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The perpetuation of an error

a
Frances Tustin
a
17 Orchard Lane Amersham Bucks, HP6 5AA, England
Published online: 24 Sep 2007.

To cite this article: Frances Tustin (1994) The perpetuation of an error, Journal of Child
Psychotherapy, 20:1, 3-23, DOI: 10.1080/00754179408256738

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 A R T I C LES

The perpetuation of an error1

FRANCES T U S T I N , Amersham
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This paper is an attempt to sort out my ideas about autism before my pro-
fessional life comes to an end. It is fitting that I should do this with the
Association of Child Psychotherapists because, as you will see, I have been
very helped in my thinking by child psychotherapy colleagues of various
theoretical persuasions.
I should like to think about an error made by many psychoanalytic
therapists (including myself), to which I drew attention in a paper pub-
lished in The Internationaljournal of Psych-Analysis as recently as 1991.
In that paper I pointed out that observational studies of babies by
workers from many countries - such as Colwyn Trevarthen (1979) in
Scotland; Daniel Stern (1983, 1985) in the United States; Miller, Rustin
and Shuttleworth in England (1989); Piontelli ( 1 992) in Italy; Perez-
Sanchez (1990) in Spain - had shown conclusively that there is not a
normal infantile stage of primary autism to which the pathology of child-
hood autism could be a regression. This has been the mainstream
hypothesis concerning the aetiology of childhood autism to which many
psychoanalytic therapists have subscribed, especially in the United States
and in Europe. This flawed hypothesis, based on faulty premises, has
been like an invasive virus in that it has permeated and distorted clinical
and theoretical formulations. It has perpetuated these distortions and
obstructed communication between psychodynamic workers with
autistic children. It has also obstructed communication with our Jungian
colleagues, for example with Dr Michael Fordham, whose model is of
a ‘primary self‘ that innately unfolds (or not, as in autism) to reach out

0 Association of Child Psychotherapists 1994

 4 T H E JOURNAL OF C H I L D PSYCHOTHERAPY Vol. 20 No. 1

and take in the environment. In this paper, I want to think about why
so many of us have made this mistake, and also to discuss the theoretical
and clinical adjustments necessitated by its modification.
The question may be asked why such an issue is important. I would
suggest that it is important because it affects our basic assumptions about
a serious disorder. Also, as is always the case when an error is detected,
useful lessons can be learned from its revision. In this paper I want to
think about why this error has been perpetrated, and about what lessons
can be learned from modifying it. Its origins are deep in history and
fraught with prejudice. Let me outline this history. In doing this, I am
indebted to information in a letter from an American psychoanalyst,
Dr Gillette, which was published in The Journal of the American
Psychoanalytic Association as recently as 8 January 1992.
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HISTORY OF T H E E R R O R

In this letter, Dr Gillette suggested that the hypothesis of childhood

autism being a regression to a stage of normal primary autism had been
so acceptable to many psychoanalysts because it had seemed to be
consonant with certain statements made by Freud. One of these was that
primary narcissism was a stage that followed autoerotism prior to anaclitic
object choice (Freud, 1914). Thus, autism was seen as a stage which pre-
ceded primary narcissism which was also seen as a state of non-object
relatedness.
Another of Freud’s statements that was often quoted in this connec-
tion went as follows:
A neat example of a psychical system, shut off from the stimuli of
the external world, and able to satisfy even its nutritional require-
ments autistically . . . is afforded by a bird’s egg with its food supply
enclosed in its shell. (Freud, 191 1; italics added)
(This quotation was on the dust cover of my first little book on child-
hood autism: Autism and Childhood Psychosis, Hogarth, 1972; now out of
print in English.)
Victoria Hamilton has related this to Margaret Mahler’s formulations.
She writes:
Mahler’s stress on [what she had called] the infant’s ‘inborn unre-
sponsiveness’ . . . leads her to expand on Freud‘s fiction of the bird’s
 THE PERPETUATION O F A N E R R O R 5

egg so that it permeates her whole conception of development. Her

scheme is full of egg-like metaphors such as ‘hatching’, ‘cracking’
and ‘autistic shells’. (1982: 37)
Hamilton sees clearly that Mahler had been influenced by Freud’s state-
ment. Metaphors that are appropriate for a description of the pathology
of autism have been misapplied to normal infantile development. This
has affected ideas about early infantile development and made it difficult
for Mahlerians to communicate with those psychoanalytic therapists who
did not subscribe to Mahler’s classical Freudian hypothesis. In connection
with this Dr Gillette cites Milton Klein’s 1981 paper titled ‘On Mahler‘s
autistic and symbiotic phases’, in which Milton Klein relates Mahler‘s
work to Freud. Dr Gillette quotes as follows from Milton Klein’s paper:
The autistic and symbiotic phases rest on a cornerstone of Freudian
economics, namely that stimuli are inherently irritating. . . . Mahler’s
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metaphorical portrait of the normal infant existing in an autistic

