fe 1. Paycho-Anal (1991) TR 585 | pease 4, | boi REVISED UNDERSTANDINGS OF PSYCHOGENIC AUTISM FRANCES TUSTIN, Loxoow REASONS FOR REVISION After many years of working with a certain type ‘of autistic child, and after attempts to digest this experience by writing books and papers, I have come to the conclusion that I made a mistake in following the general trend of psyehoanalytical writers in using the term autism for an early stage of infantile development, as well as for a specific pathology. I now realize that it is more correct, and leads to clarity in our thinking, if the term autism is solely reserved for certain specific pathological conditions in which there is fan absence of human relationships and gross impoverishment of mental and emotional life; these impairments being the result of the blocking of awareness by an early aberrant development of autistic procedures. Observational studies of babies by writers such as Brazelton (1970), Bower (1978). Tre- varthen (1979) and Stern (1986) have shown us that, in normal development, there are periods of.lert awareness and active questing even from the beginning of life. This had been confirmed by my own detailed baby observations and also by reports from motbers. Thus, to view autism asa halt at. or a regression to, what is conceived of as a normal early infantile stage of autistic ‘unawareness, is no longer tenable for me. T realize that those who have based their work on such a scheme of understanding will find it dificult to change their views. But in my ex- perience the revised understandings which are to be described lead to greater freedom and clarity in one’s thinking. The crux of these revised understandings is that autism is an early de- velopmental deviation in the service of dealing with unmitigated terror. ‘THE AUTHOR'S PRESENT VIEWS ‘The clinical material of the patients on whom the ensuing findings are based can be found in various books and papers (Tustin, 1966, 1972. 1981, 1986, 1990). These findings have come Irom the type of autistic child who has responded to the kind of psychoanalytic therapy that was used, (In this. the Infantile Transference played an important pari.) T have come to term their autism, “psychogenic autism’, since psychogenic factors seem 10 have been most operative, al- though some of the children may have had minimal organic damage which could not be detected by the investigative methods at present available. If this had been present, it would seem that it had been possible to modify it by the type of psychotherapy that was used. I have come to realize that autism may arise in several different situations—for example, as @ reaction to brain damage or to sensory defect, as well as t0 2 traumatic situation which seems to threaten life and limb. The latter is the type of autism I have ‘treated with a certain amount of success. FINDINGS ABOUT PSYCHOGENIC AUTISM My first discovery came from the first autistic child 1 treated. This was 4-year-old John, who had no discernible brain damage, but who showed me unmistakably that his infantile awareness of bodily separaveness had been trau- matic. and had been experienced as “a black hhole* associated with elemental panic and rage about the seeming loss of part of his body. Dr Vietoria Hamilton, who has usefully defined the erm ‘trauma’, writes as follows:586 ‘The word trouma should be reserved for responses to events which arouse ia most of us inten felings of horror. a sense of outrage and very often a feline of esusion and trning away. We would rather not know or hear (1989, my ital. In these terms, autism can beseen as a massive snotknowing’ and ‘not-hearing’ provoked by traumatic awareness of bodily separateness. AS such, it would seem to be an intensification and entrenched exaggeration of an inbuilt set of reactions which are specific to trauma. ft is a survival mechanism. Clinical material indicates that. in the type of ‘autistic child Ihave treated, the traumatic stress which had provoked the autistic reactions had been experiences of unbearably sudden and painful awareness of bodily separateness from a ‘mother with whose body they had previously felt fused and equated. Prior to the alarmingly lunexpected awareness of bodily separaten they had not been aware of a mothering person. as such. They had taken her bodily presence for granted. They only realized that it" had been there when they felt that "it’ had gone. When awareness of their separateness from the ‘mother’s body was suddenly experienced. it was as if they had lost a part of their body. This brought their vulnerability home to them. They felt unprotected and at risk. Autism became an impenetrable protection which shut out painful awareness. (The nature of autism will be dis ‘cussed later.) Thave come to see that the illusion of fusion ‘which existed prior to the catastrophic awareness of bodily