From Ashes to Ashes: The Heroic Struggle of an Autistic Boy Trying to be Born and Stay Alive

“Life is a semi-transparent envelope surrounding us from the beginning of consciousness to the end.”

Periodically our planet has been subjected to geologic upheavals that have nearly destroyed all life on earth. The most recent of these, the huge meteor that crashed into the Yucatan peninsula, caused the extinction of 70% of all life and brought about the demise of the age of dinosaurs some 60 million years ago. Records of this cataclysm abound: fossils unearthed through the detailed work of archeologists and paleontologists provide us with ample evidence that ties this catastrophe to the disaster in the Yucatan. The names of the dinosaurs, which ones were plant eaters, and the others ate flesh, are the stuff of myth that both entertain and terrify in nightmares school-aged children and adults alike. But we have names for these creatures and a more or less coherent narrative about their fate that has enabled us to imagine this disappeared world as represented in books, films and individual fantasy.

However, nearly 200 million years earlier, an apocalypse occurred during the Permian epoch

that destroyed all but 5% of the species on earth. While it is not entirely clear what brought on this immense extinction, current thinking (Benton, 2005) is that massive volcanic eruptions lasting a half million years choked the atmosphere and “life itself teetered on the brink of oblivion” (Benton, 2003, p.38). Millions of years of evolution were dramatically reversed by this Permian extinction and the only surviving species were simple creatures like shell encased mollusks that required very little food and could swim in the shallow, deoxygenated mudflats. There is no existing narrative for this barely described era; only a handful of nameless primordial survivors dragging themselves along in an endless trek through the most unimaginable hostile environment. The deep layers of sedimentary rock in which the history of life on earth is recorded in fossil remains and climactic readings show a sudden lifeless level of material and low levels of atmospheric oxygen during the Permian era.

In this paper I discuss the psychoanalytic treatment of a boy with psychogenic autism whose beginning development was shut down due to extreme parental neglect, resulting in a picture of classic autism diagnosed at 20 months. By the time he came to see me at 3 1/2 years old because of temper tantrums and aggressive behavior, there were few traces of his autistic history. It was as though he had endured a psychological version of a Permian extinction: an initial period of development that was snuffed out by a deoxygenated “facilitating environment” (Winnicott, 1965) and survived only through encapsulation in a protective autistic shell (Klein, 1980). He appeared to come alive again through intensive behavioral treatment, but where were the traces of his former autism? Were these worked through or transformed into newly evolved modes of being or, perhaps, lying fallow in some split off autistic pocket (Mitrani, 2001, 2011)? I will address these questions through an in-depth examination of my analytic work with Sean.

Frances Tustin (1986) has described psychogenic autism as

“a reaction to a traumatic awareness of separateness from the sensation-giving suckling mother. Autistic reactions divert attention away from this mother who is spurned in favor of self-generated sensations which are always available and predictable, and so do not bring shocks” (p. 27).

Implicit here is that the infant is in the earliest stage of psychic development in which a skin envelope (Anzieu, 1986) must first form in order that a developing “core sense of self” (Stern, 1986) has a boundaried and safe wrapper in which to grow. According to Meltzer (1975), this container for the emerging self is formed through a process of “adhesive identification” by which the infant adheres as great an area as possible of its skin surface to that of the mother's. In this manner the boundaries of the nascent self begin to be demarcated; however, when a traumatic early awareness of separateness occurs the result is an experience of a porous “skin boundary frontier” (Grotstein, 1980, 1984) with accompanying terrifying fears of dissolving, spilling and leaking out of oneself. Without a psychic “home”, i.e., a skin envelope in which to grow, the emerging self will fail to flourish. Furthermore, in order to shore up this defective “skin envelope” the psyche resorts to primitive defenses, perhaps actually closer to inborn tropisms (Bion, 1992; Korbivcher, 2014), that are maneuvers aimed at plugging the psychic holes created by premature separateness from the mother. In the absence of a mother to adhere to in order to gain a fortified boundary, the infant relies on autistic objects (Tustin, 1980, 1984) which are always available and under its complete control. In higher functioning autistic patients, the purpose of autistic objects to bind the terror of fragmentation may also be served by metaphorically leaning up against the analyst's voice (Power, 2016) or perhaps a ruminative state (Ogden, 1989).

