In response to repeated requests, I am here making available unpublished papers as well as some published ones that have become difficult to access, as they have not yet been collected in book form.
My second purpose for creating this website is the opportunity it gave me to re-read, update, and supplement my previous papers before publishing them on line and Michel Haag as well for his ones. This possibility to re-read our papers was not provided us by any of the sites (except for the CIPPA – Coordination Internationale des Psychothérapeutes Psychanalystes s’occupant d’Autisme et members associés – http://www.cippautisme.org) that do nevertheless present some of our papers although they were written long ago and, thus, do not present recent developments.
We intend to periodically add new papers to those presented at the creation of this website.
THESE ARTICLES MAINLY ADDRESS THE CONTRIBUTION OF PSYCHOANALYTICAL CLINICAL WORK WITH CHILDREN WITH AUTISM TO :
– a deeper understanding of autistic states, which allows a better calibration of treatment interventions with the child; of parent support work, which is an indispensable part of such treatment interventions; and of interdisciplinary collaboration;
– a deeper understanding of the earliest stages of development in all children, arising from the mutual fertilisation between clinical work and the naturalistic observation of infants in their home environment according to the method developed by Esther Bick.
CONVERGENCES – Many of the insights arising from this work, which was pioneered by the English psychoanalysts who taught us — Donald Meltzer, Frances Tustin, and Esther Bick – preceded, and then converged with findings from cognitivist and neurophysiological research. To my mind, these findings are far from being inconsistent with ours; indeed, they can be seen to provide much confirmation, though these studies are still a long way off being able to encompass the complexity of clinical phenomena. Cognitive science, which is essentially experimental, contributes much detailed knowledge concerning the major mental functions. We can benefit from this knowledge, since it can clarify, enrich and sometimes challenge our perception of clinical phenomena. Similarly, functional magnetic resonance imaging can clarify neurophysiological substrates of mental activity, and can detect some morphological and functional abnormalities in autism, thus opening up many lines of enquiry, though without resolving the issue of aetiology. Indeed, in the present state of knowledge, which remains limited in spite of the significant advances that are being achieved, those articles aspiring to uphold scientific rigour limit themselves to a description of observable anomalies and simply ask the question, ‘Cause or consequence?’ However, the move in neurophysiological research towards the study of neuronal connectivity suggests a convergence between the study of underlying neurological phenomena and the complexity of the mental phenomena that we attempt to address in clinical practice. In my view, some of our observations and psychodynamic hypotheses would be well suited to inspire further research. This implies bridging the divide between psychoanalysis and experimental science, particularly as far as autism is concerned.
THE NATURE OF PSYCHOTHERAPEUTIC WORK – Psychoanalysts specifically focus on behavioural sequences that express emotional and cognitive communications. These occur within a spatially and temporally defined framework, within which the child is provided with play material appropriate for his ability level. The rule of free association remains valid, even for non-speaking children who engage in stereotyped activities. Within this framework, these children led us to decipher the preverbal language in which they endeavour to convey to us the nature of their bodily distress: painful experiences of falling, of liquefying, the vertiginous conditions which, as we now understand, underlie the bodily stiffening and the rhythmical kinaesthetic movements observed in the stereotypies. This distress corresponds to the failure to have constructed a first level of representation of the basics of the body image, that is to say the basics that allow the individual to “se sentir dans sa peau” (literally, to ‘feel in one’s skin’). This experience of possessing an intact skin means being protected from the painful bodily experiences mentioned above, through the constitution of a central, linking core in the oral zone, followed by the establishment of the two intersecting main bodily axes and of the stable linkage of the limbs to the trunk and of the extremities to the limbs. This primary level of representation turns out to be the capacity to have an image of the fundamental geometric shapes, firstly of the circle or rather sphere, as well as of simple rhythmical forms. Indeed, thanks to interpersonal relationships which became established despite serious communication difficulties, the children showed us how these representations are constructed within their relationships through the gathering together of sensory channels. This applies particularly to communication by means of eye-contact, which, as we know, is particularly difficult in autism. The children communicated the nature of their fears of the gaze, which makes it possible to reduce these fears through interpretation and gradually to free them from the effects of these.
