Medium 9781855751101

Autism and Childhood Psychosis

Views: 1208
Ratings: (0)

This is Frances Tustin's first book and the original statement of her views on autistic states of mind and the genesis of varieties of childhood psychosis. In it, she tackles problems of diagnosis as these relate to therapeutic intervention.Autism and Childhood Psychosis was first published in 1972 by Hogarth, London, and a year later by Jason Aronson, New York. Subsequently, it was translated and published in France, Italy, Brazil and Argentina, where it is now in its third edition. In France, it is a livre de poche. Twenty years ago, the book was greeted by a group of Italian therapists working at a unit for psychotic children at the Institute of Childhood Neuropsychiatry, Rome University, as "a ship coming into harbor bearing precious cargo". Here was a theoretical model that provided an anchor for therapists bewildered by the array of bizarre behaviors that seemed to defy scientific explanation and human intervention.

List price: $31.99

Your Price: $25.59

You Save: 20%

Remix
Remove
 

12 Chapters

Format Buy Remix

One. Autism

ePub

IN recent years, as a result of the upsurge of interest in the syndrome described by Kanner as Early Infantile Autism, there has been a tendency in popular speech to restrict the use of the term autism to severe pathological conditions. This is not in keeping with its use in psychological literature. More important still, it misses the point that pathological autism seems to be an arrest at, or regression to, an early developmental situation which has become intensified in a rigid form. In this book autism will be used to denote an early developmental situation, as well as development which has gone awry.

Autism literally means living in terms of the self. To an observer, a child in a state of autism appears to be self-centred since he shows little response to the outside world. However, paradoxically, the child in such a state has little awareness of being a ‘self’.

The Autism of Early Infancy. This is a normal condition. There is little awareness of the outside world as such, which is experienced in the mode of the infant’s bodily organs, processes and zones. A normal infant emerges from this state because of an innate disposition to recognize patterns, similarities, repetitions and continuities. These are the raw materials for such mental processes as recognition, classification, object creation and empathy. Through these processes, the child builds an inner representation of commonly agreed reality and becomes self-conscious. The study of children who have failed to emerge satisfactorily from the state of normal primary autism brings home to us the complexity and delicacy of the time-consuming process of becoming aware of the world and its objects, persons and other minds.

 

Two. Psychotic Depression

ePub

‘What we seldom see, and what is rarely described in the literature, is the period of grief and mourning which I believe inevitably precedes and ushers in the complete psychotic break with reality …’ MARGARET MAHLER, 1961.

THE aim of this chapter is to describe in detail, with the help of clinical material, the ‘grief and mourning’ to which Mahler refers in the above quotation. Winnicott has termed it psychotic depression and has distinguished it from reactive depression which is the conscious reaction to the loss of a loved person. Of psychotic depression Winnicott (1958, p. 222) writes:

For example, the loss might be that of certain aspects of the mouth which disappear from the infant’s point of view along with the mother and the breast when there is separation at a date earlier than that at which the infant had reached a stage of emotional development which could provide the equipment for dealing with loss. The same loss of the mother a few months later would be a loss of object without this added element of loss of part of the subject. (My italics.)

 

Three. Autistic Processes in Action

ePub

‘A neat example of a psychical system shut off from stimuli of the external world, and able to satisfy even its nutritional requirements autistic-ally … is afforded by a bird’s egg with its food supply enclosed in its shell.’

SIGMUND FREUD, 1911.

IN the previous chapter clinical material was presented to demonstrate the operation and origin of psychotic depression. In the present chapter therapeutic sessions from another psychotic child will be presented to demonstrate processes of secondary autism which arise to protect against psychotic depression (die ‘hole’).

CASE MATERIAL

David was referred aged 10:10 with the diagnosis of child psychosis. The significant facts in his early history were that David was the younger of two boys. Mother had wanted a girl and when David was born with a slightly twisted spine, she felt that she had a flawed child. The father had had the same defect but it had not greatly incommoded him. This was long before the work on the effect of early separation from the mother had become a subject for the popular press. When David’s mother read of a masseuse in London who could cure his physical abnormality, she decided that he should have treatment even though it meant being separated from her baby. Widi great feelings of unhappiness, she strong-mindedly began weaning him from the breast at five months, so that at six months he could go to London to have treatment. David stayed in what she called a Baby Hotel from whence he went for daily massage. The parents lived some distance from London and so could only visit very rarely. At thirteen months, the masseuse decided that he needed his mother more than he needed treatment, so he returned home with his spine straight but with the stage set for a typical development.

 

Four. 'Grit' and 'Second Skin' Phenomena

ePub

DAVID’S material about grit in his mouth and on his body, and similar material from other psychotic children, has meant that papers on the Isakower Phenomenon have attracted my attention.