The patient's reliance on autistic objects to forestall terrors of atomizing or falling into a black hole of nonexistence makes such objects addictive and therefore relinquishing these may be felt as horrifying. Tustin (1986) cautions us to keep in mind the patient's profound need for

these objects and that “It is a serious responsibility to deprive such patients of their autistic protections” (p. 46). And speaking of the analyst's approach she says

“The emphasis in this type of psychotherapy is not on our attempting to make up for what we infer may have been the deficiencies of their infancy… The emphasis is on helping them to go through primitive processes of mourning, which will heal the wound of their too-early sense of loss, and relax the tension associated with the trauma, so that they can begin to use the capacities with which they are usually well endowed” (p. 28).

Korbivcher (2014) notes that the autistic shell in which the patient is encased is a “peculiar universe” (p. 91) governed by its own unique rules and which requires the analyst to “speak another language”, a sensory language that is a two-dimensional world of surfaces (Rhode, 2011), and to adopt more active techniques to draw patients out of their cocoons

“And then to try and help them turn sensations into emotions while favoring their development of alpha function and their ability to think” (p. 91).

Korbivcher's (2014) notion of the “peculiar” universe of autism builds on her (2005) earlier work in which she proposed the idea of autistic transformations that she views as an extension of Bion's (1965) theory of transformations. For Bion, the analytic relationship and the minds of the patient and analyst are always in flux: there is a constant process of unconscious exchange between, and within, their minds that transforms raw emotional experience into representational thought. In contrast, autistic transformations imply a movement away from the world of feelings and

“The emotional experience of the analyst in autistic transformations is one of emptiness, lack of emotion. ‘Absence of affective life’… and auto-sensual activities…” (Korbivcher, 2005, p. 1601).

Autistic transformations are not synonymous with autism proper but are characteristic of an “autistic part of the personality” (Tustin, 1981) that may be cloistered away from either the neurotic or psychotic parts of the personality. Inasmuch as the concept of transformations usually implies change of form and a constant process of emotional evolution, autistic transformations involve a flattening of emotions into a two-dimensional sensory experience of feelings that drains the patient's affective life and deadens the analyst's countertransference.

Autistic transformations, therefore, suffocate further psychic development: the protective mollusk-like shell that is formed insures a minimal level of survival from the shock of premature separateness. The autistic child is thus faced with an impossible dilemma: to live without an adequate skin boundary that leaves him vulnerable to the onslaught of an overwhelming sensory implosion or, on the other hand, to be shielded in an impregnable carapace. In both situations, the “semi-transparent envelope” of which Virginia Woolf spoke is absent and there is no dialogue between inner experience and the outer world. In the clinical material to follow, I address the question of the fate of autistic phenomena once the patient has begun to leave, or has already left, this protective stranglehold. Tustin says the patient must “go through primitive processes of mourning,” but how is this working through to be achieved and what are the methods of transformation by which this is accomplished?

Sean: Being Born and Staying Alive

A psychoanalyst's and a behaviorist's world don't often intersect, so I was surprised to receive a telephone message from a behavioral therapist asking if I had time to see a 3 ffl year old boy in play therapy. The therapist explained that the patient, Sean, had been diagnosed with autism at 20

months and had been receiving intensive behavioral therapy twenty-five hours a week which had been very successful. She said Sean was now able to invite another child over to his house to play, but had no idea of what it meant to play, and so she thought it would be useful for Sean to receive play therapy. I told her that I did not have experience with severely autistic children per se though I had treated many with Asperger's. The therapist said Sean had made excellent progress and was now more accessible, so I decided to see him in consultation.