‘shell’ or autistic ‘orbit’ fits well with Freudian principles. (Gillette,
1992: 85)
Gillette says that Milton Klein saw Mahler’s theory as being ‘representa-
tive and congruent with Freudian theory’ (p.93). He tells us that Milton
Klein thought that this explained ‘why it had become the reigning ortho-
doxy for so long. Dr Gillette doubts this ‘reigning orthodoxy’, and points
to what he calls ‘a neglect in the major journals of the work of Daniel
Stern (1985) and others refuting the “dual unity” hypothesis of Mahler
(1968)’.
Gillette instances a long history of prejudice in the United States with
regard to this matter, and cites as an example the fact that ‘Peterfreunds
(1978) challenge to traditional dogma’ (that is, the ‘dual unity’ hypo-
thesis of Mahler) ‘in a major journal was not followed by any published
debate’. He goes on to instance that what he calls ‘Silverman’s (1981)
brilliant and powerful empirical support for Peterfeund’s critique . . .
was rejected by several traditional Freudian journals before it finally saw
the light of day in an edited volume’. He was surprised about this
because, in his view, Stern’s (1983, 1985) challenge to Mahler‘s dual unity
concept was ‘very persuasive’ (p. 160). (Eventually, Margaret Mahler
also found Stern’s challenge ‘very persuasive’, so that in her eighties, with
scientific integrity, in a lecture delivered in Paris just before she died, she
renounced the concept of normal primary autism as a phase in early
infancy.)
 6 T H E JOURNAL OF C H I L D PSYCHOTHERAPY Vol. 20 No. 1

Dr Gillette (1 992) concluded his letter by saying that ‘the resistance to

discussing new ideas that conflict with what are believed to be Freud‘s
views is a significant obstacle to scientific progress in psychoanalysis’. In
spite of our gratitude to Freud, without whose work we would not exist,
a blind unquestioning loyalty to him can be an obstacle. With regard to
the aetiology of non-brain-damaged childhood autism, such adherence
has perpetuated an error. One lesson that we can learn from this error is
that our loyalty should be to understanding rather than to personalities.
The cult of personality is rampant in psychoanalysis. One reason for this
is that our work is so anxiety-provoking that we feel the need to cling
tenaciously to those people who have shed light on a dark scene.
Naturally, we are grateful to them, but this can lead to prejudice and
sterile controversy. Our thinking will get ‘stuck‘.
However, there is another reason that caused some of us to accept
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the erroneous view that the pathology of autistic children had stemmed
from a regression to a normal phase of perpetuated autistic ‘at-oneness’
with the mother that was absolute and constant. This was the type of
clinical material that we encounter in deep psychotherapy with such
children.
Let me now present the kind of clinical material that led me to the
erroneous conclusion that there was a stage of normal autism in early
infancy. This material also demonstrates particularly clearly a traumatic
situation that is crucial in the precipitation of non-brain-damaged child-
hood autism. It is the crux of that precipitation.

C L I N I C A L M ATERIAL

This material was presented in Azltism and Childhood Psychosis (1972)

USA (1973) and in a later book, Autistic Barriers in Neurotic Patients
(1986). I must ask you to forgive me for drawing it to your attention
again. I do so because it has played an important part in my thinking
about autism. I would like to draw your attention to sessions with an
autistic boy whom I called John. John was 3 years 7 months when he first
came into treatment. He did not speak, but his mother told me of nine
words that he understood. These wer2 ‘John, mummy, daddy, Nina (his
sister), pee-pee, baby, potty, spin, spinning’. However, I soon became
aware that there were more words than these that he understood.
(Psychotherapy with these children is showing us that we have tended to
underestimate how much they understand. This is being confirmed by a
 T H E P E R P E T U A T I O N OF A N E R R O R 7

recent investigative technique being used with autistic children called

‘facilitated communication’.)
John had all the characteristics of Kanner-type autism. At first he came
once a week, then increased to three times, and finally came five times
a week. In the presented sessions he was coming five times a week and
was 5 years old. He had begun to say a few words of which ‘gone’ and
‘broken’ were new words that seemed very significant for him. Janet
Anderson (1992) also found this with her autistic child patient and I have
found it to be the case with other autistic children I have treated since
John.
The material I want to present begins with session 130. John was now
talking. The session took place in December prior to the Christmas
holiday. There had been changes in the routine of bringing John due to
his father being away from home. O n the day of the session I am report-
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ing, his father, having returned home, brought him. As they came up to
the front door, the father nearly missed his footing on the front steps.
During the session John seemed to be trying to keep his father alive by
jumping up and down on the couch saying, ‘Daddy gone! Daddy
mended!’ At the end of the session when his mother, not his father, was
waiting for him, he screamed, ‘Daddy gone! Daddy broken!’ Following
this incident it was reported to me that he had a nocturnal screaming fit
in which he said such things as, ‘I don’t want it! Fell down! Button
broken! Don’t let it bite! Don’t let it bump!’
Following this, just before the Christmas holidays, some sessions
occurred that were very important for my understanding of John. They
began with session 140 in which John came into the consulting room and
said in tones of great astonishment, ‘The red button grows on the breast’.
I had never used the phrase ‘red button’, nor had I used the word ‘breast’.
(As I am a Kleinian you will find this very surprising, but this was my
first autistic child patient and I had decided not to impose a theoretical
scheme upon him, and to see what words he used himself.) After this
session I talked to his mother and she told me that John had seen a friend
of hers feeding her baby at the breast, and he had seemed very fascinated
by it. It seems to me that this incident triggered off a whole series of com-
munications that made me aware of the traumatic experiences John felt
he had suffered as an infant.
Following his astonished remark, I asked him in a matter-of-fact way
what he had thought about the ‘red button’. He pointed to his mouth
saying ‘Red button here!’. I was intrigued and surprised. There is more
about this to come as John depicted the infantile traumatic situations for
 8 T H E JOURNAL OF C HI L D PSYCHOTHERAPY Vol. 20 No. 1

