Encounters with Autistic States: A Memorial Tribute to Frances Tustin

ENCOUNTERS WITH AUTISTIC STATES: A MEMORIAL TRIBUTE TO FRANCES TUSTIN. Theodore Mitrani and Judith L. Mitrani, eds. Northvale, NJ: Jason Aronson, 1997. 414 pp.

This volume, containing twenty remarkable papers from psychoanalysts and child therapists around the world, is a fitting homage to the independent-minded, straight-talking woman who devoted her career to penetrating and understanding the inner world of autistic children. Contributors include students, colleagues, collaborators, supervisees, and friends, who add rich case material and considered theoretical review and extension to revealing memoirs of Frances Tustin herself.

Born in 1913 in England, Tustin came to study at the Tavistock Clinic to become a child psychotherapist. Under the tutelage of Esther Bick, founder of Kleinian infant observation, she also studied with John Bowlby, who originated attachment and bonding theory, and began a 14-year personal analysis with Wilfred Bion. In a time of bitter splits in the London schools between loyalists to Melanie Klein's theories and to those of Anna Freud, Tustin seems to have culled the best of influences from her teachers and is seen by James Grotstein to have matured intellectually as closer to the Independent School, particularly Winnicott, than to either faction. Research led her to the Putnam Center in the 1950s, where she met Margaret Mahler, Selma Fraiberg, and others of the American developmental psychology movement, an offshoot of ego psychoanalysis. She was also an admirer of Bruno Bettelheim's Orthogenic School in Chicago.

Grotstein's essay, titled "One Pilgrim's Progress: Notes on Frances Tustin's Contributions to the Psychoanalytic Conception of Austism," traces the development of the therapist's insights, based on copious clinical observation and orderly inference, and places her discoveries in the context of general analytic knowledge. Tustin concluded that autism was the result of the dyadic failure of a pathogenic mother and a pathogenic infant. She was interested in psychochemical aspects of autism but did not systematically incorporate these factors into her writing. (She looked at the actual physical birth of her patients and the pregnancies preceding them but worked with a trauma theory of etiology.) Hers is a conception of ego defect, not intrapsychic conflict. She asserted that autism could not be discussed as a problem of narcissism, since the infant has no sense of self. Says Grotstein, "she believed that her patients' early primal depression had thrust them into a virtually objectless state characterized by a primary deficit, from the object relations (Independent School) point of view" (p. 258).

The importance of this volume is in the richness of Tustin's clinical insights into children struggling with sensation-dominated phenomena, which inform work with an array of patients with primitive psychological difficulties. She considered herself a clinician and teacher, not a theorist, and wrote clearly about data which led her to modify conclusions and to adjust her techniques throughout her career. For example, in her final paper, read in 1993, Tustin "corrected" her previous adherence to the idea that there is a normal development stage of autism. She had come to believe that pathological autism is not a regression to an ordinary state of being but is the result of specific traumatic interaction between a vulnerable individual and the environment. This adjustment, she asserted, would affect not only basic assumptions about serious disorders but also bring about reorientation in treatment methods (p. 6).

Tustin discovered that autistic children are occupied with sensory impressions related to an experience of physical incompleteness, as though they have no vessel for the mind. They use objects, first "hard" objects in an effort to create a sense of wholeness, which must precede a sense of self. These efforts leave them entirely isolated from external objects and social learning. Progression to use of "soft" objects (literally, fabrics, stuffed animals, music, voices) precurses the possibility of relating to persons and environmental demands.

There is rich child case material in this collection, notably Maria Rhode's case of Thomas, who moves from perceptions of bodily disintegration to incomplete body to incomplete body with use of language for body completion, and Anne Alvarez's patient Robbie, reported into his thirties, whose uninterrupted rituals moved toward addiction and perverse, fetishistic functions. The latter paper, "Verbal Rituals in Autism," demonstrates the therapist's use of countertransference experience to plan interventions designed to "allow the children to control and regulate the amount of stimulation" (p. 237) generated by rituals, which are observed first to be lowering arousal, then raising arousal. Alvarez underscores the ego syntonicity of rituals and reminds us that autism is a relatively conflict-free state. She uses some of Tustin's later, more assertive interventions to help the patient to move closer to cooperative interaction.

Sheila Spensley and David Rosenfeld both point to the contributions of Tustin's work to the understanding of varieties of autistic expression in adult psychopathology. Spensley, Tustin's biographer, shows that the study of autism may illuminate psychosis and psychotic aspects of functioning, as well as extending learning about somatoform disorders and their treatment. Rosenfeld cites autistic phenomena in psychosis, and drug addition among Holocaust survivors and in a new group of patients who develop specific psychodynamic symptoms following organ transplants. He concludes that the transplant patients employ hypochondria as a tool to cover the "black hole" left by loss of actual body parts, "that these transplant patients seem to repeat the same defensive maneuvers and mechanisms as autistic children who move from autism to psychosis" (p. 176).

Maria Pozzi presents the analysis of a young woman who fits Tustin's description of a neurotic patient with an autistic "capsule," supervised by the teacher herself. The dreamlike quality of the girl's sense of existence is traced through treatment, conceptualized as careful separation from the adhesive early object state through building of the patient's sense of identity. Victoria Hamilton reflects on another case supervised by Tustin, a nine-year-old girl who cannot read.

Tustin's work grew from a zeal to pierce the isolation of autistic children, to explore their inner world and to free them from the prison of their sensation-dominated existence. Her adherence to an idea of psychogenic autism attracted criticism in an intellectual community which holds the idea of constitutional and organic factors in opposition to psychological reversibility. Like schizophrenia, autism is seen as descriptive of a range of phenomena strongly influenced, if not entirely determined, by biological factors. In practice, her patients did progress, sometimes to psychosis or manic depression, sometimes to depression. She "proved that psychological understanding was transformative in autistics" (p. 276).

The application of psychoanalytic research and technique to disorders conceptualized as the result of brain dysfunction continues to be controversial. Factions are distracted by arguments over interpretation of the burgeoning neurobiological insights available to inform our work. Some of this debate within the field of psychoanalysis recalls the controversies between Kleinians and Anna Freud's followers and, like them, belies the imperative to amass clinical data and adopt useful, fundamental theories, to expand the impact of psychological interventions across the array of mind-body pathologies. This book (and the work of the woman it memorializes) contributes to such an effort, even as it reflects the problems inherent in theorizing about what we see in the consulting room.