I initially met with Sean's paternal grandparents with whom he lived and who had custody of their grandson. They were decent, goodhearted people deeply involved in Sean's life, providing most of the emotional support. They explained that they had been involved in Sean's life from the outset, visiting frequently although he lived in another part of the country with his parents. They reported that Sean appeared to be developing normally in the first few months of his life, then regressed. Sean's mother had been addicted since she had 16 years old to crystal meth and heroin while his father had been diagnosed with schizoid-affective disorder and was also heavily using drugs. The grandparents became alarmed on a visit when Sean was 18 months old that he was nearly non-responsive and they found him in his playpen self-stimulating while his parents were asleep in a drug stupor. The grandparents then arranged for Sean to come to Boston for an evaluation at Children's Hospital where he was diagnosed with autism. He had no speech at 20 months old and no eye contact with others. The findings from that evaluation observed that

“He did not walk until 17 months of age and now walks on his toes. He does not play with toys appropriately and tends to turn over things like cars and spin the wheels…. He is fascinated by watching lights and fans. He does not respond to his name… and will turn the lights off and on continually and recently has started examining his shadow.”

Sean was seen in an early intervention program and intensive applied behavioral therapy (up to 25 hours a week) was initiated, mainly in his home, where he lived with his grandparents, father and a nanny who was with him 10 hours a day five days a week. His mother moved to the area, but rarely saw Sean because she was so disorganized that she couldn't make appointments; however, when she did see him, she sat next to him and was unable to interact with Sean. The grandparents described this as deeply sad for Sean. I also met twice with Sean's mother who was like a vacuumed-out ghost with obvious cognitive limitations. Thus, on the level of reality, she has had little to do with him though, in his play, the mother figure assumes a central role.

In my first meeting with Sean, I was surprised to see this robust 3 ffl year old come right into my office, make good eye contact with me, and start to play interactively. I had the thought, “This is the wrong boy, where's the nearly obliterated boy I was expecting?” There were only a few remnants of his “autism”: he occasionally walked on his toes and carried with him a small wooden object in the palm of his hand. I asked about it and he shrugged off my question, saying he liked to carry it with him. I asked if he had a name for it and he said “mom,” to which I questioned, “You mean ”mom“ like ”your mom?“ Sean replied, ”No, it's not my mom, I just call it that.“ This seemed to be a hard object (Tustin, 1980, 1984) that did not represent his mother, but which instead was an object that gave him the sensory experience of leaning up against a smooth and substantial surface. At times in this first session, he interrupted the play and lay parallel on one of the arms of an office chair, hugging it while in a near fetal position. I said, ”It looks like a good feeling to hold onto the arm of the chair“ and, surprisingly, Sean responded, ”It makes me feel strong.“

However, these vestiges of autism were in the background in the consultation visits and more prominent was Sean's symbolic play that had to do with feeling injured and broken. A variety of play characters endured broken limbs, falls, accidents, etc., so that the ambulance was kept very busy shuttling these patients to the hospital

and back. He introduced a character, “Mr. Fixit,” played by one of the toy figures which I enacted with instructions and dialogue provided by Sean. Also, in these first couple of visits, Sean played out a mother putting a baby to bed in its crib and forcing it to stay there despite the infant's pleas for her. I said the baby must be very scared and needs its mother and asked if Mr. Fixit might be able to help but Sean said he couldn't help with this problem. I thought that Sean was telling me that the damage to his infantile self could not be repaired, even by the uniquely talented Mr. Fixit. I subsequently met with the grandparents and recommended analysis, but they lived nearly an hour away and questioned whether he could tolerate spending so much time in a car travelling to sessions. Thus we agreed to three sessions a week and, in addition, that I would meet every two weeks with the grandparents. Not surprisingly, Sean is eager to come to all his sessions and the car rides with his Nanny are generally pleasant; however, we continued at three sessions a week because of time considerations.

