Excerpts from: Autistic Barriers in Neurotic Patients
Tustin, Francis (1986). Autistic Barriers in Neurotic Patients. New Haven, Conn.: Yale Univ. Press
Normal primary autism & pathological autism
3—Autism is a state in which auto-sensuousness holds sway, attention being focused almost exclusively on bodily rhythms & sensations. Objects in the outside world may be attended to, but on close observation it becomes clear that these are experienced as being part of the body or very closely akin to it. People & things outside are scarcely used or seen as having a separate existence. They are experienced as an extension of bodily activity & in terms of the sensuous experience of them, particularly the sensuous experience of touch.
Primary narcissism & autism differentiated
5—There seems to be a period immediately after birth in which the child reacts to the outside world in terms of his own body and its in-built dispositions. This establishes his body image as a basis for personal identity. this early time is a stage when experience with body-centered ‘sensation-objects’, and with the mother experienced as a ‘sensation-object’ which is part of his body, prepares the infant for later relationships with ‘not-self’ objects experienced as separate from the body to which he has to learn to adjust.
5—The crux of the psychotic child’s damaged condition is that he has had an agonizing awareness of the ‘not-self’ before he had a sufficiently integrated self to cope with the strain.
It is tenable that the primary state of autism is not absolute. There are likely to be flickering states of awareness of separateness which, if they are bearable, prepare the child for emergence from the primary, sensation-dominated state to one in which emotional relationships with people, experienced as separate and different from his body, can begin to develop. However, such emergence is not absolute either, for throughout life there are transitory states in which there is a relaxation of the stresses and strains of separateness.
Normal Primary Autism
6—Bodily rhythms and vibrations experienced in contact with the mother’s body seem to be the ‘mother’. Such a working simulation is adequate at the early time. We call it ‘illusion’. At this time, although the sensation-basis for the development of a sense of self is present, there is little sense of being a self separate from the other selves. The sense of self develops as the ‘not-self’ is experienced. The way in which the infant develops awareness of the ‘not-self’ is crucial to his sense of individual identity.
An important part of the hypothesis to be presented in this book is that the psychotic child has encountered the ‘not-self’ in a way which experienced as traumatic because he had not developed the necessary neuro-mental integrations to cope with the strain.
The sensuousness of the infant in the state of normal primary autism and his relatively undifferentiated, global awareness, combined with the adaptability of the mother arising from her ‘maternal preoccupation’, protect the newborn infant from ‘not-self’ experiences. They provide a protected intermediate stage between being inside the womb and being outside of it. Thus, they constitute a kind of post-natal womb.
6-7—The first four months of the infant’s life should be considered as an extra-uterine pregnancy. In my view, this shelters the infant from realizations which are more than his elementary neuro-mental apparatus can deal with. The newborn infant makes little or no adaption to the mother’s body as being separate and different from his own rhythms and sensations. As far as he is concerned, the sensations in his mouth are the breast, his own bodily rhythms create an auto-sensual construct of ‘mother’.
7—Rhythmical co-operation helps to preserve the illusion of ‘oneness’ with a mother who is constructed in terms of the infant’s own bodily sensations. In normal development, this auto-sensual construct of a mother who is experienced as being part of his body is based on in-built patterns of response experienced in terms of bodily sensations, expressed in bodily movements and evacuations. This auto-sensual construct is a useful simulation which enables the infant to feel that his experience of the mother is a continuous and unbroken one.
Awareness of the ‘not-self’
8—The feeling that the sensation-giving mother is an exciting part of the child’s body is at variance with the realization that she is separate from him and has to be shared with others. The feeling that he ‘creates’ the world is at variance with the realization that it is a world to which he has to adapt and adjust.
9—He has been ‘born’ prematurely or in too confused a fashion from the postnatal womb, and thus has the delusion of having lost a part of his body. Pathological autistic reactions come into operation to cope with the disaster of his body seeming to be damaged; ‘broken’ is the word often used by children to denote this condition.
