EVALUATION AND PSYCHOTHERAPY FOR AUTISM
I focus on the psychology of the autistic child—on emotions, self-understanding, and aversion to relationships—while monitoring at all times the interaction between the child’s unique neural endowment and his experience. I also help the parents, who suffer profoundly when they can’t reach their child.
The Surprising Value of Psychotherapy with Autistic Children
Parents’ Dilemma. In the last 20 years, the incidence of autism has increased ten-fold. Today, one out of 500 children has classic autism; one out of 110 has an autism spectrum disorder. Experts believe that broader diagnostic criteria, increased awareness and changing trends in diagnosing have contributed to the rise, but can’t entirely explain the surge. There is no consensus on the cause of autism.
In addition, the rapidly growing numbers of parents with autistic children face a dizzying array of treatment options—therapies that modify behavior, teach communication and social skills, and promote sensory integration; diets to eliminate allergenic food; even chelation to remove toxic metals. Given autism’s complexity and its mystery, it is hard for anyone to select an appropriate treatment.
Parents face a dizzying array of treatment options; they worry that they’ve missed the “magic key,” or that their hope of understanding their child is forever out of reach.
In their desperation and concern, parents can become confused, overwhelmed and even paralyzed. They worry that they aren’t doing enough for their child or have missed the “magic key,” or that, on the contrary, they have recruited too many providers, each addressing one part of the child. They worry, privately, that their hope of understanding their child, their child’s soul, is forever out of reach.
What does psychotherapy offer autistic children and their parents? Above all, psychotherapy respects the whole child; it aims to reinforce and consolidate, rather than confuse, the family’s knowledge of the child’s personhood, the child’s unique mental and behavioral strengths and weaknesses. Psychotherapy also supports the parents, who suffer profoundly when they can’t reach their child. Psychotherapy is sensitive to the interaction between an autistic infant’s unique neural endowment and his experience. For example, a newborn with difficulty coordinating eye movements and making sense of visual input is more easily overwhelmed and agitated by ordinary parental behaviors.
Psychotherapy respects the whole child; it aims to reinforce and consolidate knowledge of the child’s personhood.
There is a profound interaction between the baby’s and parents’ minds. The baby’s problems deeply affect the parents; the parents process this effect according to their unique personalities, and return a modified response, a response that mingles fear and hope. The baby, in turn, refracts this parental signal through the lens of his own nervous system, producing an idiosyncratic “knowledge” of his parents’ feelings toward him. It is along such complex lines that the baby’s mind develops. The analytic psychotherapist, alert to such complexities, is well-prepared to understand the devastating derailments of the autistic child’s emotional and social life. This approach to autism—that is, a psychological approach--is, unfortunately, little known in the United States; it is better understood in Europe, and it is my approach.
Infant-parent psychotherapy can disrupt the vicious cycle of deepening alienation when parents spot early troubles, helping parents re-engage their infant in pleasurable interactions.
Early identification and treatment is key to the autistic child’s success, and we now know the early signs:
Preference for looking at objects instead of people
Difficulties with soothing
Often, parents sense trouble early, and their anxiety can plunge them into a downward spiral of deepening alienation between themselves and their child. Infant-parent psychotherapy can disrupt this vicious cycle, helping parents re-engage their infant in pleasurable interaction. In many cases, psychoanalytically-informed work with infants and their parents actually averted an impending diagnosis of autism.
The family and I develop an understanding of the young child’s strengths and challenges; then we identify interactions that facilitate, and that obstruct, pleasurable social contact.
The initial sessions include parent interviews, child-parent playtimes, and my direct work with the child. During this evaluation period, the family and I develop an understanding of the young child’s strengths and challenges; then we identify interactions that facilitate, and those that obstruct, pleasurable social contact. When the assessment is complete, I make a diagnosis, if appropriate. I build therapy into the evaluation, my intention being to leave parents with hope and knowledge about ways they can better reach their child.
When a child has already seen a speech or occupational therapist, I will integrate their assessments into the psychological evaluation to give parents a coherent picture of the whole child. I will also consult with the child’s physician to discuss the diagnosis and indications for further medical evaluation.
In analytically-oriented psychotherapy with autistic children, I study the sequence and details of the child’s behavior: how he plays, where he looks, how he moves and holds his body, what sensations he gives himself and, especially, how he responds to me. This stream of observations and the feelings the child evokes in me help me understand the child’s inner life. Then, I give this understanding back to the child with words or playful actions that the child can assimilate.
Does a symptom, like lining up cars, reflect developmental delay, a protective coping strategy, or a perverse pleasure in control? The answer guides my response in psychotherapy.