This phenomenon was first described by Isakower in 1938. The gist of the phenomenon is that something dry, soft and gritty or wrinkled seems to fill the mouth and is felt on the skin surface of the body to be manipulated with the fingers. There is sometimes also a visual sensation of a shadowy mass, indefinite and mostly round, approaching and growing enormous and then shrinking to practically nothing. Isakower associated this phenomenon with pre-dormescent states and linked it with reminiscences of the infant’s falling asleep at the breast when satisfied.

Spitz (1955) also associated it with satisfying experiences at the breast. However, both Max Stern (1961) and Benjamin (1963) related it to situations of oral deprivation. Benjamin suggests that it: ‘… might represent… a regression to an early pathogenic fixation point.’

 

Five. Autistic Processes: Further Discussion

ePub

IT will have become clear that in studying primary autism we are studying an embryonic ‘Self’. The inner sense of’linking’ provided by satisfying experiences of encircling the nipple in the mouth, of being encircled in the mother’s arms, and of being held within the ambience of the mother’s caring attention seems to be a vital first step from which integration can begin to take place. This is integration of the various parts of the personality, and also integration of the emergent self into a situation where other ‘wills’ exist apart from his own. If this sense of primal linking is lacking, processes exclusively centred on the child’s own body compensate for the lack. These become a closed system for which a dog circling round itself to catch its own tail seems an apt image. Lacking basic integrity, and the consequent introduction to reality, the child’s development is uncontrolled and ‘false’.

Entrance to normal primary autism is difficult since the infant cannot tell us about it and we ourselves have no conscious recollection of it. Bion suggests an avenue of entry through the ‘reverie’ of the nursing mother. Winnicott makes the point that paradoxically, the infant only becomes aware of the primary ‘holding situation’ if it is missing. Thus implying that the study of children for whom primary autism was disturbed may throw light upon this state. As we have seen, processes of secondary autism develop instead. Difficult though it is, investigation of pathological autism is easier than that of normal autism.

 

Six. Autistic Objects

ePub

(a) Parts of the child’s own body.

(b) Parts of the outside world experienced by the child as if they were his body.

In the first half of this chapter selections from a two-year observation of a normal infant, Susan, will be presented to illustrate the part played by autistic objects in the child’s development. This infant was observed at the same time each week and detailed notes were made.

Susan is two weeks old. She is always bathed on her mother’s knee. On this day she cries sharply whilst she is lying flat on her back for her tummy to be washed. When she lies with her tummy flat on her mother’s lap so that her back can be washed, she gives contented little grunts. When she is again put on her back so that her front can be powdered she starts to cry but stops as she mouths to the breast. When she doesn’t get the breast, she starts to cry again. Finally, she stops as her fingers and the string of her bib accidentally get into her mouth during the threshing around she does whilst crying.

 

Seven. Systems of Pathological Autism

ePub

THE formulations which will be suggested in this and the following chapters are based on a large quantity of observational and clinical material from which selected examples have been quoted in previous chapters. In the present chapter three main systems of pathological autism will be described and differentiated from each other. A precipitating factor for all types of pathological autism seems to be the mouth-experienced ‘hole’ type of depression associated with feelings of terror, helplessness and defectiveness. This has been termed psychotic depression. The first system of pathological autism to be discussed will be termed Abnormal Primary Autism (A.P.A.). Abnormal Primary Autism is an abnormal prolongation of primary autism due to one or other of the following factors:

i. Gross lack of essential nurturing. 2. Partial lack of essential nurturing.

(a) Due to grave deficiencies in nurturing figures.

(b) Due to impediments in the child.

(c) Due to an interweaving of factors (a) and (b).

As Bowlby (1969) has emphasized, infants need other things than the provision of food. Two of the essential ingredients in their nurturing seem to be the provision of bearable sensory stimulation from without, and the relief of excitements arising from stimulation from both internal and external sources. They also need parents, particularly a mother who has been enabled to bear the inevitable frustrations and difficulties associated with differentiating herself from the outside world, and with making intra-psychic differentiations. Parents or a marriage partner who are/is too malleable can prevent these processes from taking place satisfactorily.

 

Eight. Classification as a Basis for Treatment

ePub

VERY often, each new psychotic child that we see seems to be unlike any other that we have seen before and to form a diagnostic category of his own. This baffling variety of presenting appearance is because inborn characteristics and impediments in the child intertwine with those of the parents and with outside circumstances which have been catastrophically disturbing. In this chapter, differential diagnosis on the basis of the type of autism manifested by the child will be suggested as a means of classification which would avoid what Creak (1967, p. 369) has termed ‘cramping over-simplification’. The common psychiatric division of psychotic children into those suffering from Early Infantile Autism and those suffering from childhood Schizophrenia is too rigid and leaves out many children who do not fit into the above categories.

The classification to be suggested could only be made after several weeks of study in a clinical situation by a worker trained in deptii psychology who has had considerable experience of psychotic children. It would seem to have the advantage that it provides an integrative scheme which relates the autism of such conditions as blindness, mental defect and brain damage to the autism of the Kanner syndrome and allied disorders, as well as the autism described by Bleuler (1913) in relation to schizophrenia.

