The autistic moment in psychotherapy

This is a report on the author's experience in treating four autistic children and their families. The importance of making available the therapist's own autism is stressed. The difficulty in doing this and reverting defensively to an administrative approach is described. A previous paper discussed the corrective autistic experience with a focus on the autistic person. This follow-up describes the autistic moment which is a relational experience between the therapist and both the autistic person and the autistic family. The family needs to have an experience of its own autism as a continuum of normal before it can relate to an autistic child. To the extent that the therapist can bring his own autism into the therapy can the family experience its own. The patients are the person, the relationships, the family, and the therapist.The author would like to thank Richard B. Anderson, MD, Lindy T. Barnett, MSW, David V. Keith, MD, JoEllen Barnett Smith, MA, and Orion Smith for their participation as cotherapists. The comments made on an earlier draft of this paper by the members of the Atlantic Psychiatric Clinic are warmly acknowledged. Valuable editorial assistance has been extended by Robert Garfield, MD, and Stuart Sugarman, MD. Lastly, the author would like to extend his appreciation to Robert R. Haubrich, PhD, for stimulating his interest in the field of comparative ethology.Presented at the Conference Honoring the Retirement of Carl A. Whitaker, MD, in Madison, Wisconsin, June 25, 1982.     

The little puppet: working with autistic defences in mother-infant psychotherapy

This paper outlines a constellation around birth in our society that is related to advanced western medicine and the way that families move around the globe. It describes a brief therapy with a three-year-old child who was diagnosed as autistic, and a mother who resorted to 'heroic' defences against the anxiety of being unsupported in a strange country. The therapist undertook to process the catastrophic experiences of the birth as expressed in the child's play and transform the accompanying monstrous fantasies into human experiences and thoughts. By providing a maternal container for both mother and child, the therapist was able to dissolve the couple's negative enmeshment and help create a space in the mother's mind in which she could process her own feelings, and thereby process and understand the child's feelings and communications.     

A social learning therapy programme with an autistic child

Undergraduates were trained in a predominantly operant conditioning therapy aimed at acquiring a measure of control over the behaviour of an autistic child in the setting of a day-care centre. Objective measures of therapist-control prior to therapy showed that the workers initially had no influence whatever on the child. Post-measures indicated that both therapists had achieved a markedly greater degree of control. Controls for mere familiarity and for generalization to workers other than the therapists led to the conclusion that, during the programme, the child had become significantly more responsive to adults in general. The case study material, gleaned from the daily reports by means of which the author monitored the treatment, demonstrated many specific instances of behaviour-change, including the apparent desensitization of various fears. In view of the fact that the treatment setting was far from ideal for this approach, the positive results were regarded as strong support for the suitability of operant conditioning techniques for manipulating psychotic behaviour in children.     

Individual psychotherapy as an adjunct to group psychotherapy

This paper describes a form of combined psychotherapy in which the individual sessions are used as an adjunct to group therapy. Each group member is seen regularly in individual sessions to focus primarily on the member's ongoing group work. The individual sessions are scheduled on a rotating basis. Typically, each group member is seen in an individual session once every four weeks. Additional individual sessions are available only when immediate attention is appropriate and necessary. The group is viewed as the primary therapeutic component. A cost-effective therapeutic approach that uses both individual and group methods, this modality lends itself well to a clinic and to a private practice setting.     

Naturalistic treatment of an autistic child

The present research experimentally evaluated a "naturalistic" treatment program for an autistic child administered by the parents over a 2-yr period. Operant reinforcement techniques previously developed and tested in laboratory settings were initially assessed in a clinic and eventually in the family's home. Experimental manipulations were performed in both settings on rituals, crying and whining, compliance, non-verbal imitation, and verbal imitation. The results clearly indicated that parents can effectively treat autistic behaviors provided that they receive adequate training and supervision in operant reinforcement therapy, and provided that sufficiently potent reinforcers are available to maintain behavior.     

The ecological assessment of an autistic child

The behavior of an autistic child was observed in his natural environment. Observations were made in three settings, over approximately 6 months. Sixteen behaviors of the child and six behaviors of adults and peers were recorded. A cluster analysis was performed to identify response classes within the behavioral structure of the child and to see if correlations existed between response and stimulus events. To examine intra- and intersetting changes, Spearman rank correlations and ttests were also computed. This autistic child exhibited a diversity of behavior over time in a given setting and across settings. He persistently ignored other nonautistic children, although he was responsive to adults. Response classes reflected an inverse correlation between the child's selfstimulatory behaviors and his attentiveness to the environment. Elevated levels of adult attention were consistently related to reduced levels in most self-stimulatory behaviors. Two response classes showed inverse relationships between self-stimulatory behaviors. Reducing the frequency of some self-stimulatory behaviors might cause increases in others.This study is based on a dissertation submitted by the first author to The University of Tennessee in partial fulfillment of the requirements for the Ph.D. degree. The research was conducted under the chairmanship of the second author. The authors wish to express their appreciation to Dr. Edward E. Cureton for his help with the statistical analyses.     