What Does a Symptom Mean? Here is an example of how I think about an autistic symptom: A 3-year-old child repeatedly lines up cars. I wonder why. Perhaps the child has not learned other ways to play; this implies developmental delay. Or, the precise arranging of cars may be protective, a magical wall raised again and again against the child’s internal chaos, confusion, or inner terrors. Or, I might think, growing concerned, that his compulsive play is entwined with deep pleasure, a pleasure that would otherwise occur in human interaction. In this case, the child has substituted a perverse and unwholesome pleasure within his control for the vital, wholesome but less predictable pleasure of interacting with other human beings. The trance-like satisfaction of arranging cars is blotting out the longing for human contact. The degree to which I understand the repetitive car play as developmental delay, a protective coping strategy or a perversion guides my response. Depending on my conclusion, I either suggest new ways to play or speak about the chaos, confusion, or terror the child is trying to manage. Alternatively, I might frankly comment on the stuckness in this play, explain the perversion of his enjoyment, and describe the consequences of this perversion for the child’s mental development.
Modified Technique to Reach Autistic Children. Analytic psychotherapists modify their technique for autistic children. The late Frances Tustin, a British psychotherapist who successfully treated many autistic children, insisted on firm rules, on doing things properly, and, above all, on “proper relating.” Proper relating is more than good manners. Proper relating is guided by respect for the other person’s mind, a separate mind, a mind different from one’s own. Tustin helped children notice when they disrupted proper relating, told them why they did it, and explained why it was necessary to work with other people in order to grow up properly.
Psychotherapy, modified with firm rules that teach a respect for the other person’s separate mind, can help autistic children vastly expand the non-autistic, growth-seeking parts of their personality.
More recently, Anne Alvarez has emphasized the importance of staying active and lively with autistic children, drawing them into pleasurable interactions. Such innovations, in the context of disciplined psychoanalytic therapy, engage children without overwhelming them, respect their defenses while making them aware of uncomfortable feelings, and maintain the working relationship while still challenging children to grow. With these modest innovations, psychoanalytic therapy can help autistic children vastly expand the non-autistic, growth-seeking parts of their personalities.
Psychoanalytic therapy is dedicated to uncovering and sorting out the deep confusion in the child’s early development; it touches the child at the deepest emotional levels.
How Psychoanalytic Therapy Differs from Other Interventions. What sets psychoanalytic therapy apart from other interventions with autistic children is its dedication to the psychology of the child, its commitment to uncovering and sorting out the deep confusion in the child’s early development. This is not band-aid therapy; it doesn’t cover up a fragile and disturbed sense of self with new skills or socially-acceptable behaviors. It touches the child at the deepest emotional levels. Through understanding, psychotherapy has helped many autistic children lead normal lives.
Psychotherapy—focusing on emotions, self-understanding, and building healthy relationships—can help autistic children make the most of the brains they have.
However, in today’s culture of care, the analytic therapy of autistic children is nearly invisible, and this invisibility is dangerous. A case study reported by Bianca Lechevalier-Haim reminds us of how much we have to lose when we, as a community, dismiss analytic approaches to autism. An infant with serious motor difficulties and no eye contact developed symptoms of autism. Over a long course of analytic psychotherapy, the girl learned to function well academically and socially in a regular classroom, and even improved her motor impairments. An MRI later identified extensive cerebellar damage, which, had it been known initially, would probably have discouraged the parents from getting psychotherapy for their “brain damaged” child. In fact, psychological treatments--focusing on emotions, self-understanding, and building healthy relationships--can help autistic children make the most of the brains they have. Psychotherapy works, not by reversing neurological damage, but by providing new experiences that engender compensatory brain structures and wiring. It is a humane and humanistic approach to a human misfortune.
1. For research on the effectiveness of psychodynamically-informed treatments, see Alonim, H. (2004). The Mifne Method, Israel: Early intervention in the treatment of autism/PDD. Journal of Child and Adolescent Mental Health, 16 (1): 39-43. For case examples, see Acquarone, S. (2007). Signs of Autism in Infants: Recognition and Early Intervention. London: Karnac Books.
2. Tustin, F. (1981). Autistic States in Children, (revised edition). London: Routledge & Kegan Paul, 1992.
3. Alvarez, A. (1996). Addressing the element of deficit in children with autism: Psychotherapy which is both psychoanalytically and developmentally informed. Clinical Child Psychology and Psychiatry, 1 (4), 525-37.
4. For case examples, see Tustin, F. (1981). Ibid.; Rhode, M. & Klauber, T., eds. (2004). The Many Faces of Asperger’s Syndrome, London: Karnac Books; Alvarez, A & Reid, S. Eds., Autism and Personality: Findings from the Tavistock Autism Workshop. London & New York: Routledge.
5. Lechevalier-Haim, B. (2003). Long-term mother-child psychotherapy: Infantile autism with cerebellar anomaly. Paper presented at the Annual Frances Tustin Memorial Prize and Lectureship. Psychoanalytic Confederation of California, Los Angeles, November.