
than those that the child wants. These are the 'feel' of their
surfaces and outlines. Autistic 'objects' are different from the
soft, amorphous 'shapes' in that, as well as being hard, their
outlines are rigid and static. They do not change as those of the
malleable, fluid 'shapes' can do.
Both Bick (1968) and Meltzer et a/.(1975) have described
the way in which unintegrated children feel that their skin
surfaces 'adhere' to other surfaces in order to offset their terror
of falling apart or spilling away. Autistic 'objects' meet this
need. The autistic child presses a skin surface against the hard
surface of an object, for example, a small car held tightly in the
palm of his hand. The hard, well-defined cluster of sensations
caused by this gives him a sense of bodily definition as well as
making him feel secure and safe. Since the child's body
becomes equated with the hard objects to which they adhere,
'adhesive equation' would seem to be a more appropriate
description of them than the term 'adhesive identification' as
suggested by Bick (unpublished paper). Bick was obviously
dissatisfied with this term since in private communications she
changed it to 'adhesive identity'. Based on Eugenio Gaddini's
180 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
so could avoid the bodily separation which meant loss of the
sense of 'being' which we call 'death'. The comedian Woody
Allen described such evasion pointedly and humorously when
he said, 'It's not that I'm afraid of death. It's just that I don't
want to be there when it happens.' Disembodied states in
relation to the terror of death will be illustrated in Chapter 11,
'Falling'.
One function of the autism of autistic children seems to be to
feign 'death' (loss of being), by the reactions of immobiliz-
ing their bodies and numbing the sensations in their extrem-
ities. By these means, they feel that they avoid sudden and
catastrophic 'death' (bodily separateness from the eternal
'breast'), which happens uncontrollably and unexpectedly. In
some ways, it is akin to the 'freezing' 0f.a frightened animal.
Chiara Cattelan, an Italian paediatrician who, from time to
time, brings clinical material from an autistic child for
supervision with me, has described her child patient thus: 'M
seems like a mummified body. He is like a Pharaoh who finds in
death the possibility of keeping his body splendidly intact. His
eyes are the only part of the mummy which is not bandaged up,'
This image of a mummified body is particularly apt because
life in ancient Egypt was dominated by the need to preserve
bodily continuity to avoid the ending and parting of death. The
penultimate chapter of this book describes a neurotic adult
patient whose analysis was dominated by the need to preserve
the delusion of bodily continuity, in order to protect her from
terrors associated with bodily discontinuity from the mother of
her infancy. It was only when, drawing on my work with
autistic children, I became aware of her use of crude autistic
devices to maintain this delusion, that termination with this
patient became a possibility. The next part of the book will be
concerned with such neurotic partients.
 THE WORLD OF AN AUTISTIC CHILD 179
practices cut them off from the actual mother and from other
human beings, as well as impeding emotional development and
effective thinking.
Daisy's use of the plastic straw as an autistic object and her
use of 'gesture drawings' as autistic shapes illustrate these
points. But Daisy was emerging from autism and could talk
about it. When the child is in an out-and-out autistic state, he or
she is paralysed by it and cannot speak. Daisy can speak and
uses the phrases 'savage thoughts', 'sad thoughts' and 'bliss-
ful thoughts' for what, in my writings, I have referred to as
'tantrum', 'grief' and 'ecstasy'. A depressed mother whose
capacity to bear these extreme states is very restricted cannot
help her infant to come to terms with them. Faute de mieux,
the infant is driven to develop the autistic reactions that have
just been described to protect him or her from unbearable
sensations. Daisy refers to these autistic reactions as 'cover
thoughts' or 'blanket thoughts'.
But Daisy is also beginning to feel that she has to give up
these autistic evasions of reality: to make 'sacrifices', as she says
- if she is to get the desired 'luciotta'. With the illumination of
D r Levis' insights, she is beginning to become conscious of
some of the states against which the autism had been a
protection. In a confused way, she communicates with Dr
Levis about this by writing, drawing and speaking. However,
after being startled by the interruption of the sound of her
mother leaving, the desire to communicate with him took
second place to Daisy's alarmed and frantic need to feel
continuous with her 'mum-father-doctor'.
As these autistic reactions abated, Daisy was aware that she
could not really fly away. (You will remember that she says,
'having that you see it would be beautiful as if I could fly.')
When fully immersed in an autistic state, she would not have
recognized this as an impossibility. She would have felt that she
And flown away from her terror of endings and partings. She
might have felt that she was inside the body of the powerful
'mum-father-doctor', or that she was outside her own body, and
128 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
useful clarifications (1969), 'imitative fusion' would seem to be
another possible description.
It is important to realize that, since the child's body seems
fused with 'autistic objects', these have scarcely reached the
status of an 'object' in the usual sense of that term. The child's
attention becomes so riveted upon these hard, object-like
clusters of sensations that they prevent the normal use of actual
objects, distinguished as actual objects which are separate from
the body. They also prevent the development of relationships
with people, who - by contrast with autistic 'objects', which are
always available - seem unreliable. 'Autistic objects' need to be
differentiated from Winnicott's 'transitional object' which,
having reached the status of an object, and being a combin-
ation of 'me' and 'not-me', can facilitate ongoing psychological
development.
Let me now return to the discussion of autistic 'shapes' and
try to elucidate their function for the child.
The function of autistic shapes As well as distracting the
child's attention away from the 'not-me' outside world, the per-
severative recurrence of self-induced, familiar 'shapes' is
important in calming autistic children after an explosion of
tantrum or ecstasy. These extreme states are terrifying to such
children. They feel that they will be blown apart and spill away.
The hardness and definition of autistic objects helps the child to
feel safe and secure - they feel 'all buttoned-up'. The amor-
phous softness of auto-sensuous shapes is soothing and com-
forting. They are like a self-induced warm bath which is always
on tap. The 'shapes' induced by bedwetting are an example of
this function.
Mr Park, the father of an autistic adolescent girl, Elly, has
written an interesting paper in which he describes the
obsessional 'shapes' Elly used to calm herself down after
such explosions (Park and Youderian, 1974). He calls them
'ordering principles'. Twelve-year-old Elly's shape-producing
equivalents of bodily substances were numbers. For Elly some
 CHILDHOOD PSYCHOPATHOLOGY 129
numbers produced 'nice' sensations and others produced 'nasty'
ones. Some numbers aroused such 'rapture' (as the father terms
it), that they were unutterable; Elly could only write them.
The moon was number 7 for Elly. The father describes her
unutterable rapture about the full moon. 'On the nights fol-
lowing a full moon, it rises outside Elly's window and stays for
..
several hours partly visible behind a large tree . she will not
say its name but will refer to "something behind the tree". . . if
the moon is obscured, Elly lies in bed and cries her tearless
autistic cry' (p.316). As well as the moon's being number 7,
so were the sun and a cloudless sky. Seven was a rapturous
number.
Elly had a system of doors based on numbers with which she
dealt with her states of rapture. Here is her drawing of that
system :
The sun with many rays and no clouds obscuring it represented
Elly's greatest joy. For this, she had to have four doors to cope
with her ecstasies about it. A sun with fewer rays and one cloud
178 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
They are what Dr Bion has called 'thoughts without a thinker'.
Dr Levis had to be the 'thinker' for them until Daisy could
'think' them for herself. She felt turgid with these unthought,
unthinkable 'thoughts'. These partook of the nature of bodily
evacuations ('discharges', as she called them). Her depressed
mother had not been able to tolerate these in either their bodily
or mental aspects. By accepting them and trying to understand
them Dr Levis was helping Daisy to accept and to come to
terms with them.
These unbearable 'sensation thoughts' concerned Daisy's
infantile feelings about bodily separateness experienced in a
state in which the mother and her breast, when lost, seemed to
have been an immortal, everlasting 'being'. Prior to its loss, it
had been taken for granted as being part of her body. Over-long
association with this mother, and the mother's over-supportive
attitudes, had confirmed this delusion. Sudden and inevitable
awareness of bodily separateness from such a being had seemed
to be a catastrophe from which Daisy never recdvered. She had
felt denuded of the very thing which made her exist. As an
infant, Daisy did not 'think' this as a 'thought'. It was a
sensation of loss and lack which has later depicted as a 'hole' or
as an empty space. It was experienced as a break in bodily
continuity - as what is later called 'death'.
Work with autistic children shows that this babyhood
experience has had far-reaching and longlasting effects. The
actual mother was rejected because she could not satisfy the
child's unrealistic expectations of her, although many of these
mothers struggle manfully to do so. (This is why the un-
founded criticism of them prevalent at one time amongst psy-
chodynamic clinicians was so hurting to them.) Instead of
relating to the mother, the child resorts to fabrications such as
autistic objects and autistic shapes. The significance of these
artefacts to the children is that they feel that they have a tangible
bit of an ever-present, everlasting, continuous pseudo-'mother'
which obviates the gap of separateness. But these autistic
 T H E WORLD OF AN ALJTISTICCIIILD 177
objects is to seem to block the hole of bodily separateness so that
a semblance of bodily continuity can be re-established. It will
be clear from this account that the infantile transference was
now in operation, and that Daisy was experiencing Dr Levis as
a powerful 'mum-father-doctor', continuity with whom en-
sured her own continuity of being. Without this 'mum-father-
doctor'- originally the mother's breast, or its substitute, and all
that is associated with this experience - Daisy felt that she
would cease to exist.
Dr Levis recorded that Daisy left with 'a dull and troubled
smile'. After a couple of minutes there was a ring at the door. It
was Daisy and her mother, who had rung 'by mistake', as
mother said, adding, 'We wanted to turn on the light.' It seems
that mother, as well as Daisy, feels the need for a 'Luciotta' to
protect her from the darkness of the chasm of interrupted
continuity with the all-important being who is felt to be the
source of power, comfort, security and 'thereness'.
Discussion
First of all, I want to say a few words about Daisy's use of the
words 'love' and 'thoughts'. It is useful that Daisy lets us into
the autistic world through a medium with which we are fami-
liar; but the words often have meanings which are idiosyncratic
to herself alone. The teaching she had had before coming to Dr
Levis had stimulated her to speak and to 'bark at print', but
these words were often used autistically. We need to try to
understand what the words meant to Daisy and to be careful not
to impose our own more sophisticated meanings upon them.
However, I think it is safe to say that from being virtually
devoid of emotions and thoughts, Daisy is touching the fringes
of such potentialities. At the moment for Daisy, 'love' seems to
be getting what she wants in a sensual way, and 'lovers'are those
who give her this.
Similarly, 'thoughts' are sensations and feelings which are on
the verge of becoming 'thoughts'. They are 'protothoughts'.
130 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
needed three doors. A sun with even fewer rays and three
clouds needed one door, whereas the sun with scanty rays and
four clouds obscuring it needed '0'doors (p.3 16).
In this we see the number basis of Elly's world. Just as
a younger child would have used the 'shapes' arising from his
bodily substances to create his world, so Elly used the 'shapes'
arising from numbers. This meant that she expected
arithmetical precision both from herself and from other people.