separateness was not 2 normal early infantile stage, but that it was an abnormal state with which both mother and child had colluded. and for which there may have been a genetic susceptibility in both of them. as well as there being environmental pressures which provoked it. Inevitably. since there was felt to be no space between them, this undue closeness hampers the development of “object relations’. This means that cognitive and emotional developments are impeded. The closing down of autism isa further impediment. Let me discuss this. Autistic children are nat fully born—they still feel part of the mother's body. To exist—r0 “be'—seems fraught with danger. Thus. they are very immature and have many deficits, @ crucial ‘one being that theearly fusional clinch between FRANCES TUSTIN mother and infant means that they are “un- bonded" in the ethotogical sense. Also. the abnormal state of fusion with the mother is very enervating. The autism increases this weakness still further. because they have no practice in dealing with the exigencies of life ‘Although, in reality. they are so weak. the adhesive equation” with the mother's body will hhave increased che eariy infantile sense of omni- potence. This means that when this omni- potence is assailed by awareness of bodily separ- ateness. and their weakness i¢_ momentarily brought home to them. such awareness is un- bearable and traumatic. They have no “back- ground presence of saiery’ {Grotstein. 1980). no “background of safety’ (Sandler. 1960). to help them to “breast” this crisis. It is avoided by autistic reactions, but she effects of this trauma lic in the depths of the somatic psyche like an unexploded bomb. As hey recover. this may be expressed in psychosomatic manifestations such as boils or other skin eruptions. Insulated by the autism, the unhealthy omai potence becomes monstrous. so that when they began to talk. autistic children will say such things as “I am God". or “Tam a King", In an futistic state they are unaware of their actual weakness and neediness. Also. their fusion with the mother and. later. zhe autism. mean that the father’s influence is absent. Thus, they do not experience the discipline of sharing the mother with the father. This means that wayward omni- potence is not checked. Underneath their pas- sive exteriors. autistic children are extremely wilful and tyrannical. And now, with the help of a writer and an artist. let me evoke :n picture language the situations which precipitate the swaddling pro- tections of autism, |A STATE OF FUsiON Joyce McDougall *s given us a graphic description of fusionl interlocking. In her books. The Theaire 0 ie Mind (1986) and The Theatre of the Body \'989). she has described how. in certain circustances, a mother may unwittingly use her sxfanc as an inanimate ‘object—as what MeDougall calls “a cork child’—io fill the hoie of her emptiness and.REVISED UNDERSTANDINGS OF PSYCHOGENIC AUTISM 587 loneliness, In my experience. such a mother is under-confident and/or bewildered and/or de- prived and/or depressed, or she may have expenenced a shock. tragedy or bereavernent around the time of the child’s birth. Some of these sicuations seem to have been operative in the early mother and infant fusion of the autistic en T have encountered. although some of the children and their mother seem to have experienced the trauma of separateness at the ‘moment of birth itself. since the foetus had been unduly experienced by the mother asa solace for her loneliness and sense of deprivation. Birth in such 2 situation was unusually traumatic for both mother and baby, and would precipitate a fusional ‘clinch’ which. if this were not modified by subsequent nurturing, would result in the catastrophic consequences of feeling torn apart when awareness of bodily separateness could pot be avoided. ‘THE RESULT OF TRAUMATIC SEPARATENESS A Henry Moore sculpture. a photograph of which is on the cover of my recent book The Protective Shell in Children and Adults (1990), poignantly expresses the effect of separation From such a state of absolute fusion. In what ‘was Moore's last great work. called “Mother tand Child: Block Seat", mother and child are each swathed and enveloped, and are thus out of contact with each other's body. The mother’s tunswathed left breast has a black hole where the hippie should have been. The infant. although sitting on her lap, iscut off from touching her by the swathes which cover “its” body. Instead of 2 ‘mouth “it” has a cork-like protuberance. This would block the tlow of milk from the breast instead of being 4 means of sucking at it. The realistic function of both breast end mouth has bocen oecluded. In my experience. such a per- version of natural functions lies at the root of autism. Thus. in my present view. autism is a system of perverse reactions, provoked by a traumatic experience