 

Nine. Early Infantile Autism and Childhood Schizophrenia as Specific Syndromes

ePub

THE various kinds of pathological autism have been differentiated and compared by means of the charts at the end of Chapter Six. In the present state of our knowledge of child psychosis, differential diagnosis in terms of the type of autism is a useful rough and ready way of classifying psychotic disorders of childhood on the basis of a critical feature of its psycho-dynamics. This method of classification by types of autism prevents our lumping together all the heterogeneous cases of child psychosis into a ‘hotch-potch’ (Kanner 1958, p. 142), and yet it also ‘leaves the door open revealing our perplexity and confusion’ (Creak 1967, p. 368). However, as more psychotic children are being seen and described, two syndromes seem to be emerging which can be distinguished with some exactitude. These are Early Infantile Autism and Childhood Schizophrenia. (This still leaves many psychotic children who fall outside these two categories.) In terms of the type of autism, Early Infantile Autism comes into the category of Encapsulated Secondary Autism (E.S.A.) and Childhood Schizophrenia into the category of Regressive Secondary Autism (R.S.A.).

 

Ten. A Clinical Description of Childhood Schizophrenia

ePub

RALPH will now be briefly presented as one example of a schizophrenic child manifesting Regressive Secondary Autism (R.S.A.).

Ralph was a second child born to a couple in Australia. He was an extremely good baby (‘we didn’t know we had him’), and was bottle fed. When he was ten months old the mother went to take a University course in Psychology in another town in Australia and the baby was left with the maternal grandparents. When the mother returned he was eighteen months old. She found a child who had had eczema (which had cleared up) and who was inclined to be ‘chesty’. He was also ‘whiney’ and miserable.

When Ralph was three years old the family moved to another part of Australia and he was sent to kindergarten. Here, he functioned like a mentally defective child, and mother became very worried, for it confirmed her worst fears, having been absolutely convinced when she was pregnant that her child would be subnormal.

When Ralph was six years old the family moved to England and the mother decided to try to find help for Ralph who was beginning to live more and more in a world of bizarre fantasy.

 

Eleven. A Setting for Psychotherapy

ePub

A PSYCHOTIC child’s first and most urgent need is to feel that the explosive violence which threatens to burst everything apart can be held and contained within a setting which can bear it. Any method of treatment needs to take into account that at root such children are terror-stricken. Every particle and cell in their body seems to have been touched with a potent irritant. As one recovering psychotic child said, ‘It was like hobgoblins in the blood.’ After the rage and terror have been worked over and abated, the child may go on with autistic habits, simply because they have become habitual and firmness is needed to help him to give them up.

Psychotherapy is one way of treating such children and there are many methods of psychotherapy. My own method which is psycho-analytic is based on the work of Melanie Klein.

In this type of psychotherapy, the child is seen at the same time each day (if he is seen daily), or at the same time each week (if he is seen weekly). If he is seen only once a week it is helpful if he attends daily at a special unit where the teacher provides a predictable and supportive setting. During the therapeutic session the child remains in the same room all the time. He is not allowed to wander around the clinic. The arrangements of the room are kept the same from session to session. He had his own drawer of toys which is locked after he goes. These are simple toys such as wild and tame animals, figures to represent a family, cars, a wooden bridge, paint and crayons. There is also a tap with running water in the room.

 

Twelve. Phases in Psychotherapy

ePub

IN this chapter various phases of the psychotherapeutic process with psychotic children will be described. These will be in the sequence in which they are likely to occur when treatment is carried out in the firm containing setting described in the previous chapter. In this manner of presentation, treatment will seem to be much more easy, smooth-flowing process than it actually is. In practice, one phase overlaps with the next one, and there are set-backs in response to such events as holiday breaks or disturbing happenings at home or at school. However, in looking back over the whole course of treatment the following phases can be discerned in therapy with E.S.A. and R.S.A.(i) children.

PHASE I

This is an extremely difficult phase in that we have to attempt/tfycAotherapy with a child who to all intents and purposes has very little psychic life other than that of sensation, in which, in some cases, he has lived too much. The feeble flame of his psychic life has to be fanned by every means at our disposal. He has to be helped to respond to the outside world in a more realistic way. Autistic objects have to give place to trait’ sitional objects and finally to symbol formation. This often has to be done whilst we become increasingly aware of our own insecurities and uncertainties.

 

Details

Print Book
E-Books
Chapters

Format name
ePub
Encrypted
No
Sku
B000000020164
Isbn
9781781810798
File size
2.03 MB
Printing
Allowed
Copying
Allowed
Read aloud
Allowed
Format name
ePub
Encrypted
No
Printing
Allowed
Copying
Allowed
Read aloud
Allowed
Sku
In metadata
Isbn
In metadata
File size
In metadata