Enraged frustration resulted when her calculations were
disappointed.
Mr Park gave an example of this. It occurred when a guest
took the first helping from a salad which Elly had made, and
from which she had arranged in her mind that she would be the
first to take a helping. Another person's unexpected action
disturbed her world. T o calm herself down after the tantrum
which this provoked, she embarked on a skilful manipulation
of multiplication and division sums with large numbers, to
which she knew all the answers beforehand. From these manip-
ulations she got 'shapes', in this case the answers to her sums,
which were known and familiar. These numbers were
completely at her service and under her control. She
manipulated them so that she got 13691369 as the answer to her
sums. For Elly, the symmetrical 'shape' of such a number was
always comforting. The two sides were the same; they matched
each other.
This desire for matching 'shapes' and fear of lack of fit for
'shape' was illustrated by an autistic eighteen-year-old whom I
will call Tony. As with Elly , Tony's autistic condition had been
ameliorated by a caring family. After being sheltered by this
family and by a Rudolf Steiner school, Tony expressed the wish
to go to the local college of further education, which he did at
seventeen years of age. This was too stressful for him. He had
a breakdown in which he deplored his loneliness. T o solace
this, and to calm himself down after the upsetting experience of
the college, he resorted to what he called his 'play'. This con-
cerned 'shapes'. The caring parents could only sit on the
 CHILDHOOD PSYCHOPATHOLOGY 13 1
sidelines. They were completely cut off from him. The
headmaster of the college suggested to them that it might be
helpful to Tony if he made a tape recording of his'play'. He was
very willing to do this and the parents have allowed me to make
a copy of this tape recording.
The essence of what Tony said was that the right people had
to be 'matched' with the right house. The letters of the alpha-
bet were used as the basis on which this 'matching' took place.
For eighteen-year-old Tony, the letters of the alphabet were
equivalent to the malleable bodily substances of the younger
child, from which comforting 'shapes' would be manufactured.
The alphabetical system from which Tony's 'shapes' were made
is as follows.
If people had certain letters in their name, for example
d,o,m, then they would match with a house which had a name
that contained those letters. This idea was repeated over and
over again throughout the 'play'. Thus, Tony reinstated his
comfortable and reassuring view of the world by enveloping
himself in repeated familiar shapes which matched each other.
(I should say here that neither Tony nor Elly had had psy-
chotherapy, so their material was quite unaffected by psycho-
analytic ideas and by my views on 'shapes'.)
These children are powerful enough to impose their private
pattern of concocted 'shapes' upon the public shapes of the
outside world, and to get people to collude with these. They
want to keep everything on a dead level of sameness. Extreme
states of ecstasy or tantrum threaten to send them 'mad' with
excitement. In popular parlance, which is very revealing, they
threaten to send them 'off their rocker'. Both Elly and Tony
illustrated their frantic attempts to get back on to their 'rocker'.
Mr Park describes how Elly would sit in her little rocking chair,
listening to hard rock music. When it threatened to become too
much for her - that is, when it threatened to send her 'off her
rocker' - she would cover her ears to shut it out. Perseverative,
solitary rocking is very characteristic of these children. It is
their self-made brand of tranquillizer. The self-induced autistic
176 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
to get presents
to have sweet dreams.
Daisy also drew some butterflies. These, like the angel, were
'blissful thoughts'.
After engendering these 'blissful thoughts', Daisy's agitation
subsided and she wrote a somewhat less confused and frantic
communication to Dr Levis. In translation it read 'mum-father-
doctor having that you see it would be beautiful as if I could fly.'
You will notice that Daisy wrote 'as if I could fly'. A child in a
more total state of autism would have felt that he or she was
flying. Daisy was merely wishing that she could do this. As it
was near the end of the session, Daisy was probably sensing and
reacting to this imminent interruption to her 'going-on-being'.
When Dr Levis said that it was time to go, Daisy became very
upset and hastily started to draw some birds on the empty space
which was left on the sheet of paper she had been using. These
heavily drawn birds had a different 'feel' from the lightness
and delicacy of the angel and the butterflies. They seemed to
block the gap of separateness between her and the powerful
'mum-father-doctor', bodily continuity with whom she felt
guaranteed her sense of 'being'. When he seemed to speak in
'harsh and rude tones', that is, when he said things she did not
like, it broke Daisy's sense of bodily continuity with him, and
she felt reduced to a 'non-being' - to an empty space.
Dr Levis talked to her about her attempts to fill the gap of
separateness between them. After putting on her shoes Daisy
rushed to the bathroom saying, 'I'm thirsty. I'm thirsty.' D r
Levis interpreted this as her need to fill up the empty space so
that she did not notice the gap of separateness between them.
After this interpretation Daisy accepted that it was time to
leave. She met her mother, who had brought some bread baked
with olives. Daisy took this and ate it voraciously. 'To fill up the
hole', as D r Levis said, just as the plastic straw in her mouth had
performed this function at the beginning of the session, when
she had separated from her mother; one of the uses of autistic
 THE WORLD OF AN AUTISTIC CHILD 175
further interrruptions to her 'going-on-being'. Dr Levis has
given me translations of this disjointed, confused, frenetic
writing.
On the first sheet of paper, after writing her name, Daisy
wrote 'savage thoughts infinite' as a heading. She then wrote
what provoked these 'savage thoughts'.
(1) that dangerous things happen to me
that people talk in harsh and rude tones.
(2) that I find lovers who cry at me to drive
me away
that I find wrong lovers, because they do me
harm
that is to say they or other harms
that I am hated by people
At this stage of the session, although Daisy was still trying to
communicate, the flow of her writing was also important in
giving her the feeling that life went on in an uninterrupted way.
In the sentence 'that is to say they ... or other harms', Daisy
indicated that interruptions provoked 'savage thoughts'.
After a time the writing did not sufficiently discharge her
agitation, and she discharged it by some hyperactive capering
about the room. Eventually, however, she calmed down a little
as Dr Levis talked to her about how much she wanted him to be
a 'luciotta' - a light to lighten her darkness. Following this
interpretation, Daisy took another sheet of paper on which,
after writing her name as usual, she drew a stylized flat image of
an angel with wings, against which she wrote 'blissful
thoughts'. It was as if these were to counteract the 'savage
thoughts'. Dr Levis' translations of these 'blis-sful thoughts' are
as follows: 'blissful thoughts infinite' was the heading. Daisy
then wrote what provoked these 'blissful thoughts'.
to make the lover fall in love
to drive on the highway at full speed
to go to Heaven early
132 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S
objects and autistic shapes stimulated by this rocking are not so
much an attempt to express feelings as an attempt to clamp
down on them and to banish them. Of course we all do this to
some extent, but in autistic children it is a perpetually dominant
state. Thus, their inner and outer worlds do not grow and
change as do those of more normal individuals. They are not
sufficiently modified by interactions with the actual charac-
teristics of actual objects and with those of other people.
Their simulation remains a freakish construction which does
not help them to relate effectively to the actualities of the
outside world nor of themselves. Thus, the 'not-me' becomes
increasingly strange and frightening to them. Autistic objects
and autistic shapes divert their attention away from this
strange, frightening 'not-me'. The more their attention be-
comes focused upon these autistic procedures, the more remote
and strange the everyday world of ordinary people becomes.
Thus, the effect of these practices is that of alienation. In study-
ing autistic shapes and autistic objects we are studying the
anatomy of madness. An important part of psychotherapy with
these children is to lead them away from their idiosyncratic
autistic world into the shared world of sanity and common
sense, whilst at the same time preserving their originality and
individuality. T o do this tactfully and skilfully we need to
understand the nature and function of their diversionary dis-
tractions. For this we need to have some understanding of why
they may have resorted to them.
After many years of work with autistic children, I have come
to think that psychogenic autism is the result of an interaction
between a temporary state of depression or underconfidence in
the mother during the child's early infancy, and the particular
nature of the child (for an insightful understanding of the
mothers of these children, see Tischler, 1979.) Also, the father,
in my experience, has played a negative part in that he is either
absent, or too malleable for this powerful child. Although as
infants these children were physically well-cared-for, the psy-
chological ambience surrounding them was not adequate for
 CHILDHOOD PSYCHOPATHOLOGY 133
their needs. Ordinarily, the mother, in co-operative interaction
with the father, provides the child with a means of interpreting
and managing the world of sensations and emotions. Lacking
this, the autistic child has invented his own naive scheme
concocted from repetitive self-induced shapes. Excessive auto-
erotism stimulated by certain material objects has attempted to
compensate for their psychological lacks. Thus, 'me'-centred
manipulations and auto-sensuality have remained unduly
important.
By nature, autistic children react to difficulties by retracting
their psychological feelers. They opt out. This lack of empathy
affects their capacity to relate to other people (Hobson, 1986).
Also, work in the Institute of Childhood Neuropsychiatry of
Rome University suggests that some of these children may have
minor brain irritations and hormonal imbalances (De Astis and
Giannotti, personal communication, 1983). All this makes
them tricky infants to rear, even when a mother is functioning
normally. It has seemed to me that what began as their
particular .reaction to the mother's underconfidence and in-
attention becomes hardened over the years into terror-stricken
strategies. Almost the whole of their attention becomes focused
upon rigid contrivances, and thus they seem to be inaccessible
to human care. Without decisive therapeutic intervention, they
continue on the treadmill of their repetitive, all-powerful
'shapes' which are facile rather than facilitating.
Let us now consider the type of psychoanalytic therapy
which can modify the child's recourse to such restrictive
practices.
Psychoanalytic psychotherapy
Such psychotherapy gives the autistic child the chance to meet
some of the inevitable facts and frustrations of life, but in a
protected and caring setting. Frustration is inevitable because
no psychotherapist, however good, can understand him all
the time. The interpretations are not always accurate, nor do
they always meet his needs. Sometimes they are not even un-
174 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
thoughts.' Dr Levis has given me translations of what Daisy
wrote on the paper. These were: 'Bird-thoughts, invading,
flying.'
After a while, Daisy handed the sheet of paper to D r Levis.
It was completely covered with confusedly interweaving
shapes. Still on her knees, Daisy raised herself up to take an-
other sheet of paper. She was uncertain whether to take a larger
one or a small one like the one she had just used. She made up
her mind to take the smaller one and remarked, 'Some time ago
I would have used a lot of superlatives. Now I am content with
writing how big they are.' It is characteristic of autistic children
that when they begin to speak they like using long words as, for
instance, Daisy's use of the word 'superlative'. It seems that
Daisy was saying that she could take the smaller piece of paper
and did not need to use 'superlatives', because she had been
relieved by the 'discharging' she had been able to do with D r
Levis. These children feel turgid with accumulated feelings
experienced in a sensation way. T h e aggravation and irritation
of pent-up feelings would have been the cause of Daisy's
hyperactivity when she first came to see Dr Levis. This had
now been moderated by his acceptance of her evacuations, and
by his attempts to help her to put them into words and then to
think about them.