The psychotic child’s hypersensitivity
9—Normal primary autism is a set of automatic reactions which have survival value in that they cocoon the infant in a sensuous way from what are felt to be damaging impingements from the outside world, for example, excessive stimulation which provokes awareness of bodily separateness.
9—Awareness of bodily separateness from the mother means that he encounters the ‘not-self’ mother (that is, a mother who is not part of his body) whilst he is in a hypersensitized and over-reactive state in which everything is magnified. This makes the experience intolerable. Massive automatic reactions are set in train to block out awareness of the ‘not-self’ mother. Auto-sensual activities are intensified to preserve the illusion of (a) fusion or (b) confusion with the mother. Psychodynamic features of shell-type children
29—Since his first traumatic experience of bodily separateness, the child has had virtually no sense of bodily separateness. It is only as treatment helps him to bear the fact of his bodily separateness from that outside world that he also shows that he feels he is separated from it by a barrier and indicates that he feels enclosed in a shell.
For most of the time the child behaves as if fused with the outside world, and outside objects are experienced as a prolongation of his bodily sensations or movements. In his state of imitative fusion, everything is experienced as ‘me’, although, paradoxically, he has no sense of ‘me’ and ‘not-me’ except in fleeting moments of awareness as he begins to respond to treatment. when these moments occur, the ‘not-me’ is quickly made into ‘me’, by feeling that it is part of his body and under his control.
38—The autistic ‘armor’ of the confusional child does not have the homogeneous quality of that of the Encapsulated child. The latter’s ‘shell’ is formed in terms of ‘me’, the ‘not-me’ being experienced as ‘me’. For most of the time, such children have little sense of ‘me’ and ‘not-me’. By contrast, as the result of their greater awareness of both ‘me’ and ‘not-me’, the predominant delusion of the confusional children is that they engulf and entangle the ‘not-me’ and draw it into the ‘me-ness’ of ‘me’.
39—Both types of child use the image of a ‘hole’ to express traumatic awareness of the bodily separateness which has precipitated their psychosis. But the Confusional children are teetering on the verge of becoming aware that they are flesh & blood, and they occasionally experience and express this experience as a ‘wound’. Encapsulated children make no differentiation between animate & inanimate. For them, objects and people are all ‘things’.
‘Things’ have ‘holes’, not ‘wounds’. It is only flesh and blood which is capable of having a ‘wound’. As the morbid pathology increases, the hole becomes a black hole’, and the ‘wound’ becomes a festering sore. Autistic Objects are felt to block the ‘hole.’ The soft objects of the Confusionals are felt to staunch the bleeding and mop up the pus. When they become aware of bodily separateness, both types of child live in an extreme world of ‘haves’ and ‘have-nots’, which the child experiences as ‘fullness’ and ‘emptiness’.
51—Awareness of bodily separateness on these basic levels is experienced as a loss of part of the body, which leaves a ‘hole’ or a ‘wound.’
56—The ‘not-me’ is felt to be inimical because it brings unbearably painful awareness of bodily separateness which is experienced as an amputation.
68—The Encapsulated psychotic child experiences bodily separateness from the other as being left with a hole. The delusion is that hard objects block up the ‘hole’ to prevent inimical substances from entering or getting out. Pathological objects have survival value in that they seem to keep the threat of ‘death’ at bay, and to compensate them for the limb they have lost.
68-9—A sensuous impression which he had taken for granted as being ‘there’ was suddenly ‘not there’. To relate this to the everyday experiences of normal people, we might say that it had something in common with our feeling of something being missing when we have forgotten to put our watch on to your wrist. A customary sensuous impression was suddenly not there. It could also be similar to the experience quoted by K. H. Pribam:
After the elevated railway which ran through New York’s Bowery was dismantled, people often woke in the night at the time when a train should have passed and telephoned the police, saying that something funny had happened.
A sensuous impression that they had unconsciously taken for granted as being ‘there’ had gone.
