No, it really isn’t Bruno Bettelheim who serves as the inspiration of the many psychoanalysts who devote themselves to the study of autism, in spite of repeated statements to that effect in the media. Rather, the intellectual foundations were laid by the British child psychotherapist Frances Tustin[i] and psychoanalyst Donald Meltzer[ii], whose work has been translated, disseminated, taught, and extended during the last three decades, in France and elsewhere. It is important to note that Bettelheim’s conception of autism did not have psychoanalytic roots: it derived from his observation that some concentration camp inmates withdrew into a state that had some resemblances to the behaviour of children with autism. He applied these observations to the families of these children in a way that did indeed, most regrettably, impute blame. This was clearly wrong. But why should it be right that this mistake, committed half a century ago and constantly emphasised in the media, should continue to have a harmful influence on the field ? At the present time, this harmful influence consists in overshadowing all the psychoanalytic work on autism that has been done since Bettelheim’s day, and which has completely different implications from his pronouncements. Nor do we know of any colleagues who would advocate ‘removing children from their parents as much as possible’: treatment is offered on an outpatient basis, except for those cases where parents and professionals together reach the conclusion that a boarding placement would be in the best interests of child and family.
They carry out the most detailed observations possible in the service of detecting and understanding what children, adolescents and adults with autism feel and think, and, despite their impairment, try to communicate. When they are invited to express themselves spontaneously and to associate freely, they lead us to decode their gestural language, which at first sight may appear meaningless. (Free association and spontaneous self-expression are both cornerstones of the psychoanalytic method, though people with autism require the therapist to participate more actively than would other client groups). For example, they will use the sense of touch to explore the architectural features of the therapy room, and its furnishings, as though they were seeking representations of bodily and emotional containment, the impairment of which is such a fundamental feature of autistic states. Equally, they find ways of dramatising devastating fears – of falling forever or of bodily liquefaction – which they may seek to protect themselves against by clinging onto the purely sensory qualities of objects or their own stereotyped movements. This use of the therapy room is a level of proto-symbolisation that precedes the capacity to use toys. People with autism also attempt to communicate their reasons for avoiding eye contact: they may be frightened of feeling emotionally flooded, or penetrated in a way that feels physically wounding. But this ‘language’ also serves to communicate their awareness that, in the course of treatment, ordinary developmental processes are re-activated. These children have taught us a great deal about the processes involved in the elaboration of their body image and of the conception of space. When these are impaired, it is very difficult to engage in spontaneous exploration and in play, even for a child who wants to learn. This means that our therapeutic approach complements the approach of specialist teachers, which can lead to a highly desirable creative exchange within institutions (Hochmann[iv]) and in the course of training (Amy[v]), as well as in specialist centres such as the Centres Ressource Autisme. This complementarity could usefully be built on and taken further than it has been so far.
Furthermore, several teams headed by psychoanalysts have put in place the conditions necessary for early diagnosis, followed by intensive intervention by multi-disciplinary teams. Examples include Pierre Delion’s Depist’ autisme[vi], and the Préaut research led by Marie-Christine Laznik and Graciela Crespin[vii], which includes training paediatricians to be alert to early warning signs.
Many research findings from cognitive science and from neuroscience converge with psychoanalytic observations. For instance, clinical observations have long suggested to us that eye contact may be experienced as being hard, explosive or dazzling. Donna Williams[viii], an adult with autism, describes this very well: such an encounter felt engulfing and, for a time, would make her lose whole swathes of meaning. It must therefore remain debatable why people with autism have difficulty in reading emotions from facial expressions. Some researchers have argued that this is a primary impairment linked to the non-activation of that region in the brain that governs face recognition. But one could argue that the non-activation is itself a consequence of how rarely a child with autism experiences direct exposure to the face of another person – precisely because of problems with eye contact. Indeed, a remarkable literature review published in Sesame-Autisme (the journal of the parents’ association Sesame-Autisme, Nr. 155, July 2005) tells us that neurophysiological researchers have recorded a strong emotional response associated with eye contact in people with autism, while other research shows that eye contact makes children with autism feel threatened: ‘this implies a functional role for the avoidance of eye contact’. We have suggested a similar line of reasoning in connection with the failure of adults with autism to respond to the human voice, as revealed in experiments by Zilbovicius (2004)[ix].
For the last twenty years, psychoanalysts have investigated phenomena that converge in fascinating ways with the findings of non-psychoanalytic researchers. Such researchers include Jacqueline Nadel (Paris) on early imitation; Colwyn Trevarthen (Edinburgh) on primary intersubjectivity in ‘proto-conversations’ between mothers and babies; and André Bullinger (Geneva) on the development of sensory systems and ‘sensori-tonic and tonico-emotional platforms’. It is in no way accurate to suggest that those psychoanalysts who study autism are hampered by a ‘theory’ that has no points of contact with ‘scientific’ reality: without abandoning their grounding within their own scientific discipline, they engage in a lively interaction with the international scientific community in respect of a number of areas of investigation. Many are mindful of current genetic research, which promises to reveal much concerning those innate vulnerabilities or individual predispositions that have long been a focus of psychoanalytic conceptualisations. We hope that the multidisciplinary dialogues that are already a feature of a number of teams – most particularly around issues concerning early diagnosis – will continue to develop, in the interests all patients, not just those with autism. Some cognitive-behavioural approaches, such as ‘thérapies d’échange’ (Catherine Barthélémy, Tours) are of great interest.