Daisy now drew what she called a 'flash', meaning a streak of
lightning, and with arrows pointing to the 'flash' indicated that
'flashes' of. lightning were 'savage thoughts'. She had just
started writing the first line of 'savage thoughts' when she was
startled by hearing her mother walking away down the corridor
outside the room. It was as if she had been sunk into her bodily
flow and this interrupted it. She said, 'She is leaving', and
immediately left an empty space on the sheet of paper on which
she was writing. Her 'thereness' had been assailed. As a reaction
to this startling interruption, Daisy started to write feverishly as
if to be reassured that the flow of her being could still go on. She
filled the whole sheet of paper, even filling in the space she had
left empty. She ignored what D r Levis said, as if to shut out any
 THE WORLD OF A N AUTISTIC CHILD 173
child from relating to the actual human mother in a normal way.
She is either used as an autistic object or as an autistic shape,
that is, as an ever-ready part of their body which either calms
them down or makes .them feel invulnerable. This means that
the children are out of touch with her as a real human being. But
at times, Daisy is beginning to feel that she will have to give up
these delusory tranquillizers and invulnerabilities, and begin to
depend upon and trust a light which is other than her body, and
which is real although intangible. Daisy's desire for a 'Luciotta'
seems to be similar to the behaviour of normal small babies who
will focus on a light and then seem to feel pulled together and
safe.
However, at the beginning of this session, having just left her
mother, and having just entered Dr Levis' room, Daisy needed
the plastic straw and the 'gesture drawings'. Dr Levis sat on the
couch and Daisy sat there also. She gathered three cushions and
bunched them. together on part of the couch as if to protect
herself from him. As she took off her shoes, Daisy asked
seductively, "Do you know how many lovers I have got, mum-
father-doctor?' (Here I think we see that, as well as her autistic
objects and autistic shapes, Daisy is marshalling her auto-erotic
feelings to help her to deal with excited and frightened feelings
about being wih the 'mum-father-doctor'.) When Daisy
continued with her seductive questioning, Dr Levis interpreted
to her that she felt that she needed a 'Luciotta' so that she was
not so afraid. This interpretation was good enough to help
Daisy to feel safer. After it, she slipped to the floor and, on her
knees, propelled herself to a small table where there were sheets
of paper and pencils. She put down the plastic straw, which she
had by now transferred from her mouth to het hand, and took
two sheets of paper and some crayons. Then she lay on her
stomach on the floor and, after writing her name as she had
been trained to do at school, she started to draw some birds -
masses and masses of them. Dr Levis asked her what she was
drawing and she answered, 'These are flying thoughtslbirds.
Flying faster than light.' Later she said, 'These are invading
134 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
derstandable by the child! Nor are the shapes which occur as
precise as these exacting chidren demand. There are inevitably
holidays, and days when the therapist is not working as well as
usual. From this point of view alone, psychotherapy is a very
salutary experience for these children, for they meet these facts
in a situation in which the therapist's only work is to listen to
them and imaginatively to try to understand their difficulties
whilst strengthening them to meet them. But understanding
does not mean sentimental collusion with their pathology. Such
children are pied pipers who have led their 'shapes', and will
lead us if we are not careful, away from the concourse of human
beings into the darkness of the autistic mountain. We must
not 'walk the child's autistic way', as the late George Stroh
expressed it (1974). However, 'calling their bluff' without a
therapeutic ambience to relieve and contain the murderous rage
provoked by this is unnecessarily assaulting, and is likely to
result in further autistic manoeuvres. If we are to help these
children to change, we need to have therapeutic insight into the
use their autistic behaviour has for them. We do not strip them
of their means of comfort and protection without providing
something better.
Autistic objects and autistic shapes are not merely
psychological curiosities. They are barriers to more normal
functioning. Insights into these phenomena promise to be the
keys by which we can tactfully enter the world of the autistic
child to enable changes to take place there. These changes
result in the child's becoming interested in using the percepts
and concepts which he can share with other people. These
process incoming information and facilitate co-operation with
other human beings and with the object world. Some workers
have become pessimistic about the possibility of basically
reorienting an autistic child. They think that the only changes
that can take place are the development of ever-widening circles
of more and more complex autistic functioning, and that their
autistic pivot will remain unchanged. In my experience, these
insights into autistic objects and autistic shapes promise to
 CHILDHOOD PSYCHOPATHOLOGY 135
provide a means whereby the child's autistic approach to life
can be radically changed.
The precise details of how this occurs in psychoanalytic
therapy are still somewhat mysterious, but that it does occur,
particularly with younger chidren, is borne out by my own
experience. (Some older children have been habilitated.)
However, if it is not to be damagingly intrusive, such a trans-
forming entry into their world has to be insightfully tactful. At
these levels we are working with psychosomatic and neuro-
mental elements. The therapist has to use those human resour-
ces which are suitable for these levels of functioning - the
human being's capacity for empathy with another person's
states is the psychotherapist's most valuable asset when
working with such children. Psychotherapy is an art as well as
a science. As in all detective work, progress in understanding
comes from empathic identification with the person being
studied, by imaginative reconstruction of his situation, by
informed and inspired guesses, as well as by careful following of
the clues. If we are listening to them, the children will often put
us right if we are wrong.
When children introduce us to their 'shapes' it is a sign of
developing trust. It is important not to abuse this privileged
entry into their world. We need to be careful not to use our
knowledge to impose a conformity on these children by flatt-
ening out those private personal shapes which will become part
of their originality and individuality. These children are often
poetic, artistic and musical. We do not want them to lose these
gifts. And, after all, a little eccentricity is refreshing! Good
psychotherapy is a kind of sanctuary in which private 'shapes'
can be safely shared with someone who respects and reveres
them. In Bion's (1962a) terms, they are held in a caring person's
'reveries'.
Let me now summarize a psychotherapy session with an
eight-year-old boy, whom I will call Peter, talking about his
'shapes'. For those who are interested, this session is given in
full in my book Autistic States in Children. This session was a
172 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
called 'blanket thoughts'. Sometimes she drew these 'thoughts'
and sometimes she wrote them.
In this quieter period Daisy brought a book to her therapy
session which was by Professor Resnik, called Person and
Psychosis. She had taken this book from her mother. Daisy
pointed out to Dr Levis a chapter headed 'Language and
communication', subtitled 'Speaking and listening'. She par-
ticularly drew his attention to a sentence which read: 'Some
qualities of tone, either harsh or rude, are experienced as real
threats.' This had been underlined. As agreat secret, Daisy also
told Dr Levis that she wanted her parents to give her a
'Luciotta' for Christmas (an electric lamp which gives a small
light in children's bedrooms during the night). Daisy said that
she wanted this lamp even if it cost hundreds of thousands of
lire. T o get it, she said, she was willing to do without many
things that she liked; she was willing 'to make sacrifices'.
Thursday 29 November: 23rd week of treatment Dr Levis
recorded that Daisy got out of the lift smiling fatuously.
Between her teeth she had a plastic straw. Dr Levis welcomed
her and led her into the therapy room. In.the room Daisy shook
her head to induce what she called 'gesture drawings'. These
were drawings which arose from sensations in her body. They
were a developed manifestation of the autistic shapes which
were described in Chapters 7 and 8. Autistic shapes are calming
and comforting, and they also assist in the discharge of body
sensations. In terms of my scheme of understanding, the hard
plastic straw is an autistic object, that is, an object which
stimulates sensations which help the child to feel invulnerable
and impenetrable.
Autistic objects and autistic shapes are both auto-sensuous
fabrications which are associated with and confirm a state in
which the child's body feels undifferentiated from that of a very
powerful being (not really differentiated as a mother). They are
both felt to be ever-present bits of that powerful being which
are under their manipulative control. As such, they prevent the
 THE WORLD OF AN AUTISTIC CHILD 171
Significant features of Daisy's early infancy
As is often the case in children with psychogenic rather than
organic autism, Daisy's mother had been very depressed when
Daisy was born. As the result of this, baby Daisy and her
mother had had an unduly close association with each other (it
cannot be called a relationship), in which the mother tended to
use Daisy to satisfy her own needs rather than satisfying those
of her infant. Another significant feature of Daisy's infancy was
that the mother had been very disgusted by nappy changing and
used to hand the baby over to her mother (Daisy's grand-
mother) to do this.
Clinical material
Daisy was an eleven-year-old post-autistic girl who was seen
three times a week. At the time of the session reported here in
detail, she had been in treatment for five months. Prior to
starting treatment with Dr Levis she had been seen by a
psychologist for educational therapy, and had learned to read
and write in a somewhat confused way. Although Daisy still
had marked autistic features, she was more in touch with the
terrors which assail autistic children than are those children
who are still massively protected from such terrors by their
autistic evasive reactions. As you will see, these evasions were
being modified.
During the first few weeks of Daisy's visits to Dr Levis she
was very hyperactive. She then settled down and became much
quieter. During this quieter period, she said that she was
carrying on 'an investigation of thoughts'. T o do this, Daisy lay
mostly on the floor, writing something that she did not want Dr
Levis to interrupt until she had reached the bottom of the page.
She said, 'I am discharging', by which she meant 'evacuating'.
The writing she did was of lists of 'really savage or sad thoughts'
which could magically change into 'blissful thoughts', or into
'cover thoughts'. Daisy drew the 'savage thoughts' as zigzag
lines which she associated with thunder and lightning. She
drew the 'cover thoughts' as a blue blanket; they were also
136 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
turning point for Peter, who made a definite move out of his
autistic way of functioning to becoming more accessible and co-
operative. The week before this session occurred Peter had
asked his mother what 'autistic' meant. I do not know what she
told him, but she ended by saying that Mrs Tustin was helping
him with this. This information seemed to be operating in the
session. Also, at the end of the session his mother told me that
Peter had been very constipated. As you will see, this seems to
be operating in the session also. His revelations about 'shapes'
had been heralded in the last session of the previous week when
he told me that he made shapes on his skin by tickling it, and
also by making bubbles with his spit.
Up to the time of the session reported here, he had never
done anything approaching what could b; called play. At the
beginning of the session which is being reported, he went to the
drawer which contained his toys, so I was both surprised and
pleased. He was now talking, though somewhat laconically, so
when he took out the toy giraffe and started to tie a long piece
of string which went around the giraffe's body, I asked him if he
was thinking about the giraffe which had fallen down. The
news bulletins on the radio had been full of a giraffe in a zoo
which had fallen down; ropes had been used to help it to stand
up because if it did not stand up it would die. It seemed as if the
whole of Britain was in suspense as to whether the giraffe would
be hauled to its feet so that it could live. It was clear that Peter
was very worried about this giraffe and, indeed, identified with
it. I talked to Peter about his feeling that he had 'collapsed',
'flop' or 'collapse' being the child's way of experiencing the
psychotic depression which is at the centre of autism. Peter said
the giraffe had to be 'raised up', so I talked with him about his
wish to grow up properly and not to be 'flopped'.