Caregiver interactions with autistic children

Caregiver interactions with young autistic children were contrasted with those involving caregivers and developmentally matched mentally retarded and normal infants. Caregivers of autistic children were similar to other caregivers in their responsiveness to child nonverbal communication bids and in their engagement in mutually sustained play. Caregivers of autistic children were similar to caregivers of mentally retarded children in their greater use of control strategies. However, these two groups of caregivers differed in the particular strategies they used to shape their children's behavior. Caregivers of mentally retarded children pointed to objects while caregivers of autistic children spent more time physically holding their children on task. Individual differences within the autistic sample indicated that caregivers regulated their children's behavior less and showed more mutual play and positive feedback to more communicatively able autistic children. These findings suggest that caregivers respond differentially to the specific deficiencies shown by their children.     

Reformulating infant and toddler social competence with peers

Efforts to identify children at risk for social and academic difficulties at an early age have begun to apply conceptualizations of social competence with peers from childhood to infancy and toddlerhood. These attempts have had limited success, in part because social behaviors studied in later childhood such as negative or aggressive acts may not capture relevant dimensions of social competence with peers during the infant and toddler years. The present study conducted an exploratory factor analysis to begin developing a conceptualization of social competence with peers that is appropriate for use with infants and toddlers, and that captures individual differences capable of predicting later social functioning. Results indicate three dimensions of infant and toddler social competence with peers: peer sociability, active peer refusal, and passive peer avoidance. Negative and aggressive behaviors loaded on each of the three factors rather than emerging as a unique dimension of social competence. Each factor demonstrated both convergent and predictive validity, indicating that early identification of social skills remains a reasonable goal for practitioners and researchers alike. Finally, antecedents within children, families, and out-of-home child care environments helped to explain individual variability in each of these three factors of social competence with peers.     

Atypical memory performance in an autistic savant.

This study explored the mechanisms underlying the hypermnesia of an autistic savant (NM) through three experiments. The first two served to assess whether absence of interference was responsible for NM's exceptional list memory. The third investigated the type of cues used in recall. Results indicated absence of retroactive interference but presence of slight proactive interference in list recall of proper names. Normal interference effects were found, however, in list recall of common nouns. Exceptional performance was also demonstrated in a missing-name task involving spatial and verbal recall cues. The findings suggest that the outstanding episodic memory presented by some savant persons with autism might be related to an abnormally high resistance to interference.     

Towards an integrated model of group psychotherapy with the elderly

Three current approaches to the group therapy of the cognitively intact, depressed elderly are reviewed. Examination of the strengths and limitations of these three models--self psychology, developmental considerations such as reminiscing and life review, and cognitive-behavioral therapies--points in the direction of the usefulness of an integrated model. The main objectives of an integrated approach include: stabilization of the individual's sense of self, establishment of interpersonal competence, and enhanced mastery over the affects of depression and demoralization. Clinical illustrations are provided to demonstrate the practical considerations in this model of group therapy.     

Emotional turbulence during the ending of psychotherapy with an anorexic adolescent

In this paper I reflect on the phase of the analytic process which precedes the termination of a psychoanalysis and describe my work with an adolescent girl. Adolescents with serious eating disorders relive in a particularly violent way, in the final phase of their analysis, the catastrophic anxiety of separation and the fear of annihilation connected with this. The perception of the final date, felt to be irrevocable, reactivates in these patients the psychotic part of their personality, which tries through a phantasy of omnipotent possession (expressed through pathological projective identification) to obscure the reality of separateness and loss. It is useful with these patients to set a date for ending at least a year in advance to enable the working through of these psychotic anxieties. Clinical material illustrates how in the final year of treatment all phases of the analytic process are relived in a violent way, and how this emotional turbulence manifests id as a battle between omnipotent phantasy and an increasing insight into psychic reality.     

Rediscovering trust: Towards an alternative psychotherapy

The collapse of significant human relationships is a primary cause of psychosis. When basic trust is extinguished, a person can feel that his or her actual existence is threatened by genuine relationships. Yet, every human being has a powerful innate need for relationships. Such is the tragic paradox of psychosis: the person is, at the same time, in terror over the possibility of a relationship and in despair over the impossibility of a relationship. An alternative psychotherapy must emerge that allows the psychotherapist and the disturbed person to build a bond of mutual care. Each person unconditionally accepts and confirms the other for what he is, and for what he may become. The psychotherapist must enter the bizarre psychotic world as a partner in a journey to recover the lost wholeness of the psychotic person. This relationship can serve as a bridge which allows the psychotic person to creatively discover a way to rejoin the normal world.     

Nonverbal psychotherapy with infants

A psychoanalytically oriented nonverbal technique was developed to help four withdrawn infants. In three of the four cases, treatment began in the first year of life. Each case presents a different combination of infant/caregiver difficulties that contributed to the infant's withdrawal. After analysis of the difficulties in the infant's first relationship, appropriate preverbal sensory experiences served as a means to establish communication between mother and infant. Regression to the newborn stage gave mother and child a chance to reexperience the earliest stages of infancy. This process led to the recovery of the failing primary bond between mother and child and enabled the infants to compensate for constitutional deficits that prevented adequate attachment. Very early recognition and treatment of some mother-infant attachment disorders may prevent emotional withdrawal, functional retardation, and failure to form meaningful relationships.