NATURE OF THE FINDINGS – It is unjustified to accuse us of “tacking on an arbitrary pattern of outdated theory” or of “allowing ourselves to get carried away by our imagination”: the formulations we were led to through what the children showed us were completely unrelated to our previous ideas. This applies particularly to this genesis of the “body ego”, which Freud had merely suspected to be “the first ego”. The living spirit of contemporary psychoanalysis lies in its openness to understanding the most fundamental layers of mental activity. These are impaired in the serious and early pathologies, whatever the aetiology of these may be that is now being investigated mainly by genetic means. In any case, geneticists themselves stress the importance of not neglecting the impact of the environment on the final expression of genes (epigenesis). Neither should we overlook the reasons for hope provided by the cerebral plasticity present to varying degrees, according to the alterations of the genome found in the so-called ‘syndromic autistic presentations’.
SHARING THE FINDINGS – However that may be, as psychoanalytical therapists what we note is that even the children with the worst deficits are sensitive to verbally elaborated communication of the understanding that they have helped us acquire. This seems to be part of the very process of construction of their “body ego”. Of course, this construction implies the basics of communication that we share with the best non-psychoanalytical educational and therapeutic approaches: a quality of attention pervaded with empathy and deployed for a sufficiently long period. Why not share this deeper understanding with the families, educators, and carers? This helps greatly in the endeavour to sustain attention and empathy… It can lead to emotional interpretations mediated by people in the child’s environment, and to a joint attention enriched with the meaning we have learnt to decipher in some behaviours. Such interpretations can only help the child in all the various settings in which his life unfolds. I have been convinced for decades that one must share with the families and with the multidisciplinary teams the understandings arising out of our work, and which are further enriched in the course of multidisciplinary dialogue.
ENVIRONMENTAL INTERPRETATION – But, the reader will ask, does this mean that everybody will start making psychoanalytical interpretations? What then would be the psychoanalyst’s role? At the primitive level of experience with which we are concerned, naturalistic observation of development within the family teaches us that parents during the first year of their child’s life do in fact “interpret” his or her anxieties of falling or drowning (for example, when they notice their baby stiffening, bracing himself or clutching onto them). Environmental interpretations do arise from the state of “primary parental preoccupation”. But this state does not endure for the whole of life. In dealing with autistic children and other serious developmental disorders, the knowledge that characterises this early phase must be revived, re-experienced, retrieved from the “relegated” area to which consciousness consigns knowledge that we no longer need. (I purposely use the word “relegation” rather than “repression”, which lead to a confusion with the repression described by Freud).
THE SPECIFIC NATURE OF PSYCHOANALYTIC WORK – What is then remains as the psychoanalyst’s specific contribution to the treatment of people with autism? The understanding of later, better-known levels of emotional development, and of the complexity of work within the so-called transference relationship, make it possible to accompany the child during the ongoing process of integration. This involves the increasing complexity of the child’s foundations, which are constructed — or reconstructed — through the continuing re-working of drives and the associated conflicts (oedipal or fraternal rivalries) until and including adolescence.
This is often a particularly difficult time, involving as it does a fresh shake-up body image (body Ego). Though this occurs in everyone and during all pubertal restructuring, it will inevitably meet the residual fragility of the body image in the adolescent with autism. However, adolescence can also be a fruitful time during which this basic aspect of the personality can be re-worked and consolidated, particularly if psychotherapeutic work was already possible in childhood.
THE DEVELOPMENT OF CHILDREN WITH AUTISM – One particular difficulty of the autistic child — the need for mastery (which, to my mind, is linked to the symptom of intolerance to change and unexpected events and may be one of the “biological givens” of autism) is very possibly the root of the obsessional behaviours that are so frequently met with during the development of children and adolescents with autism. Psychoanalytic work can really help to modify these defensive strategies, which are well known, but encountered in a greatly heightened form in these individuals.
Similarly, psychoanalytic work can help to deal with some manic and depressive conditions, which are not “co-morbidities” alien to the basic constellations of autism, and with the problem they create for the development of the sense of identity. These children’s awareness of some of their disabilities, in particular during adolescence but often much earlier, is frequently at the root of quasi-melancholic self-deprecation (which may be masked by manic reactions). These contradictory tendencies can be understood as defensive and are analysable, without nevertheless ignoring the possible need for auxiliary medication over a longer or shorter period.
ABSTRACT – The nature of anxious conditions, which can be serious in people with autism, therefore need to be investigated so that a distinction can be made between elements deriving from bodily anxieties, which always are easily aroused in them, and the anxious states deriving from drive conflicts. People with autism, like others, have to deal with these but with particularities which psychoanalysts are well placed to recognise and understand.
Geneviève & Michel Haag