After he had hauled up the giraffe on the string from the
bottom drawer, where his toys were kept, to the top drawer,
where his pencils and paper, etc., were kept, he proceeded to
fasten other toy animals on to the string and to haul these up
too. But there was a difference in the way in which he dealt with
 CHILDHOOD PSYCHOPATHOLOGY 137
these animals. For one thing, as he put each animal on the string
he said, 'And now I will put this shape on to the string.' Also,
when I asked him, 'What are you doing, Peter?' he said, 'I'm
taking the shapes from the bottom to the top.' These remarks,
and the loose way in which he handled the animals, made me
realize that for Peter, at this point in the session, the animals
were unclassified 'shapes' rather than specific animals. At that
time I was not as aware of the importance of autistic children's
'shapes' as I am now. This was one of the sessions that drew
together for me the other autistic children's remarks about their
'shapes'. Looking back, I realize that the toy animals were being
equated by Peter with the retained faeces his mother had told
me about at the end of the session, and that they were being
used as 'shape-producers',
I realize now that at this stage in the session Peter was
resorting to his self-induced 'shapes', just as Tony and Elly did,
to calm himself down after a shock. The shock had been his
identification with the fallen giraffe as the 'flopped' part of
himself. He was trying to 'raise up' both his shapes and himself
into a better frame of mind. By the magical act of raising the
'shapes' he was trying to reassure himself that all was well. I did
not understand that so well at the time, but I asked him
questions to try to clarify what he was doing and then drew his
attention to the obvious. Knowing that autistic children tend to
equate their body with inanimate objects rather than iden-
tifying with people, I asked Peter if the chest of drawers was like
his body. He said that it was and, since he had the top and
bottom drawers, I suggested that the top one was his head and
the bottom one his bottom. I also suggested that the locked
drawers in the middle part might be his tummy, to which he
replied firmly and dismissively, 'That part is missed out.'
Significantly, the middle drawers contained the other chidren's
toys and were locked, so he could not touch or handle the
contents.
In the light of this, I pointed out the obvious fact that if he
had no stomach, then his head was not connected to his bottom.
CHAPTER TEN
A glimpse into the world of
an autistic child
Be near me when my light is low,
When the blood creeps, and the nerves prick
And tingle; and the heart is sick,
And all the wheels of Being slow.
Be near me when the sensuous frame
Is rack'd with pangs that conquer trust;
And Time, a maniac scattering dust,
And Life, a Fury slinging flame.
Tennyson, In Memoriam, XLIX
he first part of this book began with a description of the
T external appearance and behaviour of psychogenic
autistic children. Let us now end it by having a deeper
look into the world in which such children live. This will be a
preparation for recognizing the autistic behaviour of the
neurotic patients whom we shall meet in Part Two. Daisy, the
post-autistic patient to be discussed in this chapter, could
speak, so she was able to put into words some of the primitive
mental states in which such children live. These states have had
to be inferred in the non-speaking, autistic children with whom
I have worked. Daisy was being treated by D r Enrico Levis
from Italy, who discusses his work with me from time to time,
and I am grateful to Dr Levis for his permission to use this
clinical material.
 EhIERCENCE FROM PSYCHOGENIC AUTIShI 169
alongside such patients, and able 'to talk them through,' this
painful but inevitable situation of disillusionment in a way
which is meaningful to them.
For this reason I feel grateful to the friends and colleagues
who sent me the observations quoted at the beginning of this
chapter. They have made me look at old truths with fresh eyes.
Also, they have suggested a way of talking to patients in terms
which are consonant with their preverbal, shape-making
experiences.
And now, a final word. I n this process of unearthing the
basic elements of human functioning, it has seemed important
that we should be held by the integrated aesthetic patterns that
man has evolved for this purpose. T h u s poetry has seemed to be
a necessary part of the exposition. Our aim in working with
unintegrated or disintegrated patients who have swung out of
human care and 'holding' is to help them to leave their
idiosyncratic pseudo-creativity, and to turn to the more au-
thentic shared creative influences by which they are sur-
rounded. Our own use of such influences will increase our
therapeutic capacity to help them to do so.
138 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
This drew his attention to the lack in his sense of his body
'shape' - his 'felt-self', as Jonathan Miller (1981) has termed it.
Whilst Peter was in this state of bodily unintegration, he needed
the magical envelopment by his self-induced 'shapes' to seem to
hold him together and to reassure him against the ever-
imminent catastrophe of being 'flopped'. His use of the 'shapes'
was a kind of rumination in which he chewed the cud of known
and familiar shapes. What went in at his mouth came up again
unchanged because there was no stomach in which it could be
digested. But he was puzzled about how what went in at his
mouth as food came out of his bottom as 'poohs'; how and
where did the changes take place?
Later in the session he stopped taking his magical 'shapes'
round and round on a string. He accepted the fact that he had
a stomach and that processes of digestion took place there. He
obviously felt that the tummy-button buttoned up the stomach
and that if that came undone, all sorts of 'monsters', as he called
them, would pop out. So his stomach, and indeed any stomach,
were frightening places where 'not-me' things, including other
children, might pop out to hurt him. As these 'nameless dreads'
were 'stomached' in the therapeutic ambience of the session he
no longer needed his magical envelopment by 'shapes', and so
we could settle down to a discussion of 'growing up' properly.
This was concluded when I said that I had turned over his
'shapes' in the stomach of my mind and he had turned over my
'shapes' in his, and something new had come out; to which he
had replied, 'I suppose that's thinking', to which I replied
somewhat sententiously, 'And you can't touch or handle
thoughts.'
Is it too far-fetched to think that, during this session, Peter's
perseverative ruminations associated with his idiosyncratic
'shapes' had been transformed into 'thoughts', through inter-
play with another person's 'shapes', which facilitated a process
of psychological digestion? The details of how this trans-
formation occurred are somewhat mysterious to me, as also to
Peter.
 CHILDHOOD PSYCHOPATHOLOGY 139
A helpful way to get in touch with these non-verbal processes
is by way of metaphor and allegory. Peter's session, in which
he obviously experienced the psychological ambience of the
session as a great big stomach in which significant changes took
place, reminded me of one of the sequences in a television series
called 'Monkey' in which Chinese allegories were brought to the
western screen. In this sequence a pale young man of indeter-
minate sex symbolized 'pure thought'. (This young man's
rarefied, innocent look reminded me of an autistic child. He
was like a marble statue.) In the allegory, 'pure thought' loses
his impulsive monkey and also a strange faceless creature called
'shape-changer'. 'Shape-changer' and the impulsive monkey go
into the cavernous belly of the monster who makes earthquakes
and volcanoes. The irrepressible monkey and shape-changer
are transformed there, presumably because they felt that the
volcanic eruptions of their earthshaking passions had been held
in experienced containment. Having been through these basic
experiences, they were reunited with the young man whose sex
seemed more established and whose thought, we can take it,
would become more earthily dynamic and less cerebrally 'pure'.
Perhaps this allegory expresses better than any words of mine
the mysterious transformations that can take place within a
context of psychotherapy which understands the violent
tempests of human nature, and is realistic about the need to
contain them within the transforming crucible of a caring
person's mind. It will be obvious that in this work with Peter I
was influenced by Bion's (1962a) formulations concerning
'maternal reverie' and its importance in the transformation of
what Bion calls 'raw beta elements' by the mother's 'alpha
function'. I was also influenced by Segal's (1957) paper on
'symbolic equations'. Autistic shapes and autistic objects are
part of the early presymbolic mental phenomena dealt with by
these writers.
Both Milner and Winnicott were aware of .the importance of
providing a containing medium for the expression of these
entirely personalized 'shapes', so that violent passions could be
168 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
A brief word now needs to be said about the state into which
such patients move as they abandon their autism.
After autism T h e psychic situation into which such patients
emerge from their autism has been described by Margaret
Mahler as a symbiosis between child and mother (therapist and
patient). In this state processes of projective identification, as
described by Melanie Klein and elaborated by Bion, become
very active. T h e state is also associated with Winnicott's
transitional object, as witness Sam's piece of shawl. In this state
some degree of co-operation has been established; but it can be
an entangling state too, and this has to be modified by the
psychotherapy. As Sydney Klein says, neurotic patients with a
capsule of autism manifest 'a rather desperate and tenacious
clinging to the analyst as the sole source of life ...' (1980). T h e
modification of this state is the theme of the penultimate
chapter of this book.
Conclusion
Inevitably we come to a point beyond which our understanding
of these elemental situations cannot go. Ultimately, it is beyond
the power of mind to study itself, or to express non-verbal
mental experiences in words. When writing about them, we are
constantly haunted by the discrepancy between what we can
intuitively apprehend, and what we can manage to express. But
we are driven to go on trying, even though we know that the
only certain knowledge is that we can never know 'ultimate
reality'. We have to accept being surrounded by mystery. It is
the standpoint from which this book has been written. T h e
autistic child and the autistic part in all of us hanker after
certainty, after freedom from doubt, after complete knowledge,
after unalloyed satisfaction. T h e hard fact that this is un-
attainable is the sharp rock upon which psychogenic autistic
patients' ongoing psychic development has foundered. Their
emotional and cognitive development has been crippled by the
umbrage aroused by it. It is important that we should be
 EMERGENCE FROM PSYCHOGENIC AUTISM 167 140 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
had to pattern an influx of sensations which otherwise would held and expressed through the shared experience of fun and
have seemed to be simultaneous, one on top of the other. play which had a very serious purpose. Milner (1969), by her
Geometrical shapes, which are a specific type of 'innate form', 'doodles' and Winnicott (1958), by his use of the 'squiggle
help to order the sensations of touch and sight in terms of the game', enabled the child to share his personal shapes so that
space encountered as separateness from the mother is mental and emotional assimilations could take place. But when
acknowledged. Otherwise the space would have been exper- he first comes into treatment, a young autistic child does not
ienced as a formless void. However, these geometrical shapes, put pencil to paper, nor does he co-operate and play. An
which the children talk about or draw, do not seem to be understanding of the function and nature of his inhibiting use
metaphors in quite the same way as Eliot's 'prickly pear'. For of autistic 'shapes' is necessary if he is to be freed from their
patients emerging from autism, they seem to be the primary thrall.
moulds in which the early experience was cast.
Clinical work with autistic children indicates that psychic
development has been arrested at this early, basic level of 'in-
nate forms'. Thus it has seemed important to know some of the
detail of this early experience, rather than to talk in global
terms about 'unresponsive mothers' and 'unresponsive babies'.
If we are to give effective psychotherapy we need to understand
how our patients' minds work. T h e appearance of geometrical
forms seems to be an important step in psychic development.