of bodily separateness. and is nor a defensive regression to a. s0 called. normal autistic stage of infantile development, AUTISM AS A PROTECTIVE REACTION Infiuenced by a paper by David Rosenfeld (1986), 1 have realized that autism has @ pro tective and preservative function. { now seit as aan elemental “protomental” state (10 use Bion’s useful term (1979)), which is an automatic. psychochemical reaction to traumatic sirss. (The term ‘psychochemical” is used to indicate clementary mental states which are closely assoc iated with and affecred by body chemistry.) The psychological development of such an infant has been shocked into taking an autistic direction, Normal on-going psychological development has been halted in a way that is either well-nigh total. as in an autistic child. or partial. as in neurotic, borderline and even relatively normal individuals, who have 2 "pocket" of autism. (There are a few autistic children, the so called ‘idiots savants". who develop an isolated talent along @ narrow line in an obsessive way. to a remarkable level of achievement. although ia other respects—for example in toilet 1raining— they may be quite immature, Such an unusual development seems, 0 some extent, 10 bein the service of ensuring that they live in acontrollabie. predictable world, in order to save them from a Te-evocation of the alarmingly unexpected ex- perience of bodily separateness from which they had recoiled.) By contrast with che autistic child. through the containing medium of his art, Henry Moore had been able to tolerate, objectivize and depict the “black hole” catastrophe of sudden and alarming awareness of separateness from the body of a mother with whom there had been fasion and a sense of being inanimate. Perhaps Moore had always been working against “this ‘backward pull to be inanimate’, as Freud expressed it (1920), but for Moore it had been a stimulus for creativity rather than for the development of autism. [AUTISTIC PHENOMENA Clinical material demonstrates that infants who experience bodily separateness from the ‘mother traumatically, experience the gap be- ‘ween their uvo bodies as filed with rivalrous and predatory other sucklings who threaten to annihilate them by pushing them outof existence in order to take their place. (The father is sometimes experienced as a particularly danger588 ‘ous rival.) Thus, to exist becomes a life-or-death struggle. For such children to exist—to have an individual identity—becomes fraught with hor- tific dangers, The reaction to these existential dangers is an endogenous auto-sensualicy which generates what, in an effort to conceptualize these unconceptualized sensation-dominated reactions, I have called ‘autistic sensation ob- jects’ (1980) and ‘autistic sensation shapes" (1984). These seem to swathe such children in 4 sensual protective “shel. (Dr Esther Bick has aptly called it “a second skin’ (1968, 1986). ‘This auto-generated protection is made up of “autistic sensation objects" shich make the child feel strong and safe. and “autistic sensation shapes’ which are calming and tranquilizing. These are not objective “shapes” but are en- dogenous swirls of sensation. Similarly. itis not so much the *object” that they carry that is responded to, but the sensauons on the skin that it arouses. These sensations distract attention from unbearable bodily separateness. and as- suage the terrors which bese: these children, but they have deleterious side effects. AS one re- covering autistic patient once expressed it, “My sanctuary became my prison’, These sensation- engendering activities are moze primitive than masturbation in that they are not associated with fantasies, They are a kind of autogenerated. hypnosis which make the child feel safe and comfortable. They contribute to the “attention deficits’ so characteristic of autistic states. If their “spell’is disturbed. che child will break into inconsolable grief. Paradoxically, these attempts to avoid aware- ness of bodily separateness result in such children becoming increasingly separate, alienated and ‘cut-off’, situation of whica such patients are unaware until, and if. they begin to emerge from their protective autistic shell. To us, as observers, these auto-generated. aute-sensual protective reactions appear in externai behaviour as what are usually called “stereotszes' (rocking. hand fapping, finger ficking, ewiring, object twirling. toe walking, etc). Such stereotypes are a ubiqui- tous feature of autistic chiigren’s overt behav- jour. When, and if, the endogenous pro- leetive manoeuvres are abated. these stereo- typed activities cease to be behavioural characteristics, FRANCES TUSTIN AUTISM AS A REACTION TO UNBEARABLE STRESS Clinical work has brought home to me that when these automatic. sensation-dominated re- actions to infantile rauma are used persistently and exhaustively, pschological development be- ‘comes increasingly. pathological. Autism be- comes an entrenched way of life, This means that itis increasingly dificult to ameliorate it as the child grows older. It also means that the enclaves of autism which are to be found in neurotic. borderline. nd even relatively normal Patients. can constitute an obstinate barrier to sychoanalvtic work with them (Klein. 