70—The quest for a thornless rose-garden of unblemished happiness and perfection leads to disaster. In everyday life, illusions of perfection need to give way to the acceptance of that which is ‘good enough’. The desire for perfection becomes part of the appreciation of beauty & enjoyment of imaginative creations. The psychotic child is stuck in an ‘all or nothing’ world from which he cannot escape.
71—Losing one’s individuality in the social group does not lead to ‘warm and loving human contacts’. It can be a form of pathological autism to avoid the pains of separateness and the accompanying disillusionment.
In normal development, some sense of catastrophic damage & amputation is probably associated with all experiences of individuation and bodily separateness. At these levels, such activities as embraces, caresses and kisses or other soothing delights and reassurances help to heal the feeling of mutilation which is often at the root of feelings of unworthiness.
D. W. Winnicott understood the psychotic child’s grievous sense of amputation & loss, and used the term psychotic depression to conceptualize it. He uses the word privation to describe this sense of being bereft of something whose everlasting sublime ‘thereness’ had been taken for granted.
74—For the young baby, the mother is experienced mainly in a sensuous way as a relief-giving agency. In moments of bodily discomfort such as hunger, coldness, skin irritation or bodily pain, the infant encounters the fact that he is helplessly at the mercy of bodily discomfort. In these moments, the ‘mother’, who has been taken for granted as a relief-giving part of his body, with little or no differentiation being made between his body and hers, seems to be gone.
To put it another way, a relief-giving and exciting part of his body seems to be missing. He is exposed to terrible ‘not-me’ discomfort. In this early state, discomfort is hardness and roughness, comfort is smoothness and softness. Hard, rough discomfort is evacuated and is ‘not-me’ (evacuation being the forerunner of projection). Thus, the child experiences a soft, smooth ‘me’ and a hard, rough ‘not-me’.
74-5—(The child) becomes aware that there is a mother who can be both hard and soft. In these early sensuous realizations, it seems that we see the detailed steps by which the conflict between the Reality Principle & the Pleasure Principle as described by Freud (1911) takes place. Hard reality impinges upon soft, smooth, sensuous pleasure. The child has to come to terms with the black despair & disillusionment arising from this. Dealing with this disillusion, at a sensation level, prepares him for the Depressive Position described by Klein (1937), in which the child comes to terms with his emotions about the ‘bad’ disappointing mother, who is the same as the ‘good’ satisfying mother.
In the psychotic child the situation is different. The Confusional psychotic child has a blurred sense of ‘me’ and ‘not-me’; the soft ‘me’ is threatened by the hard ‘not-me’, which he tries to soften by becoming confused with it. In these procedures, seductive behavior is much in evidence. On the other hand, the Encapsulated psychotic child feels fused with the hard ‘not-me’ to make a shell to protect his vulnerable softness.
Within this ‘shell’ he feels impenetrable. The Encapsulating child uses molding of hard outside objects to have control over them and to make them part of his body. They are the ‘button-molders’ of this world. The Confusional child uses melting and ‘sucking-up-to’, to soften hard outside objects into the ‘me-ness’ of ‘me’. Both types of psychotic child have encountered the reality of hardness in a situation, and at a stage of development, when they could not cope with it.
They could not integrate the experience of hardness with the experience of pleasurable softness, in order that new sensations could be born, those of resilience, suppleness, and toughness. Instead, the feelings of loss and despairing disillusionment were so overwhelming that paralyzed or crippling recoil was inevitable. (The child needs to develop his capacity) to integrate the hard and soft aspects of experience, and thus to develop the inner strength to tolerate the ‘not-self’.
87—Autistic reactions are akin to auto-immune reactions to avoid and reject inimical alien substances. It seems that in an elemental sort of way, the mother comes to be such an alien substance to the autistic child.