Over time, Mr. Fixit has disappeared from our play as well as the remnants of Sean's autism, except for occasional moments of wrapping himself around the arm of a chair when especially distressed. For roughly the last year and a half (we have recently started the third year of analytic work), the play has been completely dominated by the story of “Little Sean,” a boy figure from the dollhouse who day after day endures the worst imaginable treatment (e. g., eaten by wild animals and dinosaurs, set aflame by dragons, thrown into lava pits and turned into ash) while desperately seeking some security from a protective defender. Each session during this long period began in an identical way: Sean, speaking with his own voice, would call to Little Sean “Sean, do you want to see something?” thus beckoning him to leave the dollhouse. Sean's (the patient) voice in inviting his little avatar out to play was a mixture of friendship as well as a taunt because Little Sean was inevitably mauled.

At first Little Sean called for his mother for protection when leaving the house, but she either was unavailable or proved to be entirely feckless. I admired his wishful determination to establish within himself an internal experience of a competent mother who, unfortunately, predictably failed him. I said that Little Sean really wanted to have his mother there to protect him, but it was very sad and scary that she could not.2 Over time Little Sean stopped calling for his mother and replaced her with a toy bird that he called “second mother” which sometimes kept him safe and, at other moments, attacked him. She, too, faded from the play stories and Little Sean turned to other figures to safeguard him, such as Batman and Wolverine, who always did their best to fend off the myriad of attackers; however, in each session he was inescapably torn away from his guardians to be chewed up, burned, etc., and then to be left for dead. It was at this point that Sean (the patient) told me to call for “Doc.” Doc was actually the Freud figure from the toy box who always brought Little Sean back to life with some magical injection or soothing salve to his burnt skin.

I have seen this sort of intensely violent play with many other children, though Sean's was especially unrelenting, and realized that I had been treating this as paranoid-schizoid phenomena; thus, the question arose again of where are the vicissitudes of Sean's earlier autism? Were these issues being worked through apres coup in Sean's powerful persecutory anxieties? Two experiences led me to think about these seeming persecutory anxieties as also reflecting more primordial fears. The first was reading Tustin's (1984) paper, “The growth of understanding,” in which she spoke about the “fear of predators” that is

“In evidence in psycho-analytic work with children who have suffered psychological separation from their mothers in early infancy. Their fear of predators does not seem to come from active projection of their own predatory impulses. Rather, these passive children seem to feel at the mercy of terrors of which they are the helpless victims” (p. 145) [italics added].

Bowlby (1964) also discussed the fear of predators from the perspective of attachment theory when he wondered about the survival function of attachment behavior. Just as Freud (1923) speculated about inherited memories from our ancient past, so Bowlby posited an inborn fear of predators that was kept at bay as long as the infant felt close to a protective adult; however, “Once the infant becomes isolated predators pounce” (p. 44). Thus, my attention shifted from Sean's anxiety of being constantly attacked to the theme of being destroyed and reborn and my interpretations were directed at Little Sean's efforts to stay alive in a scary world with little protection.

This refocusing from Little Sean's fear of constant attack to his terror of dying helped me to see the analytic work in new light but also evoked primitive fears in me that became the second experience (in addition to the references to Tustin and Bowlby) that convinced me Sean was not simply dealing with paranoid-schizoid anxieties. As the focus in the sessions turned to the fear of no longer existing, I found it difficult to be with Sean. The hours felt endless and I couldn't wait for him to leave. In one session, Little Sean was being mauled and chewed up by a huge bear which made me think, “My God, this is Sean's inner world, how horrible and sickening this is.” That night I had a terrible nightmare

“I am trying to escape someone who is after me. I see an old car, like a 1940's car that has high ceilings and lots of inner space. I hide in there and feel momentarily safe. I'm in the back seat, but it opens up into the trunk like a dark cave. Suddenly a huge bear enters the car and comes to the back, as though after me, and I can feel it pushing me into the ”cave“ in the back and have the sinking horrible feeling that ‘this is the end of me.‘”