Such forms appear at a critical point in the psychotherapeutic
process, when the patient is struggling out of the 'tomb-womb'
of psychogenic autism to achieve what we, metaphorically, call
'psychic birth'. They seem to be the harbingers of a move into
sense experiences that are shared in common with other human
beings. But at first the forms are experienced in a
preternaturally hypersensitized way, due to the patients' having
been in the hothouse of the autistic capsule. This means that
opposites are experienced in an extreme way: for example,
there is the beloved 'circle' and the hated 'triangle'. It is felt that
they must be kept apart from each other, or else the circle will
be destroyed. Through the infantile transference to the ther-
apist such patients are gradually enabled to live through and to
integrate these extreme states, so that unstable, up-and-down
reactions become modified. (This is well illustrated by the
graph on psychotherapy with an adolescent girl suffering from
anorexia nervosa, described in Chapter 14.)

CHAPTER EIGHT
Autistic shapes exemplified
in adult psychopathology
How tenuous is the nature of an image
And in the first place, since primordials be
So far beneath our senses ...
How nice are the beginnings of all things.
Lucretius, Of the Nature of Things*
There exist ... primitive somatic ... flowing-over
mechanisms which involve cathecting the apparatus of
touch and smell, and taste and temperature and also
kinaesthetic sense and that of a deep sensibility.
Margaret Mahler, 1958
T
his chapter is a revised version of a paper published in
the French psychoanalytic journal Topique in May,
1985, pp.9-23. It was also presented at a conference in
London arranged by the Los Angeles Continuing Education
Seminars in 1985.
T h e paper sought to bring further thoughts on autistic
shapes and to relate them to a seemingly inaccessible neurotic
adult patient.
The nature of autistic shapes
As we have seen, autistic shapes are tactile sensation traces
which are experienced in a tangible way as diffused swirls of
fluids or soft bodily substances. These shapeless shapes, which
*I wish to thank Otto Lichtenstein for introducing me to Lucretius, and for
suggesting the experiment by which the reader might experience sensation
shapes.
166 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
as they emerge from the encapsulation of autistic states, in a
way whicheis meaningful to them. This is particularly the case
with autistic children who are more closely in touch with
elemental modes of functioning, and also more totally in their
grip. Neurotic patients who, in a part of their personality, have
not been so cut off from outside experiences as the autistic
children have been can call upon their image-making resources
to tell us about their autistic experiences, as did the adult
patient whose dreams were quoted in Chapter 1. However, it is
only when they are on the point of emerging, or have emerged
from autism, that patients can tell us what it was like. So our
evidence comes from hindsight.
As these patients begin to bear the gap of separateness
between the mother's body and their own (in the infantile
transference, the gap between the therapist and themselves),
they encounter the fact of space in a particularly excruciating
way. Prior to this, they have been protected from this painful
awareness by the strategies of the autism. Geometrical shapes
help them to pattern their emerging sensation experiences of
space. These shapes swim into the child's awareness unbidden.
They are not the effect of teaching. They seem to arise, as do
musical and aesthetic shapes, from basic inbuilt neuromental
structures which elsewhere I have called 'innate forms' (Tustin,
1972). In relation to language, Noam Chomsky (1972) has
written about the innate 'deep structures' which programme the
child's use of language. 'Innate forms' seem to be the basic
elements from which thinking and feeling develop. They are
not archetypes as described by Jung, nor are they 'unconscious
phantasies' as described by Melanie Klein, although they may
be basic elements for these formations.
Innate f o w s These 'innate forms' are seen in 'pure' form -
that is, relatively unmodified by outside experiences - in
autistic children who are emerging from encapsulation. This is
due to the fact that the children have been relatively cut off from
outside experiences, and 'innate forms' are all that they have
 EMERGENCE FROM PSYCHOGENIC AL1TISRl
All this has been smoothed over by the autism, to be re-
encountered as the autism begins to crack.
In Sam's case the distressing triangle, and all that it implies,
is evoked by sucking his thumb which has a hard bit - the
thumbnail. This interrupts the smooth circle of his sucking
mouth. But for him this horrible experience is balanced by the
unbroken circle he gets from his soft piece of shawl, which he
can mould and shape as he pleases.
Mary is finding her encounter with the triangle to be
excruciating. Her sulky umbrage about the discrepancy be-
tween the 'birthright' her inbuilt 'blueprints' had led her to
expect, and what she had actually had, was being re-evoked in
the infantile transference to her psychotherapist. T h e trouble
with Mary is that she felt that, in the screaming of her infancy,
she had exploded away the 'circle' - the encircling arms of her
mother, and all that was associated with these. She is repeating
this experience in the infantile transference to the therapist.
When the primal umbrage is as 'crow-black' as Mary's seems to
be, it presents a serious barrier to psychoanalytic work.
As patients emerge from their autistic encapsulation, they
encounter the black despair which has been silenced by their
autistic devices. For various reasons, which have been dis-
cussed in other chapters, the infant sorrow described by Blake
has been excruciating for such patients. They come upon the
scream at the centre of their being.* As they emerge from
autism, such children often screw up the picture they have
drawn because it does not reproduce the picture they had in
their mind. I n T.S. Eliot's terms, the shadow of their massive
sulk has come between the 'conception and the creation'.
As psychotherapists it behoves us to be as closely in touch
with the nature of our patient's experiences as we can be. This
is particularly difficult if we are dealing with preverbal ones. It
has seemed to me that these insights into the shape-making
modes of the human mind can help us to talk to certain patients,
*I should make clear that I am not associating myself with treatments which
concentrate on the 'primal scream' and with 'birthing' techniques.
165 142 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
have no shared meanings, are pathological manifestations, and
are part of the autistic child's relatively undifferentiated sense
of 'being'. They are not predominantly visual images, as are the
objective geometrical shapes which we all share. Such shapes
are inchoate tactile manifestations.
Autistic shapes seem to have much in common with the
'tactile hallucinations' described by Piera Aulangier (1985).
Indeed, in my earlier paper on autistic shapes (Chapter 7,
above), which was written before I knew about Aulangier's
work, I suggested that autistic shapes were a kind of 'tactile
hallucination'. From her long experience with schizophrenic
adult patients, Aulangier differentiates these 'tactile hallu-
cinations' from the more usual auditory and visual schizo-
phrenic hallucinations. She sees 'tactile hallucinations' as pre-
serving the patient's 'existence attribute'. Work with autistic
children fully confirms that they a.re reactions to this, the loss of
their intrinsic sense of existence being autistic children's
greatest dread. Massive tactile sensations prevent threatening
things from being experienced. T h u s tactile sensations
dominate the world of the autistic child, sight and hearing being
subservient to them.
Autistic sensation-dominated shapes are experienced on
internal and external body surfaces which are not differentiated
as outside or inside. They are also experienced on the surfaces
of non-bodily objects which may not be clearly distinguished
from bodily ones. Let me bring a clinical example of this latter
type of activity. It comes from a session which Madame Claude
Cauquil presented to me for supervision in Paris in 1984. When
Madame Cauquil worked with this five-year-old autistic boy
neither she nor her supervisor, Madame Annie Anzieu, knew
about my formulations concerning autistic shapes. Madame
Cauquil has generously given me permission to use this
material.
Clinical material
As this was his first session, the mother accompanied Steve into
 ADULT PSYCHOPATHOLOGY 143
the room. When the mother left, Madame Cauquil recorded
Steve's reaction to this separation as follows:
After the mother left the room, Steve sits facing the window
turning his back to me. He drools on the window-pane, and
with his fingertips spreads saliva over the surface of the
window-pane, forming whorls of spit which invade more and
more of the glass until the window-pane becomes opaque,
and we are no longer able to see through it.
Madame Cauquil continues: 'Since his mother left, the space
between Steve and me, and his mother and him, seems to be
clogged up. I feel him to be inaccessible to me, wrapped in a wet
universe which he himself secretes.' She also says that Steve
seems 'glued to the window-pane'. Later she writes: 'Steve
discovers the crayons on the table. H e scribbles on a sheet of
paper with the same movements as he had used with his saliva.'
For many sessions after this, in the words of Madame Cauquil,
'Steve scribbles on the walls and on the floor, making me feel
bound by his drawings as if by spiders' webs.'
Discussion of Steve's material
T h e foregoing clinical material illustrates Steve's outburst of
'shapes' in the stressful situation of being separated from his
mother. T h e 'scribbling' with his spit and with the pencils
helped him to cope with the unthinkable rage and panic aroused
by finding that his mother was not under his control, and that
she could go away and leave him. Older children often manifest
such unthinkable turbulence by what is called 'fidgeting'. Such
'scribbling' and 'fidgeting' 'negate'- to use Freud's (1925) word
- the mother and the outside world.
T h e diffused inchoate whorls of spit and the scribbling
distract Steve's attention away from the mother who is not
physically connected to him. They prevent him from thinking
about that situation. Thus, the 'unthinkable' situation remains
'unthinkable'. Steve is sealed off in his 'wet universe which he
himself secretes', as Madame Cauquil so well expresses it. In
164 .4UTISTIC BARRIERS IN NEUROTIC PATIENTS
for some infants, for various reasons which will be discussed
later in the book, this disillusionment has been crippling. In an
insufficiently mature psychic state, they have been called upon
to bear the discrepancy between what is, and what they would
like it to be. Of course, we are talking about a situation which has
been known from time immemorial. In psychoanalytic terms,
we call it the dawning of the reality principle. Patients crippled
by autism have met hard, angular reality in a neuromental state
in which they could not cope with it.
The dawning of the reality principle When sensation shapes
become related to inbuilt constructs which are shared with
other people, percepts and concepts come into being. This is
the beginning of the world of common sense. In normal
development, this begins in the nursing situation when the
whole of the suckling experience, such as the sensations in the
mouth, the shining eyes and the encircling arms, are all married
together into the perception and conception of 'mother'. T h e
circle seems to be a preverbal way of expressing the experience
of feeling held - ringed around - by a nurturing ambience
which circulates around the infant as a central figure. T h e circle
is an expression of this feeling of everlasting containment and
contentment. T h e angular figure with sharp points typifies the
disturbance of this circular situation, which had been felt to be
endless. A situation in which, as T.S. Eliot says in another
poem not quoted here, 'the end is the beginning'. Angular
shapes with sharp corners are much less satisfactory. One
reason for this is that the two-line (two-body) situation of
mother and baby exclusively together is disturbed by other
lines (other bodies) coming into awareness.
Another reason is that the place where the separate lines join
brings in the notion of endings, and of changing direction in a
sudden and acute way. It typifies the dawning of awareness that
sensuous experience with the mother is not continuous and
unbroken, but is one in which there are jolts and breaks and
changes; she comes and she goes in a quite unnerving fashion.
 EMERGENCE FROM PSYCHOGENIC AUTISM 163
differentiated into the basic categories of 'nice' and 'nasty'
(pleasurable and unpleasurable). I n terms of geometrical
shapes, the observations presented imply that shapes arising
from a closed, curved, continuous line - such as the circle -are
'nice', while angular, sharp-pointed ones - such as the triangle -
are 'nasty'. It is essential to ongoing psychic development that
the sharp, angular experiences, and their musical and aesthetic
equivalents such as discord and ugliness, should not be
screamed, sneezed or evacuated into a void. They need to be
'caught' and held by an attentive and receptive caregiver.
