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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
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
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
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
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
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
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
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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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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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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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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AF TE RT H 0 U G H TS
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
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
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