My first thought was of Sean being clawed and chewed by a huge bear and that I was now in a state of at-one-ment (Bion, 1970) with his inner house of horrors: a life of feeling only “momentarily safe” before one's existence will be negated, i. e, ‘this is the end of me.‘ I also think that seeking refuge in the old car with “lots of inner space” reflected my experience of feeling my “inner [mental] space” invaded by Sean's terrors. We were now two people dreaming a shared nightmare of coming face to face with a horrible death and the threat of nonexistence. However, analyzing my nightmare helped me to more deeply understand the emotional landscape that permeated our shared field; thus, having dreamed and named the terror I felt better equipped to deal with it in myself and in Sean.

Sean's struggle to be psychologically born and to stay alive was graphically depicted in one session after two weeks of intermittent meetings because of his illness and a snowstorm. He had been worried about fire since there had been a power outage during the storm and candles were lit at home.

Discussion

This play sequence beautifully illustrates Sean's experience of his life, played out in innumerable sessions, of having begun his personal evolution into a thriving human being; however, his budding growth was brought to an abrupt halt by the profound neglect of his parents. I believe that my nightmare, coupled with the passages from Tustin and Bowlby about autistic children's fear of predators, permitted me access to the nearly unimaginable horror of non-being. I had my dream the night of a session in which I experienced an almost nauseating feeling of revulsion at coming into contact with Sean's inner world. I was unable to transform that overwhelming affect in the immediacy of the moment and these emotions lay in wait until my alpha function attempted to dream these into a meaningful dream narrative. My dream was like a traumatic dream in which the trauma is repeated and, in this respect, I had taken in Sean's trauma in order to do the unconscious work of transforming it into a more manageable affective experience. As I have written elsewhere (Brown, 2007, 2011), countertransference dreams may serve the function of processing left over affects from the day's session and also are part of the operation of transformations in O by which the analyst's dream is processing the untransformed emotional essence (O) of the session that exceeded the analytic couple's capacity to manage while awake. Thus, I gained a newfound appreciation for Sean's struggle to stay alive: to be born, only then to be destroyed and, like Prometheus whose liver was torn out each day, then to endlessly relive this repetition.

The session began in a typical way with Sean being gnashed in the teeth of bears and wolves, but the appearance of the Angry Man, played by Sean himself, who burned Little Sean and Batman, reducing them to ashes, was a new theme. I had already been thinking about the meaning of these predators as something more primeval than persecutory fears and the notion of being reduced to an unidentifiable heap of ashes brought nonexistence to my mind. Consequently, my interpretations expressed the terror of disappearing

and I was surprised when a little later in the session Sean introduced the word “exist” into the narrative. Little Sean and Batman came alive again after being turned into ashes, but then were burned to ash once more, at which point I said, “He keeps coming alive and then gets burned into nothing.”

Remarkably, Sean's attention turned to the toy birds and he said, “Look, they're turning into dinosaurs again and disappearing.” In previous sessions, he had mentioned that birds evolved from dinosaurs which had become extinct and so I heard his response to my intervention as a further deepening of the theme of nonexistence: that Sean was terrified that his current state of maturation was under constant threat of devolving into something more primitive. I then linked this story about birds turning back into dinosaurs with Little Sean's fears of turning into ash and he spun out a phantasy of Little Sean being nurtured by protective dinosaurs underneath an impermeable shell. This phantasy seemed to tell the story of his life: that he barely survived extinction and had to rely on what Mitrani (2001) calls “extra-ordinary protections,” in which his surviving infantile self was encased in an impervious autistic shell.