92—This ‘holding’ and ‘containing’ come about through the processes of ‘flowing-over-at-oneness’ described earlier. Unbearable bodily tension which is not understood, empathized and relieved by the mother quickly enough is experienced as a disturbing ‘overflow’. It disturbs the illusion of ‘flowing-over-at-oneness’. Unbearable bodily tension is uncomfortable. It feels turgid and hard. It is projected as ‘not-me’. Thus, the sense of ‘oneness’ is disturbed and ‘twoness’ results, but in a way that is unduly painful and sudden and causes a precipitate coming together as a ‘self’ which is not genuine.
Work with psychotic children has brought home to me the importance of this ‘overflow—this ‘spill-over’ of psychological and physiological tension. The child experiences it as tangible body stuff which overflows out of his control. He cannot process it. He recoils from this dangerous stuff in the ‘not-me’ outside world. Or he may feel possessed by it and be unmanageably hyperactive. In early infancy, the mother’s disciplined attitudes and behavior seem to control, channel and render harmless this overflow which is beyond he child’s control. She acts as both analyzer and synthesizer, just as the psychoanalyst has to do in a more artificial way later on, if things go wrong.
93—Bion’s term ‘container’ seems very apt for the concretized functioning in terms of inanimate objects which is under discussion. The early states of differentiation between ‘hardness’ and ‘softness’ take place before the important distinctions between ‘animate’ and ‘inanimate’ are made. These early differentiation’s are the bedrock of human personality before the ‘humanness’ of psychological functioning has emerged. They are physiological integrations with incipient psychological overtones which are extremely important in giving the personality its basic ‘set’.
100—The main purpose of Autistic Objects (that is, objects used as part of the body to give reassuring and diverting sensations) is to shut out menaces which threaten bodily attack & ultimate annihilation. Hardness helps the soft & vulnerable child to feel safe in a world which seems fraught with unspeakable dangers, and about which he feels unutterable terror. These objects help to prevent the realization of bodily separateness and to promote the delusion that impingements from the outside world are obstructed.
103—A sad situation, which often seems to be the starting place for autistic withdrawal, is that of a mother and a baby who experience bodily separateness from each other as being torn violently apart and wounded. Rosenfeld’s term ‘psychic bleeding’ seems apposite for this tragic situation. (At these elemental levels where psyche and soma are scarcely differentiated, physiological images are pat.) Pathological Autistic Objects seem to staunch the “bleeding” by blocking the wound. They also seem to plug the gap between the couple so that bodily separateness is not experienced.
107—Such a child never experiences ‘missing’. In his concretized mode of experience, absence of a needed person is experienced as a ‘hole’, which can be filled immediately with an Autistic Object. He experiences ‘emptiness’ and ‘nothingness’, which are different from missing a needed person.
108—The infant’s primary illusion is that he and the mother are a continuum of bodily stuff. This negation of the outside world seems to be a persisting umbrage arising from intense aversion to the ‘not-me’ which has been catastrophically upsetting.
120—The main function of both Confusional & Autistic Objects is that of evasion; they are a protection against & escape from the ‘not-self’ outside world, whereas the main function of the Transitional Object is to help the child to tolerate, to express and to manage his feelings in relation to it. Thus, Transitional Objects are a bridge to the ‘not-self’ mother; they enable the child to wait until she comes; they keep her alive in his mind.
Objects used in autistic and confusional ways are a barrier between the child and the nurturing people who want to help him. Through their use he avoids having a sense of need. He does not have to recognize that he has to wait for satisfaction, or face the fact that it is not always available. He does not have to bear suspense and delay action. He can and does act impulsively. The TO helps the child to bear suspense and to delay action.
121—Both types of objects are used to help the child deal with the elemental sense of ‘loss’—the loss of soothing and fulfilling sensations which were taken for granted, but which helped him to feel held together in a safe-keeping unity with the mother. In order to counter this sense of ‘loss’, the hard Autistic Object is felt to be part of the child’s body; he feels fused with it. When the sense of loss threatens, he can grasp it.