1980. ‘Tustin, 1986: Gomberoff et al. 1990). My work with autistic children has made me realize that the way in which awareness of bodily separateness is handled. and the infants reaction { it. is critical for future psychological de- velopment, in that it afecis the degree of panic. rage and anguished feelings of weakness pro- duced by stressful siuations in later life, Un- ventilate. unprocessed. ‘bottled-up" explosive panic. rage and "black hole’ anguish ean mani- fest itself in psychosomatic and phobic condi- tions of various kinds (Klein, 1980; MeDougail. 1974, 1982. 1986, 1989: Taylor, 1987; Tustin, 1986. 1990), It is a corning point in’ psycho- therapeutic treatment when this tantrum of rage and terror is exploded by the patient and received and understood. to some extent at least, by the therapist. In these states. actions speak louder than words. both on the part of the therapist. and of the child, Sucb an outburst usually comes in relation to separations from the therapist due to holidays. illnesses and suchlike inevitable breaks in the treatment. Prior to therapy, if these tantrums had been expressed, they would have vapoured away into 2 void and would not have ‘been caught and held in an understanding per- son's thinkiag and concern, Such understanding ‘can help the patient co digest and come to terms With these experiences ‘Autistic phenomena such as these would also seem likely tobe presentin Asberger's Syndrome (Asberger. 1944: Barrows, 1988: Gillberg, 1988, 1989: Wing. 1981) and also in schizoid person- alities (Weil, 1953: Wolif & Barlow, 1979: Wolff & Chick, 1980: Wolff & Cuth, 1986). Ultimately ‘utism will affect sm individual's attitude 1 dying. since this fina! event inevitably bringsREVISED UNDERSTANDINGS OF PSYCHOGENIC AUTISM awareness of bodily separateness and the threat of loss of bodily existence. ‘The NATURE OF AUTISM The difficulty in discussing autism is that one has to think thoughts that, for the patient. have been unthinkable, and to find concepts for what ‘were unconceptualized states. Such patients are not “object related”. do nor objectivize and are a-symbolic, although some of them may use symbolic equations’ as described by Hanna Segal (1957). This equation of objects affects everything that autistic children do, For ex ample, in classification—that basis for cogni tion—two objects, although different in many respects, will be equated because of a single superficial similarity. These are not similes or metaphors; the two objects are felt to be one and the same. There is no discrimination of differ- ences. Similarly fantasies are not present: only things that can be touched and handled to produce sensations are meaningful to autistic children who have been found to have no capacity for empathy (Hobson, 1986). and to lack imagination (Frith et al, 1985). Also. asi to be expected. such children do not play (Tustin, 1988. 1990). They have litle inner life and are an empty auto-sensual shell—an empty Fortress’ 28 Bettelheim (1967) so aptly calls them. They have also missed the normal slates of “flowing-over-at-oneness’ which are Rexibly interspersed with alert awareness. These alternating flexible states, which have been de- scribed by both Grosstein (1980) and Ogden (1989), gradually prepare the infant for an awareness of bodily separateness which is bear- able. The abnormal fusional states are perser- verating and rigid. In such states, awareness of bodily separateness is unbearable in that it is sudden, unexpected and traumatic. This preci- pitates aberrant autistic reactions. These patients lack a “psychic floor’ and are very dependent tupon external support. This is beceuse their “sensory floor’ as described by Ogden (1989) has become distorted and perverted by the use of inanimate “autistic sensation objects” and “aut- istic sensation shapes’. Thus. they have no internal regulator for the feelings associated with “object relations” because their early skin- 589 to-skin sensuousness with the mother has been so disturbed. Conetusios Since autistic states are not relationship orien- ted, and since there is litle inner life. such states are outside the scope of most psychoanalytical Formulations. Autistic states are psychochemical in nature, mostly with surface manifestations As is exemplified in the references. both neuro- psychiatrists and psychoanalysts have contri- bated to their description and formulation. To write about these states inevitably distorts them. The writer's