Mary's mother could not bear her screaming; the mother of
Daisy, who is to be discussed in Chapter 10, could not bear her
'dirty nappies'. I well remember the sad mother of an autistic
child who described with great honesty her post-natal de-
pression after the birth of this particular child. She described
how she experienced herself as a 'non-person', and how she
would hide the baby's dirty nappies under the bed, because she
felt so disgusted by them and could not face washing them.
The infants are also confronted with the discrepancy
between their inbuilt sensuous expectations and what is
actually forthcoming. T o get away from this disappointment
and their reaction to it, they also react in such a way as to
become a 'non-person'. In psychotherapeutic treatment, we
encounter anguished states as such patients emerge from their
encapsulation. These are reactions to the sharp, angular,
discordant shapes which were experienced before they could
bear them. In the poem presented at the head of this chapter,
T.S. Eliot called them 'the prickly pear', and described so well
the after-effects of this encounter.
This unpleasant experience has aroused a profound sulk,
which Eliot calls the 'shadow'. This sulk of disappointment -
this umbrage - which comes between 'the idea and the reality'
is the result of the discrepancy between what was expected and
what actually occurred. For all of us, there is some inevitable
disappointment of the inbuilt expectations we bring into this
world. (The Garden of Eden story is a metaphor for this.) But
144 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
this universe he can feel stuck to inanimate objects as a 'mother'
which cannot move away from him. T h e shapes made from his
spit seem to be exuded from his body like glue to be smeared on
to a surface to which he feels 'stuck'. Being stuck to 'something'
probably helps him to feel that he is a something and not a
nothing. But the 'sticking' is not an attachment or a connection,
because there is no space between the child and the object to
which he feels 'stuck'.
Later, when Steve scribbles on the walls and the floor,
Madame Cauquil feels 'bound by his drawings as if by spiders'
webs'. This is probably because Steve is trying to treat her as if
she is an inanimate object to which he feels stuck so that she
cannot move and go away and leave him. Realizing her
countertransference feelings helps Madame Cauquil to get free
from them. These children have a sort of charm, which, if we
are not aware of it, can bind us to them so that we become a 'soft
touch' and collude with their autistic shapes, instead of seeing
them as impediments to psychological growth and as a negation
of life and of human qualities. It is also inaccurate to see these
shapes as communications. As Madame Cauquil realizes, they
'clog up' the space which is needed for communication. They
are unshared shapes which are idiosyncratic and peculiar to the
child alone. Their sole purpose is to enable him to avoid the
'unthinkable' terror of the 'black hole' of disconnection from a
mother who, at one time, had been felt to be a part of his body,
and who had suddenly been found to be not so (Winnicott,
1958; Tustin, 1972).
Steve's material demonstrates the way in which the
primordial shape-making propensities of the human mind,
which can be so facilitating for psychological growth, have
been diverted into manipulative activities which impede
such growth. In normal development, these shape-making
propensities enable the baby to organize his basic sensuous
experiences. From their observation of babies, research
psychologists are finding that, in relation to certain important
gestalts associated with the mouth, the co-ordination of the
 ADULT PSYCHOPATHOLOGY 145
modalities of touch and sight normally occurs within the first
few days of life. This is a remarkable finding and has been
confirmed by several workers (Bower, 1977; Meltzoff and
Barton, 1979). The autistic child has remained stuck in a
predominantly tactile mode of functioning which does not
become differentiated from and co-ordinated with sight and
hearing in the normal way.
I have come to realize that vision and hearing, as a result of
the undue dominance of the sense of touch, become excessively
imbued with tactile sensations. Autistic children feel that their
eyes are physical instruments to control objects, which seem to
stun and transfix people, to 'cut them dead', to black them out
of existence, to annihilate them. These are not metaphors to the
children; they feel that they actually do such things. Also, if
they see something unpleasant, it feels as if their eyes are being
struck by a painful object, while a loud noise can be felt as a
blow on the ear. Such painful happenings are counteracted by
turning to the comfort of self-induced shapes. These reinforce
the unduly tactile nature of the child's experience. This means
that tactile bodily feelings become unduly important to him, as
does the physical presence of objects. People are experienced as
particularly contrary objects which get out of his control;
window-panes and suchlike inanimate objects are felt to be
much more satisfactory. This results in a negation of the
mother and her human qualities. She is replaced by tactile
shapes which are under the child's tyrannical control. These are
not a substitute for the mother which enables the child to wait
for her return. They are a tangible replacement for her which
blocks imaginative representation.
Autistic shapes
It is difficult to know what shapes the autistic child makes in
secret from his body substances and their equivalents, but I
do know that these secret shapes are ephemeral and changing.
As they emerge from their autism, some children become
fascinated by geometrical shapes such as squares and triangles.
162 A U T I S T I C B A R R I E R S I N N E U R O T I C P A T I E N T S
elementary forms there are. Two straight lines cannot make a
geometrical shape; but three lines appropriately placed can
make a triangle; and a curved line whose end exactly meets its
beginning makes an intact circle. (It is interesting that if a
curved line is drawn around the outside of a triangle,
connecting together the three points, it makes a circle.) I have
come to realize that innate shape-making predispositions play
an important part in affecting how we cast our thoughts. I have
also realized that these shape-making predispositions provide
the means whereby 'me'-sensations can be changed into per-
ceptions of the 'not-me' outside world. Thusgeometrical shapes
specifically pattern sensations arising from touch and sight into
percepts and concepts related to the properties of space.
Musical shapes These pattern the individual notes that make
u p the sensation of sound into those percepts and concepts
which are particularly related to the dimension of time. This
means that the notes can be experienced as following one
another in an ordered sequence so that there is not a hotch-
potch of notes, one on top of the other. Speech seems to be a
specific kind of musical shape which, like all musical shapes,
has amplitude as well as shape. Patients emerging from autistic
states are particularly sensitive to tones of voice, and shrink
away from harsh and loud tones. This is exemplified by Daisy,
a post-autistic child described in Chapter 10. Also, Sydney
Klein (1980) mentions the preoccupation of such patients 'with
the analyst's tone of voice or facial expression, irrespective of
the content of the interpretation'. Thus, as is characteristic of
autistic functioning, superficial and surface phenomena are
attended to, rather than inner meanings: it is the sound of
words rather than their meaning which is important. There are
also aesthetic shapes which influence our conceptions of beauty
and ugliness. However, the constitutional endowment of the
individual would seem to determine which mode of patterning
sensuous experience is used most.
Aesthetic, musical and geometrical shapes soon become
 EMERGENCE FROM PSYCfIOGENIC AUTlShI 161
dividual begins to feel - perhaps at first only momentarily - that
(s)he has distinct body boundaries. These distinct body bound-
aries indicate an inside space, they are not just edgesfrom zuhich
a swface is implied.
Clinical work suggests that a shape which has an inside space,
and which can seem to be a 'container', emerges when patients
are beginning to feel held in a caring person's awareness. They
feel less in danger of spilling away and being 'gone'. They have
a sense of existence and are beginning to have a distinguishable
identity. Being aware of an inside space also suggests that there
is the possibility of having an inner life. At first this is conceived
in terms of those events which go on in that mysterious stomach
from which attention has previously been averted. As was
shown in Chapter 7, the autistic child is not aware of the fact
that he has a stomach. The emergence of a kind of 'stomach-
mind' is an important first step in cognitive and emotional
development. Fantasies, memories and imagination of a
primitive kind become possible. The emergence of shareable,
classifiable shapes is part of this forward movement. They
indicate the development of somewhat more realistic per-
ceptions. Such shapes are part of the mental furniture of all hu-
man beings and so they can promote communications and the
extension of perceptions.
A11 the classifiable shapes of the observations presented,
except those of Dilys Daws' patient, were geometrical shapes
(although I suspect that this patient may have been
experiencing the 'wrong shape' in something like the geo-
metrical form of 'a square peg in a round .hole9).Let me now
discuss geometrical and other types of elementary classifiable
shapes.
Geometrical shapes There are two simple classes of
geometrical shapes: the closed, smooth curved kind of shapes,
of which the circle is the prime example; and shapes with
straight lines and sharp corners, of which the triangle is the
most elementary. T h e circle and the triangle are the two most
146 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
One speaking autistic child even spoke of a trapezium.
I now want to correct something I said in the previous
chapter about autistic shapes. I have come to realize that
attention to, and the drawing of, circles sometimes heralds the
emergence of the self. Drawing used in this way is not so
elemental as the autistic shapes I am discussing here. Eugenio
Gaddini, Kate Barrows and Genevieve Haag have all men-
tioned this aspect to me and have generously given me in-
teresting material about it. T h e autistic child has no sense of
being a self, and is cut off from relationships with people. He is
in what is virtually an 'objectless state', and demonstrates for us
the tragic consequences of such a state. This is in great contrast
to the symbiotic or schizophrenic-type children, who feel full of
internal objects which have the dramatic interplay with each
other which has been described so insightfully by Melanie
Klein. Objects with a separate existence and with functions
that can be shared with other people are not significant to
encapsulated autistic children. Autistic objects, which were
discussed in Chapter 6, are not objects in the true sense; they
are hard, object-like sensations engendered by grasping an
object tightly. They are pseudo-objects in that, like the soft
autistic shapes which are engendered by holding an object
loosely, they have no existence apart from the child's own
manipulations. They do not exist in space and they have no
spatial relationships with other objects. They have no shared
meanings. They are peculiar and personal to the child alone
who, by touching them, brings them into being for his own
idiosyncratic purposes. They are inseparable from the
sensations they engender.
Autistic objects and autistic shapes are like mirages in the
desert in that they are unreal manifestations which do not have
any reality apart from the child himself. Constant resort to
these objects and shapes means that autistic children, instead of
having creative internalized experiences with the mother's
breast (and all that this implies), have 'object-like' and 'shape-
like' tactile sensations on body surjhces. These superficial and
 A D U L T PSYCHOPATHOLOGY 147
unreal securities and comforts do not give them fundamental
help in times of stress. They merely prevent the child from
experiencing and learning from them. It is a truism that, to be
able to cope with stress, we have to have bearable experiences of
it in order to gain experience in dealing with it. Their sensation-
dominated avoidance reactions mean that autistic children have
missed such learning experiences.
I have come to realize that not all autistic shapes are felt to be
sticky; some of them are wet and slippery. Such soft and
slippery shapes are the autistic child's self-made form of
tranquillizer. Unlike autistic objects, whose hard unchanging
outlines seem to form a callus over body surfaces, autistic
shapes are soft and melting and also fluid and changing. T h e
fluid shapes seem to caress and stroke the child to calm him
down after stressful happenings which have threatened to
interrupt his sense of continuous existence. An important
situation of stress occurs when the infant becomes aware that he
does not control the mother's goings and comings, and that he
cannot control what happens in the outside world. Unexpected
things can occur. In the previous chapter I brought material
from eight-year-old Peter, twelve-year-old Elly and eighteen-
year-old Tony to illustrate the fact that autistic shapes of
various kinds are engendered to deal with the stressful situation
of unventilated tantrums about disappointment. T h e self-
induced autistic shapes of Steve, Peter, Elly and Tony were
calming agents on the ruffled surface of their stream of con-
sciousness. They poured oil on troubled waters.