me in a sort of dramatic re-enactment. There was a strong feeling that he

wanted me to understand something that had been very important to
him.
In session 153, after the Christmas holidays, John carehlly arranged
four pencil crayons in the form of a cross and said, ‘Breast!’. Touching his
mouth he said ‘Button in the middle!’ (I commented that baby John
seemed to want to make a breast for himself out of his own body.) He then
put out more pencils in a hasty, careless fashion to make a ramshackle
extension to the cross, saying, ‘Make a bigger breast! Make a bigger breast!’
(I said that baby John seemed to want to have a bigger breast than actually
existed.) At this, he angrily knocked all the pencils so that they spread over
the table in a higgledy-piggledy fashion. He said, ‘Broken breast!’ (I said
baby John was very cross that he couldn’t have a breast as big as he
wanted.) He said, ‘I fix it! I fix it! Hole gone! Button on! Hole gone!
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Button on!’ (I said he seemed to want to have a breast that he could make
or break as he pleased.) He again angrily pushed the pencils all over the
table and said ‘Broken!’. He then opened and shut a wooden box with ear-
splitting bangs. (I interpreted how cross he felt when he couldn’t have a
breast that would be as big as he wanted it to be.)
He said ‘Broken’ again. Following this he went to the umbrella stand
and put his hand into the glove cavity that is in dark shadow. He shud-
dered and said, ‘No good breast. Button gone!’ (I interpreted that his
angry attacks on a breast that would not be as big as he wanted it to be
made him feel that he had a ‘no good breast’ with a hole instead of a
button.)
He went to his box and fetched a piece of dirty grey cardboard and the
crocodile. He put them on top of the box whose lid he had banged
and, pointing to the Sellotape around the edge of the cardboard, he said,
‘Icy. Icy’. Then he said, ‘No good breast! Button broken!’ He slid the
crocodile around the cardboard as if it were slithering on ice. His face
went cold and pinched. (I took up his feeling that breaking the breast
made an ‘icy no-good breast‘ that was no comfort to him when he was
on his own.)
In other reports on John, I have given the following summary of occur-
rences in the period that followed:
Now that the infantile transference was well established and the
anxieties about the ‘broken breast‘ were contained in the analysis,
his behaviour outside showed great improvement. He was eager to
come to analysis and made good progress in spite of family illnesses,
 T H E P E R P E T U A T I O N OF A N E R R O R 9

changes in the routine of bringing him, and family bereavements.

He began to admit his dependence and helplessness, and would say
of things that were beyond his powers, ‘I can’t do it! Please help
me!’. This progress was maintained when his mother and younger
sister went abroad and he was left with father.
However I go on to say,
An unfortunate break now occurred in the ‘holding situation’.
This brings us to session 194.I had shown him by means of a diagram
the day he would come back to see me after the two-week Easter holiday.
Family circumstances made it impossible for father to bring him back
until one week later. In addition, he had been left with the grandparents
for one week. When he came back I was appalled. He seemed trauma-
tized and frozen. He had a stiff-legged mechanical gait. What speech he
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had left was stammered. He was indeed in the grip of the ‘icy, no-good
breast’. This had provided no comfort for ‘poor little baby Johnny left all
alone on an island (as he put it later).
As the bodily tensions relaxed, the night-time screaming fits became
such a regular occurrence that the referring psychiatrist prescribed a
sleeping draught. During the screaming fits he would hallucinate birds in
various parts of the bedroom, and say some of the phrases he had used
in his first screaming fit, the one after he had been worried about his
father’s safety: ‘I don’t want it! Fell down! Button broken! Don’t let it bite!
Don’t let it bump!’ The hallucinated birds were a great source of terror
because they threatened to peck him. However, he gradually began to
bring the infantile anxieties back into the analysis.
I now want to present session 360 in which all his terrors came into full
expression. In this session he again used coloured pencils arranged to
make a ‘breast’. (This was the first time he had done this since session
153, eight months earlier, that is, before the unfortunate separation expe-
rience.) He pointed to the carefully arranged pencils and said ‘breast’.
Then touching his mouth, he said ‘Button in the middle’. Then he stood
a pencil in the middle and said ‘Rocket’. He called the whole arrange-
ment a ‘firework breast’. (This linked in my mind with a drawing he had
done in an earlier session of a dome-shaped object with brown and red
‘stinkers’ (his word for faeces) coming out of it that he afterwards called
‘fireworks’. This had been drawn after a tantrum when I wouldn’t let him
use my hand as if it were his own.) In the session under discussion con-
cerned with the ‘firework breast’ made out of pencils, he held his mouth
 10 T H E JOURNAL OF CHILD PSYCHOTHERAPY Vol. 20 No. 1

as if it hurt, and said, ‘Prick in my mouth! Falls down! Button broken!