So, how did Sean manage to recover from this psychogenic autism? It is reported that in the early months of his life he was developing normally: smiling with good eye contact, thriving and that perhaps his facilitating environment (Winnicott, 1965), though deficient, was sufficiently nurturing to support what I assume was a strong constitution. Then the emotional equivalent of a Permian extinction occurred brought on by his parents' severe drug abuse and his father's schizoid-affective disorder, creating a deoxygenated, toxic climate that squelched his development and triggered his enclosure in the costly protections of an autistic shell. Fortunately, his grandparents intervened which resulted in Sean's being wrapped in an interpersonally rich environment with his grandparents, Nanny and the behavioral therapists that helped him come back from the brink of permanent oblivion. I think being collectively nourished by a replenishing team of loving women was internalized, thereby enabling Sean to gradually let go of autistic protections and also helped to begin the necessary process of mourning his mother (Tustin, 1986) which was continued in the analysis. Moreover, these enriching experiences fostered the rapid growth of cognitive functions and allowed Sean's native exuberance to develop quickly to the extent that when he showed at my office I thought he was the wrong boy.

In our analytic work together, Sean expressed his sense of being broken by introducing Mr. Fixit, but it soon became apparent that our work required much more than a handyman's assistance. Though Little Sean's endless horrific treatment by a collection of tormenters conveyed a boy paralyzed by persecutory fears, for a long time in the analysis I thought of this dynamic as the projection of Sean's rage over his neglect and the absence of any experience of a protective maternal presence. I was also puzzled by the apparent absence of any traces of his earlier autism, except for the short lived appearance of hugging the arm of a chair, toe-walking and cupping a hard object in his palm. I wondered whether this more typically appearing paranoid-schizoid material was an apres coup working through of the earlier trauma, but I could find no apparent link. However, after reading Tustin's and Bowlby's discussions of autistic children's fear of predators and having my awful nightmare, a new scenario fell into place: that the persecutory anxieties were like a palimpsest that covered over and subtly conveyed the underlying profound terror of nonexistence. This brings to my mind Winnicott's (1974) paper, “Fear of breakdown,” in which he states that patient's fear of breakdown is most often a fear of returning to an actual breakdown from early life. He also states in that paper that

“It is wrong to think of psychotic illness as a breakdown, it is a defense organization relative to primitive agony” (p. 90).

In this connection, Sean's psychotic-like persecutory fears constituted a “defense organization” against “primitive agony” but also communicated

the nature of that agony. In effect, by my exclusive focus on the persecutory element, I failed to be like the mother Bion (1962) describes who hears that

“The infant feels fear that it is dying… and projects its feelings of fear into the breast… [expecting that the breast] would moderate the fear component in the fear of dying that had been projected into it…” (p. 96).

It was not until my nightmare that Sean's fear of dying, which I could not bear to acknowledge, came into focus and allowed me to achieve contact with his “primitive agony” and its resonance in my psyche.

Ogden (2014), in a recent close reading of Winnicott's (1974) paper, “Fear of Breakdown,” asserts that the breakdown is an event that has never been emotionally experienced and therefore leaves the individual feeling that something vital is missing and that “What remains of his life feels to him like a life that is mostly an unlived life” (p. 215) [italics added]. Thus, it is necessary that the event that has not yet been experienced must be experienced for the first time in the analysis in order for the patient to feel whole. In addition, Ogden states that

“I view this as a universal need – the need on the part of every person to reclaim, or claim for the first time, what he has lost of himself, and in so doing, take the opportunity to become the person he still holds himself to be” (p. 216).

For a boy like Sean, whose life began with an all-too-brief glow of an infant's smile that nearly dimmed forever, the ordeal of claiming his life “for the first time” is truly a huge undertaking even for a courageous boy like him and an analyst willing to endure the terrifying uncertainty of human life. The analyst in confronting such fears must be on the alert for his own tendency to detach or satisfy oneself with quick solutions, such as my readiness to see Sean as dealing with “typical” problems and to avoid the powerful fears hidden there. In Sean's case, his anxieties about whether he would continue to exist were the true substrate of emotion which was conveyed through his persecutory fears. Paradoxically, Sean had to feel for the first time the horror of imminent death in order to gain a life that was truly lived.