Elly's behaviour also demonstrated that states of ecstasy*
were as unbearable as states of tantrum. For her, the moon was
such an aesthetic experience that she could not say the word
'moon', it touched her too deeply. T h e moon was number 7,
*In connection with the unbearable nature of states of ecstasy, James Greene
has sent me the following verse from Pericles:
Lest this great sea of joys rushing upon me
O'erbear the shores of my mortality,
And drown me with their sweetness.
160 AUTISTIC BARRIERS IN NEUROTIC PATIENTS
Discussion of non-azrtistic shapes
Autistic shapes follow each other in rapid, slippery succession,
so that they are virtually indistinguishable one from the other.
This, and the fact that they are unshareable with other people,
means that they are unclassifiable. This is the major difference
between autistic shapes and those described in the observations
presented here. We would classify the ones described in
Observations 1, 2 and 3 as geometrical shapes. Dilys Daws'
patient classified shapes as either 'right' or 'wrong', that is, in
terms of whether they were 'nice' or 'nasty'. They were
classified in terms of her preferences. In the bland state of
autism even such simple distinctions are not made. Everything
is muted and flat. T h e undifferentiated autistic shapes are
aberrant modes of patterning sensuous experiences; they are
ineffectual so far as effective functioning goes. Classz$able,
non-autistic shapes usher in a very different state of mind.
The mother of Mrs Barrows' patient referred to the circle
which her daughter had drawn as a 'proper shape', that is, it was
a classified shape. It was an identifiable shape of a specific kind
which could even have a commonly agreed name. Such an
intact circle is very different from the rounded shapes which
occur in autistic children's random scribbling, or the shapes
they make from bubbles or whorls of spit from their mouth, or
gas from their bottom. Fabricated from their bodily sensations
and from their body stuff, these latter shapes are autistic
reactions which seem to bring into being an ever-present,
infinitely controllable 'mother'. But this is an artificial 'mother'.
These autistic fabrications prevent their becoming aware of the
actual mother.
T h e circle indicates a movement towards a more realistic
perception of the mother, as being separate and different from
themselves. This acknowledgement of the actual situation in
relation to the mother may take place for only a fleeting
moment, as in Mrs Barrows' observation, but, as she so
insightfully realized, it is a significant moment. Just as the
circle has distinct and definite outlines, so the emergent in-
 EMERGENCE FROM PSYCHOGENIC AUTISM 159
"Because it makes a nice shape." When asked what shape it
made, he said "a circle". He went on to say that sucking his
thumb made "a triangle". He didn't like this, he said, "because
of the sharp points".'
Observation 3 'At a certain stage in treatment Mary, the
neurotic adult patient with marked encapsulating features
[whose autistic shapes were discussed in Chapter 81 and whose
mother could not bear her screaming as an infant, once
complained to her therapist that she had a scream "at the centre
of her being in the shape of a triangle". Such patients often
make picturesque remarks of this kind. We may feel that they
are not worthy of our serious attention, but since what they say
seems very important to them, I think that we should not brush
them aside. This patient went on to say, "Scratch the surface
and there's nothing but blackness."'
Observation 4 Another interesting observation was sent to me
by Mrs Dilys Daws, who wrote as follows:
'I thought you might like a little clinical anecdote about
"shapes" (not autistic). I have been seeing a disturbed little girl
of seven years of age, once weekly. Her family were unable to
bring her more often and it was very frustrating. She behaved
delightfully with me. I knew how appalling she was at home and
suspected that she would be different with me if I could see her
more frequently. Finally, we arranged an escort and transport
for a second session. She came to the first of these and was
irritable with me throughout. Near the end she complained that
I had made the "wrong shape" of some plasticine we were
moulding. I said I thought that she was telling me that the
whole thing of coming to see me today was "the wrong shape",
that is, coming to see me in a taxi from school, a lady escort
instead of her parents, a different time to see me, different
people in the waiting-room, etc., etc. She agreed with en-
thusiasm and has been bringing her dissatisfactions to me ever
since. '
148 A U T I S T I C BARRIERS I N N E U R O T I C P A T I E N T S
which was a very special number. We have seen that numbers,
for Elly, were shape-producers. Such shapes enabled her to
control her unutterable ecstasies as well as her unthinkable
tantrums. But they cut her off from her caring family, who
could have helped her to develop less rigid and mechanical
means of control.
Resort to autistic shapes would seem to begin in earliest
infancy. The children experienced stress at a time when their
neuromental apparatus (their elemental ego) was insufficiently
developed to cope with the strain, and in a family situation
which, at that particular time, was not adequate to cope with it
either. Autistic shapes are pre-image, pre-object and thus
presymbolic. From her long experience with autistic children,
Margaret Mahler (1958) writes as follows: 'In order to
understand normal as well as disturbed feelings of identity, we
have to go back not only to the preverbal stage, but all the way
to a stage before images were formed ... we need to go back to
primitive modalities of perception .' ..
. In the terms of this chapter these 'primitive modalities of
perception' are tactile sensation shapes, both normal and
pathological. In the quotation at the head of this paper,
Lucretius uses the term 'primordials' for the normal man-
ifestations of these primitive modes of perception. Let us now
discuss such normal 'primordials' before discussing further the
pathological aberrations of them which have been called autistic
shapes.
Normal primordial shapes
As mentioned earlier, Tom Bower (1977) and Meltzoff and
Barton (1979) have shown that in normal infants, in relation to
certain psychobiological gestalts which have survival value,
tactile and visual perceptions become co-ordinated in the first
few days of life. Thus it is tenable that, as tactile and olfactory
perceptions become associated with the more long-distance
ones of sight and hearing, awareness of objects located in space
will develop, and the infant will have increasing moments of
 ADULTPSYCHOPATkIOLOGY 149
awareness that his body is differentiated from that of his
mother. These moments will come and go in a fleeting sort of
way, perhaps even from the early days of life. It is important
that the very young infant is helped to bear the stress of these
moments of differentiated awareness of his bodily separateness
from the mother by the establishment of mental connections
with her.
Gradually, with this support, as the infant's neuromental
organization becomes more integrated, and as he internalizes a
body of satisfying experiences with a responsive mother, he will
become more able to bear the times when he is aware of his lack
of bodily connection with her. T o offset the threat of the 'hole'
of her absence, there will be memories - tactile, olfactory,
auditory and visual - of close experiences with her. These
prevent her absence from becoming a 'black hole' full of
unventilated panic, rage and despair. Provided that the times of
separation do not go on for too long, 'basic trust' (in Erikson's
sense) will develop in unison with hope, its faithful ally. Thus,
a capacity for prediction and a belief in the continuity of objects
in space will develop. In the long run, these intangibles will be
far more reassuring than the secret superficial comforts of self-
induced tactile sensation shapes.
Normal 'primordial' shapes would seem to spring from auto-
sensuous rhythms and responses at the root of our'being'. They
would seem to affect the individual's capacity for empathy, and
thus for relationships with people. These will lead on to the
apprehension of objects as objects in their own right, which
exist apart from the child and which have .distinguishing
shapes. From these shapes, differentiated images of these ob-
jects will be formed and imaginations about them developed.
Peter, the autistic boy mentioned earlier, had a session in which
he talked abhut his 'shapes'. He ended our discussion of them
by saying, 'I suppose that's thinking.' By the trans-forming
influence of therapeutic trans-actions, his pathological autis-
tic shapes had become normal ones which facilitated the
development of 'thinking', for which imagination is a pre-
158 AUTISTlC BARRIERS IN NEUROTIC PATIENTS
a mother and her child intuitively i~nderstoodthat the drawing
of an intact circle implied this. Here is her observation.
Obsemation 1 'I wondered about the connection between
shapes for the autistic child and shapes for other children. I
have always been impressed by how important some kind of a
circle - drawn by the child - is, to the child and the parents. I
have tended to think of it as connected to the child ap-
prehending something as separate and complete -whether you
call it a breast, an object or what have you. It seems, in some
way, to show that the child has an independent mind, however
fleeting this may seem, and even if the child follows u p the
shape with scribbles as before ...
'I had a clinical experience which gave form to my
longstanding feeling about this shape. It was an assessment
interview, at the hospital where I work, with a little girl of five
and her very disturbed, sometimes psychotic, sometimes al-
most catatonic, sometimes coping mother. T h e child was in a
day unit with the mother and was being assessed for individual
psychotherapy. I saw them together as neither seemed able to
separate. T h e child was withdrawn and scared and spoke in a
blurred way, omitting many consonants. At some point in the
meeting, she was drawing or rather scribbling, and I said
something (I can't remember what) about her feelings, perhaps
something to do with whether mummy and I could stand them.
She responded by drawing a definite circle. She then looked
afraid and her mother said, "It's the first proper shape she's ever
done," and burst into sobs. T h e little girl stopped drawing and
went to play with the dolls. I talked of their fear of the child
being herself. I thought that this sequence showed the mother
and child's fear of the child being herself - having a clear outline
- seeing the mother clearly.'
Obserrration2 'A four-year-old symbiotic boy whom I will call
Sam, when asked by his rnother why he sucked the piece
of shawl which he always carried around with him, replied,

CHAPTER .V/,VE
Shapes associated with emergence
from psychogenic autism
Here we go r a n d the prickly pear
Prickly pear prickly pear
Between the idea
And the reality
Between the motion
And the act
Falls the Shadow
Between the conception
And the creation
Between the emotion
And the response
Falls the shadow.
T.S. Eliot, 'The Hollow Men', Collected Poems
riends and colleagues who had either heard or read the
F papers on which Chapters 7 and 8 were based kindly
sent me observations concerning another category of
elemental shape. This, I realized, needed to be distinguished
from autistic shapes. In this chapter these elemental, non-
autistic shapes are distinguished from autistic ones, and the
significance of their emergence and the part they play in
psychotherapy are discussed. First of all, however, let me
present to you the observations which stimulated the thoughts
embodied in this chapter.
The observations
Several colleagues, amongst whom are D r Genevieve Haag and
the late D r Eugenio Gaddini, wrote to me associating the circle
with the emergence of individual identity. In particular, Kate
Barrows sent me an interesting observation which indicates that
150 A U T I S T I C BARRIERS IN N E U R O T I C P A T I E N T S
requisite. Let us now return to our discussion of aberrant
shapes and use our understanding of them to enter the world of
the autistic child.
The autistic child's world
Autistic shapes and autistic objects have helped the child to
survive the shock of meeting what seems to him to be the
stubborn intractability of the outside world. But to us, the
autistic child's predominantly tactile world of unshared shapes
and unshared objects will seem a very strange one. Only what is
tangible and manipulable will seem real. T h e long-distance
modalities of sight and sound will be overridden by the pre-
dominance of tactile sensations. T h e lack of supplementation
and elaboration of tactile percepts by an adequate use of sight
and sound means that such a child does not form an effective
representation of the outside world which he can share with us.