Nasty black hole in my mouth!’ Then, in an alarmed way, he held his
penis and said ‘Pee-pee still there?’, as if he thought it might not be.
We now come to session 367 which carries our understanding of his
terrors still further. John was in a screaming tantrum as I opened the
front door because he had fallen and bumped his head. There was no sign
of damage, but he seemed panic-stricken as well as enraged. When he
stopped crying I took him to the therapy room. Without taking anything
out of the box of toys, he went to the table to talk to me. He said, ‘Red
button gone! It fell with a bump!’ He then indicated both his shoulders
with a semi-circular movement and said, ‘I’ve got a good head on my
shoulders! Can’t fall off! Grows on my shoulders!’ He then said, ‘It was
the naughty pavement, it hit me!’ (I said I thought that he was telling me
about his fears when he fell down just now.) Touching his own mouth he
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said, ‘Nina [his sister] has got a black hole. She had a prick in her mouth.
Button broken! Nasty black hole!’ (In my notes I say, ‘I should have inter-
preted here that he was getting rid of the nasty experiences he’d just told
me about by attributing them to Nina, but I birked it‘, that is, I failed to
take up the beginning of projective identification.)
He then took the red plastic tractor, which was a toy he had attacked
relentlessly. He touched the plastic axle which was not in reality sharp.
However, as he touched it, he gave a huge shudder and said, ‘Nasty hard
tractor, it pricks.’ He spat, as though spitting out something that was
repugnant, that is, projection had begun in a quite concrete way. He then
screwed himself up and screamed loudly. (Here, I reproached myself for
not having attempted earlier to put his projective identification with
Nina into words, and so possibly sparing him from having to express it
in violent action.) In his screaming he said he was pushing away flying
beaks. I was afraid that he would fall off his chair so I took him on my
knee and talked to him through his shrieks. (I talked to him about his
feeling that the ‘red button’ was part of his mouth and how upset he felt
when he found that this was not so. He felt he had a ‘nasty prick‘ and a
‘black hole’ instead of the nice ‘red button’. He felt he spat nasty things
into Nina whom he felt had taken the ‘red button’ from him. But then
he felt that she tried to spit it back at him and her nasty mouth seemed
like flying birds.) (We had had material that showed that, on the basis
of a similarity of contour, he had equated the flying birds with mouths.)
I went on to say that without the button he didn’t feel safe and felt that
the flying mouths could hurt him. He was afraid that he might lose his
head or his penis as he felt that he had lost the button.
 T H E P E R P E T U A T I O N O F AN E R R O R 11

My notes tell me that, after this, John was afraid of certain objects in
the therapy room; one was the dark glove cavity I mentioned earlier,
another was a penis-like pipe near the ceiling, the other was the ‘dirty
water bucket’. (I had no sink in the room and the ‘dirty water bucket‘
was where we emptied the dirty water after he had used it.) I go on to
say that after these sessions the night-time screaming stopped. It came
back after a particularly worrying holiday and when the question of end-
ing treatment was being discussed.
Treatment came to an end when John was aged 6 years 5 months. In
a roundabout way I’ve heard that he went as a day-boy to a well-known
public day school, and has done well at university. He is very musical.

C L I N I C A L D I S C US S I O N
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I was very supported in the treatment of John by supervision from Dr

Donald Meltzer. Later, I turned to the writings of Margaret Mahler and
to those of Winnicott to help me to make sense of John’s revelations. This
occurred in the following way.
Throughout the sessions I’ve described, and after John’s treatment was
finished, I was worried because the Kleinian formulations in which I had
been trained did not seem to cover what I had experienced with John. In
some desperation I wrote a paper about John’s treatment called ‘A signifi-
cant element in the development of autism’. Looking through a research
report I had had from the Putnam Center (1 953) in Boston, USA, which
had been a research and treatment centre for autistic children, where I
worked for a year after finishing the child psychotherapy training at the
Tavistock, I found that what they had called ‘primal depression’ corre-
sponded to what I had encountered in work with John. This type of depres-
sion had first been described by Edward Bibring (1 953) who traced it back
to the infant’s ‘shocklike experience of the feeling of helplessness’ (p. 14).
In the paper I gave at a meeting of the Association of Child Psycho-
therapists, I used the term ‘primal depression’. After the meeting, I was
asked if I knew that Winnicott had written about the primitive type of
depression I had described in John, and was told that it was in his paper
‘The mentally ill in your case load. I say with some shame that I hadn’t
read any Winnicott. I wasn’t really experienced enough to appreciate his
work. 1 had to go to the library to read his books as I didn’t possess any
of them. (Hindsight is always painful! This whole paper is about painful
hindsights. . . . But enough of this sackcloth and ashes!)
 12 T H E J O U R N A L OF C H I L D PSYCHOTHERAPY Vol. 20 No. 1