In using a Confusional Object, the child has a hazy awareness that it is separate from his body, but it is always available to sink into in order to feel confused and hidden. The child is aware of entering the soft Confusional Object whereas, if the Encapsulated child gets inside an object, the operative sensation is of being covered over, not of entering. Hard Autistic Objects completely obstruct awareness of the ‘not-me’: soft Confusional Objects support the delusion of being enveloped in a veil, a fog or a mist.
136—Time & Time again, child patients in a state of pathological autism have demonstrated to me that their notion of how they grow is that they take bodily bits away from grown-ups or other children. These other human beings are experienced as inanimate objects from whom the bits can be plucked like apples from a tree. These ‘bits’ are felt to be stuck on to their bodies to make them taller or fatter or bigger or better or stronger.
Thus, for example, an increase in stature is felt to be under their all-powerful control. However, beneath this illusion of being in omnipotent control, there lurks the terrible dread that these ‘stuck-on’ bits will be snatched away by predatory rivals in the savage and barbarous ways by which they were felt to be acquired. The children then feel that they are in a helpless state of being a mass of holes and vulnerable to attack.
Thus, growing up is not a natural, inevitable process but a cut-throat competitive struggle to acquire extra bits to their bodies. For example, one psychotic child showed me that he felt that he had a hook on the end of his tongue, which enabled him to hook the things he wanted from the stomach of his mother whom he experienced as a ‘thing’—a sort of pond in which he fished with the hook on his tongue!
149—Over the years I have come to realize that the Encapsulated child deals with elemental terrors by feeling hard, which means to him being strong and powerful. Either he collects hard objects which he can grasp (Autistic Objects), or he feels that his hard back protects his soft front, or he feels that his body is made hard and impenetrable by exciting auto-sensual activities.
For these children, hardness becomes synonymous with the turgidity which comes from whipped-up sensual excitement. It is as if their body is a phallus. In this state the child feels that he is able to withstand threatening impingements. But when the inevitable collapse to this orgiastic experience comes, he feels soft in a flaccid and limp way. This sets in motion the whipping up of sensual excitement in order to feel hard and impregnable again. This is followed by the inevitable ‘flop’ (the ‘helplessness’ described by Bibring (1953) as characteristic of what he terms primal depression).
The aim of psychotherapy is to help both types of psychotic child to internalize protecting and nurturing care, and to get in touch with their ordinary, everyday world which is a corrective to their outlandish notions arising from auto-sensual activities.
177—Another way in which such a child avoids being aware of his bodily separateness is by experiencing everything as if it is part of, and not separate from, his body. Thus, alongside his blurring of awareness of the features which the people around him are consciously attending to, he has an ultra-sharp awareness of cues which are normally picked up unconsciously, if at all, such as the muscle ‘sets’ of people, their tones of voice, their tiny gestures and the like.
Those psychotic children who avoid looking directly at a person have a fringe awareness of much that is not normally attended to. These ‘fringe cues’ constitute their world and, through them, they avoid the need for normal channels of symbolic communication which are dependent on awareness of separateness. Thus, the psychotic child does not pay attention to the things we ask him to attend to but, without seeming to do so, is aware of much of which we are unconscious. In this way, they feel part of the outside world and feel it is part of them without feeling separate from it.
178—However, a time comes in treatment when, in spite of all his pathological autistic maneuvers to avoid it, the fact that the therapist is not part of his body cannot be kept at bay and longer. In his hypersensitized state, this is an agonizing experience to the psychotic child, who feels he has lost an all-powerful limb from his body. This recapitulates the original traumatic fracture from which the pathological autism has been a protection.
He feels he has a hole where the ‘phantom limb’ had previously been. This feeling of having a hole spreads all over his body, which he experiences as being full of holes through which ‘nasty’, hard things can enter and from which ‘nice’, soft things will spill or be pulled out. In this unblocked state, he also feels threatened by substances which have leaded out of him in an uncontrolled and uncontrollable way. These ‘leakages’ often take the form of ‘monsters’, who threaten to overwhelm and annihilate him.