only hope is thet feelings will be stirred in the reader which resonate with such eccentric and idiosyncratic conditions. If we are to get in touch with che wordless states of psychogenic autism—states which are not part of everyday experience, and which in treatment are difficult to modify—it is imporant that we should be clear about their nature and origins This paper has sought to be clarifying ia this regard. {would tke to thank Ann Alvarez Vitoria Hamil- ton and Sue Norringion for helpful discussions about he material of the paper although, of course. the responsibilty for the views expressed is my own, SUMMARY ‘The author suggests that in the light of obser- vational findings from babies, itis no longer tenable to postulate a normal autistic phase in infancy, and to view pathological autism as a halt at. ora regression to, such a phase. This has been a commonly held psychoanalytic view concerning the aetiology of autism. and she has subscribed to it. In this paper, the author pres- ents a revision of these views, in that she now reserves the term autism to refer solely to patho- logical conditions. Her present view is that autism is a system of protective. but alienating auto-sensual aberrations which have developed to deal with an infantile trauma of seeming to be wrenched away from a mothering person’s body’ She suggests that in an unduly fused nursing situation, mother and child had felt undifferen- tiated from each other. Thus, the infant had390 taken it for granted that the mother's body was a permanent part of “its body. It was an unbearable shock when this was found 10 be not so, The author suggests that autistic reactions to this shock are the source of the autistic child's many delicits. Based on clinical material pre- sented in her other books and papers. she has attempted to describe and conceptualize the protective aulo-sensual reactive aberrations Which develop to deal with this traumatic aware- ness of bodily separateness, TRANSLATIONS OF SUAMARY Als ume le ener découere i aet plas enable se postu ne phase aise normale arm enfnee Se Consderer Tuutnme patholongue comme ute te oe Se rgreon = une ttle phase Co San ne ee nce 4nslyegue communément aseptic concernant Teleionc de Fautsme, ty motte soucrt Dan ceases fresente one revhion de ees ics danse me of ‘ere muinisan le femme autre eaguement pour (See wn ptotp. No ra eve ‘Stuc e su Tautame ex on natene aber pos ‘einer a senante. Qu se sont lope pour fine {Sees un vaumatume ilatle eons lesan Fete sie Sie araché du oop dea personne eu ¢ proses foins iter. Quand lates prs nee Tenn ont icon Indien sme, mre ot fefeat eso sens {nsiérences Tun de Toute Aina Tenn sea pecans eco de mie Gait une parte peranens ce Son Ships ilu Désower quece na paoca ft pouch Scho notable En ne fondant aude eiil angue, jivessyt de coneptaler cos aberatns autosensics ‘Eas die ers nctons powers In Anbetracht wo Forshunsergebnisen der joneeen \Vergangenbolt kann man ene auteieche Pane inde een FRANCES TUSTIN Kindheit weder ale somal posture, noch pathologichea ‘Autsmus alse Verharense ce Phase over one Reptaton Turck 21 ditser Phase bezichnen Das war cine Wein serbritse psychoanaivsche Anscht aber di Aeilors des Autismus: die auch von mir petelt wurde. tn diesem Beirg betchreibe in ne Revision deser Anse. nds Sieh den Begriff cutiomas aunmenr nar noch im Zusame merkang mit pathologsches Zustinden anwende. Meine: sepenvarigen Ansichtzuflge ist Autumas sn Spiers Shutegewahrender. aber erliemdender”auoneauelee Abweichungendieentwikell weren. um item infaatien ‘Trauma ces scheintaren. Wergerscenwerdent von et Mater fenigruverden. In. ener unaagebrcht, expen Pegestuation batten sich Matter und Rind os unclf fender: voneinander emprunden, Baber ats cicesStosice alsselbaverstdndich empfinden.éabderKBrper der Matte: gin Tel wines Kérpers se. Die Enceckung. tab asm tis So ist, kam als unerrigicher Schock. Ich habe verse, lise amotensten Abueichunsen suf der Grundig FIC auchen Matera rs kosepwaliiren und be Sutank: A Ia lz de recientes descubriinto ene capo de ine bseracione de infanies ya 20 defenibe poser une fase auusia normal en i infenca x conscerar ease Batoibico como Hino egresion ne ace Ese a slg st punto’ de visia palosraiico tomunnenie ceeedide "especo lt etiologla del austae, punto de vista que yo Ne ompattido, En ese areulo revo any foes, 1ersanee sshorae mino autismo para huerreteenca Gncaoears 4 condiciones patoldgiat Mi opnicn sot ee a Ssutimo c un sistema’ de aberaconesautosersial peo lector ¥ la ver enajeanten que se cosets fora "ane in trauma infalconseaieenseaise santas el cuerpo materma. Un cugade del tebe exremadameny ‘asin hace que madre y bebe we setaniniferencadon, oe ‘modo que el bebe ces qu el cuerpo de la mace o parte Permanente de su cuerpo, Dect su equivocacion a ‘hoguetembie. 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