In the chapter I had been recommended to read, I came across the

following paragraph which seemed to be an apt description of the
experiences I had been having with John. It was comforting to find that
Winnicott seemed to be aware of the elemental levels of functioning
I was encountering. He wrote as follows:
For example, the loss might be that of certain aspects of the mouth
which disappear from the infant’s point of view along with the
mother and the breast when there is separation at a date earlier than
that at which the infant had reached a stage of emotional develop-
ment which could provide him with the equipment for dealing with
loss. The same loss of the mother a few months later would be a
loss of object without this added element of loss ofpart of the mbject.
(Winnicott, 1958: 22; italics added)
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Winnicott called this early type of depression ‘psychotic depression’ and

distinguished it from ‘reactive depression’ which was the loss of an object
recognized as separate from and not part of the body of the subject. This
made such sense of John’s material for me that I began to use the term
‘psychotic depression’ for his ‘black-hole’ type of depression.
In writing about ‘the loss and restoration’ of what she called the ‘sym-
biotic love object‘, Margaret Mahler also seemed to be aware of the type
of experiences I had had with John. She wrote:
What we seldom see, and what is rarely described in the literature,
is the period of grief and mourning which I believe inevitably pre-
cedes and ushers in the complete psychotic break with reality.
(Mahler, 1961)
I felt that both Mahler and Winnicott were on the wavelength of the type
of material that was troubling me. I also felt that Isca Wittenberg was on
that wavelength when she adopted the phrase ‘primal depression’ (although
it was not part of Kleinian terminology). In her paper ‘Primal depression
in autism: John’ (1975) she performed a useful service in relating it to
Bion’s ‘containment’ and his ‘catastrophe’ theory by describing it as ‘col-
lapse into a particular kind of catastrophic depression’ (p.56). She also says,
‘I did not feel that I was dealing with a three-year-old child but with a
young infant, terrified of falling into an abyss’ (p.59). Winnicott (1958)
also speaks of the terror of ‘falling infinitely’ and writes of a ‘flop-type
depression’. John speaks of the terror of the ‘black hole’. Sheila Spensley
(1985) has helpfully related ‘psychotic depression’ to ‘cognitive defect’ and
‘mindlessness’. These children have experienced a ‘mind-blowing’ trauma
 T H E P E R P E T U A T I O N OF A N E R R O R 13

that has left them feeling that they have a ‘black hole’ of something being
missing. They have experienced one of the ‘pitfalls’ incident upon human
development and human existence. It has been catastrophically traumatic.
Interestingly, a mute autistic child, who was being helped to commu-
nicate through ‘facilitated communication’, pointed to letters that made
the following poem:
Black Hole
Alone in Me
Fearing ripping stretching
Please let me be free from your grip
Deaden
(Evan 30 October 1990)
(Biklen et al., 1991)
In my anxiety to have formulations that seemed to make sense of John’s
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experiences, I adopted the orthodox psychoanalytical view (exemplified

by Mahler and Bibring) of pathological autism being a regression to a
phase of normal primary autism. It was a neat hypothesis. I clutched at
it as to a raft because I felt baffled, helplessly adrift and ‘at sea’. Helpless-
ness breeds the desire for certainty so I shut my eyes to the fact that this
hypothesis conflicted with the findings from the baby observations that
had been so much part of my Tavistock training. I must here express my
thanks to Anne Alvarez (1992), whose recent book Live Company is a
landmark in the integration of findings from infant observation to those
of psychoanalysis. Anne struggled with me over the ‘normal primary
autism’ issue. She didn’t say it was untenable because Mrs Klein or Mrs
Bick said so, but she sent me papers by Colwyn Trevarthen (1979) and
Daniel Stern (1983). Since these observers had no sectarian theoretical
axe to grind I listened to her, and finally abandoned the notion of patho-
logical autism being a regression to a normal infantile stage of primary
autism. But I was then left with the problem of understanding material
such as John’s which had been repeated by other autistic children I had
treated or supervised. I felt it was too important an issue to be shelved,
in that clinical work which does not take this issue into account is miss-
ing a crucial bit of mutative understanding that is important in under-
standing the reactions of autistic children.
I looked over my notes of the children I’d treated, and looked at other
people’s accounts of their treatment, and realized that a ubiquitous factor
in their early infancy had been the perpetuation of a fused, undifferenti-
ated situation with a mother who, after the baby was born, had felt
 14 T H E J O U R N A L OF C H I L D P S Y C H O T H E R A P Y Vol. 20 No. 1

herself to be a ‘non-person’, as one mother put it. I applied this to the

clinical material appearing in therapy with autistic children.