His world is relatively devoid of space because threatening gaps
are closed by sticking to surfaces. T h e play of a recovering child
in therapy, beginning to experience space, is often char-
acterized by his saying that he is in a 'space capsule'. This
is to protect him from the horrors associated with space. Prior
to his being able to play in this way, and so to express his fears
about space, the autistic child's world has been mainly one of
flat, two-dimensional surfaces with the black pit lurking
beneath them. T o avoid falling into this black pit, tactile
autistic Shapes and autistic objects have dominated his
awareness. T h e soft sensation shapes have calmed his terrors
and the hard sensation objects have made him feel invulnerable,
but they have massively inhibited his psychological develop-
ment. Let us now relate our understanding of the autistic
child's use of sensation shapes to a neurotic adult patient whose
awareness was dominated by them.
Autistic shapes in a neurotic adult patient
Mary was in her late twenties. Her therapist came to me for
supervision because she was finding it difficult to get in touch
 ADULT PSYCHOPATHOLOGY 15 1
with this patient. From our work together it became clear that
Mary had a hidden capsule of autism which was interfering with
her relationships with people and also affecting her work. A
piece of personal history which is relevant to this session is that
her mother had told Mary that, after she was born, Mary had
cried a great deal and that she (mother) had not known how to
comfort her. There is also evidence that Mary's mother was a
somewhat immature person who, in her mind, had conceived of
the baby she had conceived in her body as a kind of doll. T h u s
she had been bewildered and shocked when she was confronted
with a real live human baby who cried a great deal. Mother and
child were not able to heal each other from the primary shock of
bodily separateness.
The session
Mary began by saying that over the weekend she had been in her
withdrawn state again. She went on to say that there was a
woman who would not leave her alone and wanted to know what
was worrying her. She had told her that she was worried about
her job and about moving house, but this was not true. These
things did not worry her at all; she was worried about deeper
things, but she could not tell this woman. (Here I think we see
the conflict that Mary is in. She has deep things which worry
her, but she cannot tell her therapist about them because, in the
transference, the therapist is experienced as the mother of her
infancy who could not comfort her.)
After a pause, Mary went on to say that she was thinking
about fishes. She said that it was the sensation of them - their
suppleness and smoothness. It filled her whole mind. It was not
so much the fish, but their wet and slippery shapes. Mary then
went on to talk about a male friend who would catch fish and cut
them open before they were dead. This meant that you could
see their hearts beating. She was always very upset when he did
this, as if it were being done to her.
(Here we see another reason for Mary's fear of the therapist
getting in touch with her. I n infancy she had felt 'cut to the
156 A U T I S T I C BARRIERS I N N E U R O T I C PA'TIEN'T'S
the ceiling may come down upon their heads. This is in marked
contrast to the feelings of invulnerability engendered by their
use of autistic objects. These seem to serve a similar purpose to
what Miss Nash calls the Celts' 'personal and idiosyncratic
taboos to protect them from catastrophe'.
She makes an interesting comparison between the ancient
Celtic outlook and that of the Homeric Greeks. Catastrophe did
not just descend upon the Greeks, as it did with the ancient
Celts; it was the result of some wrongdoing. T h e mother of
Achilles did magic for him, whereas the Celts protected them-
selves by their own idiosyncratic magic, as do the autistic chil-
dren. As in the world of autistic children, so in the world of the
Celts nothing could be relied upon. There is much material in
their stories about mists and ever-changing, elusive shapes. It
was a treacherous and dangerous world in which there was little
they could be sure about. It seems feasible that their constant
experience of being uprooted from their home base had much to
do with it. The mother of an autistic child who kept wandering
away once said to me, 'She seems to have no homing instinct.'
All autistic children seem to lack this sense. They do not feel
that they belong anywhere.
T h e trouble with psychogenic autism is that once it has
started it easily becomes a rootless, empty way of life, kept
going by endless manipulations. Used in a massive way, it leads
to a devious psychopathic character and to a devious psycho-
pathic culture. I am coming to the conclusion that many of us
- some more so than others - have a bit of psychogenic autism
which has shied away from the pains and difficulties of relating
to other human beings, and has resorted to devious and manip-
ulative means to avoid these pains. We erect barriers to prevent
it from contaminating the rest of our personality, and try to
avoid being aware of it.
 A D U L T PSYCHOPATHOLOGY 155
unclearly focused shapes. This is the culture of the ancient
Celts, which she has studied intensively. In a personal com-
munication she has written as follows:
T h e ancient Celts' tendency to talk in riddles may have some
connection with their allusive (and sometimes positively
fragmented) style of design on metalwork; animals and faces
are suggested rather than depicted, animate forms are dis-
jointed; circle-based motifs can suddenly look like some-
thing else (e.g., a face) and then you lose it again. Old Irish
has no words for 'yes' and 'no', only affirmativelnegative
paraphrases. Curiously, traditional Irish music almost never
has a rounding-off phrase at the end of a piece. You don't
know it is going to end until it stops dead. (As if they had
never learned to deal with endings.)
With well documented evidence she relates this to what can be
found out about the ancient Celts' childrearing methods. I n
these, from an early age, children were fostered, both boys and
girls being sent to different families to reinforce social ties
amongst the families concerned. T h e children seemed to be
used in terms of the needs of society rather than their own, in
order to make social connections which were in constant dan-
ger of breaking down. Miss Nash instances that some author-
ities think that noble children could have had twenty-eight such
fosterages before reaching adulthood. Not surprisingly, their
stories are often concerned with disastrous separation
experiences.
Of course, autistic children have not usually undergone
actual separation experiences but they have undergone psy-
chological separations. T h e sort of world in which they live has
some striking similarities with that of the ancient Celts. Like
the Celts who would even go naked into battle, autistic children
are foolhardy about realistic dangers and yet, like the Celts,
they are in the grip of illusory dangers. For example, the
ancient Celts lived in mortal dread that the sky would fall down
upon them; similarly, many autistic children are terrified that
152 A U T I S T I C BARRIERS IN NEUROTIC PATIENTS
heart'. She feared that this vulnerable, deeply hurt part of her
would be exposed. In a previous session, before coming into the
consulting-room, Mary had thought that the therapist was
waiting for her with a knife. She had also talked about a badly
stitched-up wound. The therapist had understood that in the
core of her being, Mary felt that she had a wound that she feared
would be reopened by the therapy. In later sessions, we see that
this patient had been afraid to have a 'heart' - that is, to ex-
perience deep human emotions. Instead she had sensation
shapes.)
In this session Mary went on to say that she did not know
why, but she was going on thinking about shapes, 'not exactly
thinking about them but feeling them'. She said that she did
this a lot. As a child, in her hometown, she would watch the fish
being unloaded from the boats. There would be a big silvery
stream of fish. It was a fluid succession of slippery shapes. They
seemed to fill the whole world. 'I can feel them nowllshe said.
(These patients are always having to 'lick' their own 'wounds'.
The 'licking' is experienced as a fluid succession of slippery
shapes. These give Mary the comfort the mother was not able
to give her, and that, in the transference, she feels the therapist
is not able to give her. This was, in fact, far from being the case;
the therapist struggled valiantly to be in touch with Mary, but
constantly felt she was being made into a 'non-person'. Taking
the step of coming to me for supervision was evidence of her
care and concern for this patient. Mary's self-engendered
slippery shapes soothe and anoint the wound of disconnection
from her mother - from her 'hometown' - but they cut her off
from relating to the therapist in a deep way, and from deep
relationships with people.)
Mary's last association in this session showed how much she
wanted to change. It also brought some hopefulness that she
might be able to do so. Mary said that when she did underwater
diving, she used to see the fish slipping into holes and crevices
and was always surprised when they came out again head first,
because there did not seem room for them to turn round.
 ADULT PSYCHOPATHOLOGY 153
(This is a very condensed association in which Mary seems to
be seeing the dangers of her restricted way of life. She is
realizing that she may be immured there forever and never be
able to escape. She is realizing that 'holing' herself up in an
elemental world of self-engendered shapes is dangerous; she
may never be able 'to turn round' to live in the ordinary world
of objects and people..Although this everyday world is a less
controllable world than her world of fluid, slippery shapes,
nevertheless she wants to be 'born' into it. The association
expresses hope that she may achieve this, for the fishes turn
round and reappear from their holes and crevices.)
We hope that this will be fulfilled, and that Mary will find
that co-operative experiences with tier therapist are more
healing than this self-anointing by slippery shapes.
Conclusion
This chapter has suggested that, like autistic objects, autistic
shapes are psychophysical reactions to wounds and hurts which
need to be healed by reciprocal interactions with other human
beings. Insights into the functions which such manipulations
have for the patient promise to open the closed doors of autistic
states in both children and adults. In doing this, we are working
with something within the patient who, in the words of G.K.
Chesterton, is saying,
If only I could find the door,
If only I were born.
It has been my experience that insights such as have been
outlined here can enable the therapist to enter the enclosed and
secretive world of such patients with respect and compassion,
to help them to find the door so that they are released from their
solitary confinement and are 'born' as more fully functioning
human beings, who can have deep and enriching relationships
with other people, and also with themselves. But first of all they
must be freed from the terrors against which the sensation
objects and the sensation shapes have been a protection.
154 A U T I S T I C BARRIERS IN NEUROTIC PATIENTS
Further thoughts about autistic shapes
and psychogenic autism
I have come to realize that one source of autistic shapes comes
from the fact that autistic children do not look directly at
people, but take in a great deal by peripheral vision. (Witness
Stephen, described in Chapter 1.) This over-developed fringe
awareness means that fringe shapes are formed which can never
be clearly focused and which constantly elude the children.
Austistic children show that they are constantly tantalized by
such elusive, self-generated shapes. This increases their dis-
content. Also, in the end, such shapes are not tranquillizing but
tantalizing. Such peripheral shapes also impede the attachment
to the mother, which is fostered by looking at her face,
especially at her eyes. As a result of the tantrums of panic and
rage that she was not a part of their body that they could take for
granted, the children have turned away from the mother and
become frightened of her eyes. This separateness had been
forced upon their attention before they were ready for it. I n
Winnicott's terms it 'impinged'; they did not find it out for
themselves in their own time, when they were ready for it. This
was painful beyond all bearing. They had swerved away from
the pain, and from the mother who was the source of it. They
stopped looking at her and at other people, and attended instead
to the fringe shapes they could make by looking out of the
corners of their eyes. These brought some sort of order into
their bewildering world, but like will-o'-the-wisps, these side-
long shapes eventually isolated them in immobilizing bogs, cut
off from contact with other human beings.
Psychogenic arrtism
Daphne Nash, a specialist in ancient history who works in the
Ashmolean Museum in Oxford, has told me of a whole culture
which seems to have been based on elusive, half-formed,