The undersigned professionals attest that they do not subscribe to the idea of a purely environmentally-caused psychogenic autism. Nor do they feel that it is appropriate as a treatment technique to restrict themselves solely to responding to the child’s initiatives, however advisable this may be for other conditions. On the contrary, people with autism often need to be actively met (as described by Anne Alvarez[x] and others), in a manner as carefully adapted to their needs as possible. This means that close co-operation with the parents, and a real sharing of the difficulties they encounter, is an essential part of the work.
Our own clinical experience, and our supervision of the work of other professionals, has taught us that the three domains of treatment, academic teaching and social education must be integrated if children, adolescents and adults with autism are to be given the best possible chance. With this in view, we call on professionals working in different areas and with different orientations to forego harmful claims to exclusive knowledge and expertise, and to come together in the interests of cross-fertilisation and of advances across all domains.
Prof. M. Amar (Nantes), Dr. V. Damato (Naples), D. Amy, Dr. D. Arnoux, Prof. A. Aubert-Godart, Dr. P. Barrows (Bristol), Prof. P. Bizouard (Besançon), Dr. E. Castex, M.-Ch. Choppy, Dr. G. Crespin, Prof. P. Delion (Lille), Dr. A. Eiguer, Dr. A. Feugère-Engel, Dr. V. Flavigny, Dr. J. Fortineau, Drs. S. and Ch. Frisch (Luxembourg), Prof. B. Golse, J.-L. and A. Goyena, Dr. G. Haag, Prof. Emeritus J. Hochmann (Lyon), Prof. D. Houzel (Caen), D. Huon, Dr. F. Jardin, Dr. M.-Ch. Laznik, Dr. B. Lechevalier (Caen), Dr. E. Lefort (Corrèze), Dr. B. Lehalle, Dr. A.-E. Lenfant (Lille), Dr. S. Lepastier, Dr. A. Lévy, Dr. S. Maiello (Rome), Prof. O. Maratou (Athens), Dr. C. Masson, D. Mellier (Lyon), S. Messeca (Naples), Dr. E. Moussaoui (Caen) Dr. N. Nakov (Metz), A. Namer, Dr. L. Ouss, P. Poyet (Blois), R. Prat, Prof. J.-Ph. Raynaud (Toulouse), Dr. D. Ribas, Prof. M. Rhode (London), J. Rochette, Dr. D. Rosenfeld (Buenos Aires), Dr. R. Sandri (Brussels), C. Sternis H. Suarez-Labat, Dr. C. Tabet (Lens), Prof. S. Tordjman (Rennes), Dr. B. Touati, J. Tricaud, S. Urwand, Dr. A,-M. Vaillant (Corrèze) [place of work where not specified is Ile de France]
[i] Tustin, F. (1981) Autistic States in Children, London: Routledge (2nd revised edition, 1992). Also Autism & Childhood Psychosis, London: Hogarth, 1972; Autistic Barriers in Neurotic Patients, London: Karnac, 1986/1994; and The Protective Shell in Children & Adults, London: Karnac, 1990.
[ii] Meltzer, D., Bremner, J., Hoxter, S., Weddell, D. & Wittenberg, I. (1975) Explorations in Autism. Strath Tay: Clunie Press.
[iii] Haag, G. (2000) ‘Le moi corporel’. In Geissmann, C. & Houzel, D. (eds) L’enfant, ses parents, et le psychanalyste. Paris: Bayard.
Haag, G. (2005) ‘Comment les psychanalystes peuvent aider les enfants avec autisme et leurs familles’, in Medecine et Enfance (May issue) and in Autisme: état de lieux et horizons, 31520 Ramonville: Erès.
[iv] Hochmann, J. (2004) ‘Au risqué de la psychiatrie communautaire: une experience de suivie au long cours d’enfants, puis d’adolescents autistes.’ Revue Sesame Autisme Nr. 152.
[v] Amy, D. (2004) Comment aider l’enfant autiste? Paris: Dunod.
[vi] Delion, P. et al. (1998) Les bébés à risqué autistique, Erès.
[vii] Crespin, G. (2004) Aspects cliniques et pratiques de la prevention de l’autisme, Cahiers de Préaut, Paris: L’Harmattan.
[viii] Williams, D. (1992) Nobody Nowhere. London: Transworld Publishers.
[ix] Haag, G. [with the support of 160 colleagues and several non-psychoanalytic researchers] ‘Réflexions de psychothérapeutes de formation psychanalytique s’occupant de sujets avec autisme’. Carnet PSY March 2005. See also Le Monde, 18/05/05, article by C. Vincent.
[x] Alvarez, A. (1992) Live Company. London/New York: Routledge.
G. Haag, secretary of Cippa