The clinical material of autistic children

I began to see that, as an infant, the child had felt so unified with the
mother that abrupt and painful breaking of this sense of dual unity, when
inevitably they became aware of their bodily separatedness from the
mother, had seemed like the loss of part of their body which, until then,
had seemed to be part of the mother’s body. This disruption during the
suckling phase of infancy had seemed catastrophic for both mother and
child. They both felt left with a bodily hole. The trauma of this violent
wrenching apart precipitated autistic reactions in the child. I began to
realize that, in seeing this perpetuated state of unified ‘at-oneness’ with
the mother as a normal situation in early infancy, we had been extrapo-
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lating from a pathological situation and mistakenly seeing it as a normal

one. This was an error we must be careful not to repeat. I now realize
that the infantile state that was being re-evoked in the clinical situation
was an abnormal one. I have come to secthat autism is a protective reac-
tion that develops to deal with the stress associated with a traumatic dis-
ruption of an abnormal perpetuated state of adhesive unity with the
mother - autism being a reaction that is specific to trauma. It is a two-stage
illness. First, there is the perpetuation of dual unity, and then the trau-
matic disruption of this and the stress that this arouses.
My work has made me realize that sensations are the basis of both
cognitive and emotional life. The normal infant develops a sensuous >kin’
that helps him to feel safe, and which is permeable for incoming and out-
going experiences. As a protection against trauma, the autistic child has
developed an auto-sensuous insubtion that blocks incoming and outgoing
experiences. However, they have a fringe awareness through which thera-
peutic interventions can percolate. It is very important for us to realize
this.

Normal infantile situations and pathological developments

As in all psychotic conditions, a normal reaction becomes exaggerated. In
autism it has also become frozen. In normal infancy there are oscillations
from ‘flowing-over-at-oneness’to becoming aware of separatedness from
the mother and the outside world. In this ‘dual track‘, as Grotstein (1980)
terms it, there are alternating flickers of awareness of space and of ‘no
 T H E P E R P E T U A T I O N O F AN E R R O R 15

space’ between infant and mother. In the infancy of autistic children,

these normal oscillations have not taken place. Something that is nor-
mally fluid has become frozen. Such an infant has become traumatized
and frozen in a state of panic-stricken clinging in an adhering way to a
mother who is experienced as an inanimate object that can be clutched.
It is a fear reaction. These children are ‘in shock‘. They are ‘scared stiff’.
As I have tried to show in my books and papers (Tustin, 1966, 1972,
1981, 1986,1990,1991) this fear reaction seems to be due to the fact that
a vulnerable infant (possibly with a predisposition to depression) has
become aware of separatedness from the mother in an insecure mental
‘containment’, that is, the quality of caring attention has not been adequate
for this particular baby. This can occur, for example, with a depressed
mother who, for various reasons, has felt unsupported by the father and by
her own infantile and childhood experiences. In his inimitable way
Winnicott describes this situation cogently when he writes:
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If you feel heavy with sleep, and especially if you are in a depressed
mood, you put the baby in a cot because you know that your state
is not alive enough to keep going the infant? idea of a space around.
(1988: 20; italics added)
I have come to see autism as the reaction to an infantile version of ‘post-
traumatic stress disorder’, such a child’s trauma being becoming suddenly
aware of what we call space due to awareness of the separatedness of their
body from that of a mother with whom they had previously felt abnor-
mally merged, undifferentiated and ‘at one’ - that is, in a state of adhe-
sive ‘dual unity’.

Adhesive pathology
I was alerted to this by papers by Bick (1986) and by Meltzer (1975).
Meltzer has described ‘adhesive identification’ for which Bick prefers the
term ‘adhesive identity’. I have expanded their frame of reference a little,
since the adhesiveness I have encountered in autistic children does not
have the awareness of space associated with identification or with feelings
of identity. I have conceptualized their sense of ‘contiguous’ (Ogden’s
term (1989)), skin-to-skin adhesiveness as (adhesive unity’, or ‘adhesive-
at-oneness’ or ‘adhesive equation’. They become aware of this adhesive
closeness only retrospectively when it is disturbed, and wrenching sep-
aratedness is being experienced. At this time, they experience a sense of
loss of they know not what. Something is missing. John wonders whether
 16 T H E J O U R N A L OF C H I L D P S Y C H O T H E R A P Y Vol. 20 No. 1

it is his head? his penis? or that ‘red button’? For some patients who have
had an overly close association with the mother it could feel like loss of
the umbilical cord. One patient told me that he had imagined this close-
ness as being strangled by the umbilical cord. When this was felt to be
broken, it provoked ungovernable panic and rage, as well as relief. It was
the mixture of feelings that was so confusing.
Processes of identification, that is, feeling similar to someone, require
some sense of space between the child and other people. This helps them
to feel that they have an identity. Identification is based on empathy.
Empathy is important in ‘knowing others’, in the so-called ‘theory of
mind’ that was discussed in Dr Cathy Urwin’s paper given at the 1993
ACP study weekend. (Dr Peter Hobson (1986) has written about
empathy in autistic children and Dr Uta Frith (1985) has written
about ‘The theory of mind‘ in relation to them.)
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In ‘adhesive-at-oneness’,the child feels the same as someone and stuck to

them as to an inanimate object. This helps them to feel that they exist. It
is concerned with survival; with ‘going-on-being as Winnicott so well
calls it. It is more perseverating than ‘adhesive identification’. Indeed, it
prevents the development of identification. That which is normally a fluid
oscillation of normal states of ‘at-oneness’ (which foster empathy) alter-
nating with awareness of separatedness has become frozen into an
abnormal perpetually rigid state of ‘adhesive-at-oneness’ (which prevents
empathy). Alternating healthy swings between ‘at-oneness’ and separated-
ness are not possible. The child is frozen stiff with terror. Empathy,
identification and indeed all psychological developments, such as what
is popularly called ‘bonding, and also experiences of ‘psychic birth‘
and ‘individuation’ that are associated with processes of introjection
and projection, are all prevented. The child does not feel, speak or
respond to other people. He seems like a frozen automaton. This is never
a normal infantile state. It causes confusion to label it as such. A lesson
that I have learned is that the term ‘autism’ should be restricted to patho-
logical states, and should never be applied to normal ones. This is the
error that the ‘normal primary autism’ and the ‘regression’ hypotheses
have perpetrated.
So far we have established that there is not a primary autistic stage to
which autistic children can have regressed. Let us now think about the
concept of regression.
Regression means going back and behaving in terms of an earlier stage
of development. In some of the aetiological formulations we have been
discussing, autistic children have been conceived of as living in terms of
 T H E P E R P E T U A T I O N OF AN E R R O R 17

an unchanged early stage of infancy. This has led to the notion that it
would be helpful to let them behave as infants so that they could con-
tinue growing from there - the so-called ‘regressiontherapy’. In my expe-
rience, this has done a lot of harm. I remember how shocked was the
commonsensical George Stroh when he took charge of High Wick
Hospital for psychotic children, to find the children pushing each other
around in prams and using feeding bottles. It was clear that this had not
been therapeutic but deleterious for their development.
In the clinical situation, John showed clearly that situations in his
infancy had been evoked by seeing the friend of his mother feeding her
baby at the breast. However, he was not behaving as a baby or regressing
to babyhood. He was a 5-year-old boy re-enacting a trauma that he had
experienced as an infant. He now had more resources than when he first
experienced the ‘mind-blowing traumatic crisis of awareness of bodily
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separatedness that had left him with the illusion of a ‘black hole’ at the
root of his being, of something being missing. He was at the mercy of
black despair.
The Argentinean psychoanalyst Dr David Rosenfeld (1992) has
described how his work with Holocaust victims has shown him that
their traumatic experiences had been ‘preserved and ‘sealed off by
autism, ready to come up later, intact and vivid, with every detail of the
original experiences clear and sharp. It was an active re-evocation and
re-enactment. They now had more capacity to bear and deal with those
terrible experiences than when they had first experienced them. With
autistic children, the traumatic experiences of bodily separatedness are
triggered into action by present-day happenings, often in the transference
situation of the analysis, such as breaks in the continuity of expectations
of the analyst’s presence. It makes a difference as to how we handle such
material whether we see it dynamically as happening in the ‘here and
now’, alive with new possibilities for on-going development, or merely as
a repetition of past happenings. In therapy, it is usually the infantile
transference that lifts these past happenings into the present day. This
makes them into a new experience. It is not just the recapitulation of an
old situation, but a re-enactment of the old situation with something new
injected into it. This can bring hope. A psychic catastrophe can become
a psychic opportunity.
Dr Sheila Cassidy, who had been imprisoned and tortured in Chile,
recently described in a radio broadcast her attempt to go back to Chile
in order to relive the traumatic experiences in a new way. She said that
she thought that it would be like opening a Pandora’s box with demons
 18 T H E J O U R N A L OF C H I L D P S Y C H O T H E R A P Y Vol. 20 No. 1

at the bottom. She knew that the evoked memories would be extremely
vivid, but she would have the knowledge that it would be safe to be
frightened. She was hoping that ‘it would release some of the things that
had kept the hatches down’, as she significantly expressed it. Obviously,
she thinks that it is going to be a new releasing experience, not just the
recapitulation of an old one. She is dealing with it in a forward-looking
rather than a backward-looking way. This will counteract ‘the backward
pull to the inanimate’ (Freud, 1920).
So it was with John. His behaviour in the clinical sessions demon-
strated clearly that, as Valerie Sinason (1992) has pointed out, ‘the flash-
back of the trauma’ repeating itself needs to be seen as a communication
and not as an obstruction. He could begin to communicate about his
suffering, and so the strait-jacket of autism that had kept his explosive
‘firework‘ feelings in check could begin to be dispensed with. Instead,
these feelings could now be felt to be contained within an understand-
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ing, interactive, disciplined and disciplining relationship. This helped

him to use his emergent symbolizing capacities. It was a symbolic
re-enactment. It was the beginning of the ability to play.

The effect of this modified view

These modifications are not merely an academic exercise. This revised
view of the aetiology of autism will bring about a significant re-orientation
in our approach to the treatment of autistic children. It will affect the way
we respond to and talk to such patients. It means that we will talk to them
as if we think that they can understand what we are saying. We will not
talk down to them.
Also, if we see autism as a serious developmental aberration it will
mean that we will be firmer and less indulgent in our approach to
them, than if we see it merely as a regression to a normal stage of
infantile development. We will be more active to correct deviant
tendencies.
It also means that a sentimental and unduly romantic view of the early
mother and child situation will be modified. We will take a more stark
view that the craving for a superhuman mother can never be realized and
that an important part of early learning is the gradual coming to terms
with this frustration and all that this disillusionment implies. We will
have a more compassionate attitude towards the mothers of these chil-
dren. We will also know that we cannot achieve the perfectionism that
these children seem to demand of us.
 T H E PERPETUATION O F AN ERROR 19

AF TE RT H 0 U G H TS

1 Some thoughts from another of my papers are relevant to the theme

of this present paper.
As Bion (1977: 19) has shown, the traumatised patient experi-
ences ‘pain but not suffering. They are in the pain. The pain is
in them. They are enveloped in it. Autistic children have been
insulated from the pain by autistic procedures that I have
described elsewhere. In therapy with these children, as the pain is
experienced and abated, their autistic insulation begins to be
modified. This means that the suffering begins to be felt. The
wounded child becomes more open to healing by the therapist as
(s)he becomes able to bear the suffering of mourning for loss. (It
is significant that the word ‘suffering’ is derived from the latin
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verbferre meaning ‘to bear‘ or ‘to carry’). . . .

The pain of the trauma has caused autistic children to turn away
from people, but the sufiring that follows as the trauma is re-
enacted and the pain mitigated, stimulates the need to turn to
people for help. As they are freed from a ‘repetition compulsion’ of
the traumatic experience, they develop a co-operative relationship
with the therapist and with other people. As this occurs the autism
begins to wither away. They become able to look at the trauma
[and to represent it] instead of being in its thrall. A psychic cata-
strophe has become a psychic opportunity. (Tustin, 1993: 38-40)
This transformation occurs because they begin to turn to the ‘lifegiver’
as Symington so well expresses it (Symington, 1993).
2 A week or so after the meeting in which this paper was presented, Juliet
Hopkins sent me a photocopy of Henry Moore’s 1983 sculpture of
‘Madonna and Child’. This depicts a mother with an abdominal black
hole in which a penis-like child is inserted. This is strikingly reminis-
cent of Joyce McDougall’s ‘Chasmic Mother’ and ‘Cork Child’ that is
used to fill the hole of the depressed mother’s emptiness and loneliness
(McDougall, 1989: 78). This made me wonder whether the image of
Madonna and child, which has such psychic significance, had influ-
enced the tenacity with which the notion of a pre-relationship state of
normal primary autism had been held.
3 Jeanne Magnana also drew my attention to the fact that, in feeling part
of the mother’s body, John could have been re-experiencing the sensa-
tions he had had before he was born, and which continued after birth.
 20 T H E J O U R N A L OF C H I L D P S Y C H O T H E R A P Y Vol. 20 No. 1

The mother-infant situation after birth had reinforced the illusion that
his body and the mother’s body were a ‘dual unity’. This had perse-
verated and had become a permanent unchanging state.

CONCLUSION

As some of you may know, my husband has acquired fame as a writer of

psychological limericks. When I told him about the theme of this paper,
he gave me the following limerick:
When beliefs need some modification,
We make it with much trepidation,
For our world is then new,
And things seem all askew,
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Till we’re used to the new formulation!

This applies both to therapists and to the children we treat. As the French
psychoanalyst Professor Didier Houzel so well puts it, our work should
be informed by ‘a movement of letting go in which the spirit accepts
losing mastery of its object of knowledge in order to allow itself to be
surprised by the unexpected and be questioned by change’ (1990: 56). As
I said earlier, the misconceptions I have been talking about have been
more prevalent and influential on the European continent and in the
USA than in Britain. It is hoped that the suggested modifications will
facilitate communication between workers with autistic children both at
home and abroad. Sorting out these misconceptions will help us to avoid
insularity. When there is consistency in views about the aetiology of
childhood autism, we shall be able to talk to each other better.
I have come to think that one of the factors that has caused the per-
sistence of the error under discussion is the atmospheric adhesive quality
of the clinical material we are trying to understand. It is difficult to
be clear-headed when dealing with such elemental, persistently ‘sticky’
material. This paper has been a record of attempts to clear a way through
a mass of such primeval material so that we can be freed from being ‘stuck
in the mud’ (this being the best description of the state of an autistic
child that I know).
In this attempt, it will have been obvious that the work of my psy-
chotherapy colleagues has been indispensable. As a token of my gratitude,
I am pleased to be able to present this my last paper to the Association
of Child Psychotherapists of which I am proud to have been made an
 T H E P E R P E T U A T I O N OF A N E R R O R 21

honorary member. In writing it I have been helped by colleagues who

read the various drafts I produced. They have helped it to grow.

SUMMARY

In this paper I point out that infant observers in many countries have
shown conclusively that there is not an early infantile stage of normal
primary autism to which pathological autism could be a regression. I
show how this error has been perpetrated and perpetuated, and suggest
an alternative hypothesis for the development of autistic disorders of
children.
17 Orchard Lane
Amersbam
Bucks HP6 5AA
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England

NOTE

1 This paper was originally presented to the ACP Study Weekend,

March 1993.

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