Faulty Theory,Failed Therapy: Frances Tustin,Infant and Child Psychoanalysis,and the Treatment of Autism Spectrum Disorders

Abstract

In this article, I explore two epistemologies for theorizing infancy and treating autism—infant and child psychoanalysis expounded by Frances Tustin and colleagues and developmental psychology and developmental neuroscience. I address two main issues: (a) how early psychoanalytic insights informed empirical developments and theoretical scholarship in both infant psychoanalysis and developmental psychology, and (b) how the study of infant development within psychoanalysis has been derailed by faulty theorizing and failure to incorporate scientific scholarship on infant development into their theories and practice. First, I review current research on infancy including psychoanalytic contributions that have incorporated scientific methods and evidence. I then juxtapose this work with Frances Tustin’s theory of autism as an exemplar of the problematic theorizing about infant development that remains unchallenged, even today, in some psychoanalytic circles, and how that theory is operationalized in treatment. I discuss possible reasons for the failure to revise theory and therapeutic practice and the adherence to faulty perceptions of “successful” therapeutic outcome. Despite these derailments, I conclude that a marriage of science and psychoanalysis (that is convergent with developmental research) is not only possible; indeed, it has produced talented progeny who have immeasurably advanced our understanding of human functioning across the life span by further illuminating the mysteries of infant experience.

Keywords

unsuccessful psychotherapies infant and child psychoanalysis developmental psychology developmental neuroscience autism autism spectrum disorders Frances Tustin

Introduction

In this article, I compare Frances Tustin’s theory of infant development and its therapeutic application to childhood autism with evidence-based psychoanalytic and developmental theories of infant development and evidence-based treatment of autism spectrum disorders (ASDs; as the condition is now called). But first, a brief history.

Two major empirical developments arising from psychoanalytic theory occurred contemporaneously—the evolution of attachment theory (Bowlby, 1940) and the formalization of a method for the systematic observation of infants in the service of diagnosis and treatment. These commenced in the 1930s and 1940s with Anna Freud’s observations of infants in the Hampstead War Nurseries, and Winnicott’s (1965, 1971, 1986) documented observations of his young patients over the course of his long clinical career. Infant observation was introduced at the Tavistock Clinic in London by Esther Bick (1964) in 1948, who secured its place as a formal part of the curriculum in psychoanalytic training in 1960, at the request of John Bowlby. Although intended as an objective, nonintrusive, naturalistic observation, as indeed it was in the beginning (see, for example, the description of baby Charles in Bick, 1964, pp. 20-25), infant “observation” became imbued, if not saturated with, and predetermined by theory-driven concepts. For example, Thomson-Salo (2014) advises that “. . . observers need to develop a sensitivity for possible unconscious processes . . . and subtle projections . . .” in infants (p. 11). In similar vein, Dubinsky (2010) “observed” a 6-week-old infant, Phoebe, place her fists on both of her mother’s breasts during feeding. Dubinsky concluded that

. . . in [Phoebe’s] mind there are two breasts she can feed from and which she wants to possess. The eye pressed against her fist suggests that she has a thought of penetrating into the breast like the nipple entering her mouth . . . (p. 6)

Phoebe also displayed rhythmic finger movements, which Dubinsky inferred were “. . . an urge to identify with the flow of milk by projective identification . . .” (p. 6). When she puts her finger and thumb into her mouth after feeding, Dubinsky asserts that “. . . [f]inger and thumb provide a symbolic representation of the thought of the nipple and breast” (p. 7). These modern day “observers” have heeded neither Bick’s prescient warning about how “. . . difficult it was to observe, that is, to collect facts free from interpretation” (Bick, 1964, p. 26), nor the voluminous research on infant development that has amassed over the past 50 years. What is evident in these commentaries on infant behavior are the difficulties that arise with theory-led “observation,” not the least of which is the development of therapies/treatments based on such “observations”—a practice that is at high risk of confirmation bias (Nickerson, 1998).

These psychoanalysts subscribe to the view that Freud’s and others’ psychoanalytic thinking is always epistemologically framed, not by an interpersonally situated theory of child cognitive, socioemotional, and behavioral development, but by a concern with unconscious desire and unconscious fantasy (Mitchell, 1983). Hence, their observations are framed to “fit” their theory. “Observations” of this kind ignore insights from developmental psychology about the capacities of infants and demonstrate a fundamental misunderstanding of the cognitive functioning of neonates who are not yet capable of thought (e.g., “a thought of penetrating into the breast”), intention (wanting to possess), symbolic representation (e.g., finger and thumb representing nipple and breast), concepts of number (two breasts), or spatial concepts of inside and outside.

Infancy, as the subject of a collective psychoanalytic imagination, continues to be characterized, in some psychoanalytic circles, using metaphors, extrapolations from adult psychoanalysis, and adultomorphic notions that are inappropriate descriptors of infant experience. Early concepts in psychoanalytic theory (e.g., Klein’s, 1945, paranoid-schizoid position; Bion’s, 1962, projective identification as a primitive defense; and Winnicott’s, 1971, notion of transitional space) provided a valuable counterpoint to the reductionist philosophies of the behaviorists and the encroachment of reductive materialism (Chessick, 2007). Notwithstanding, although metaphor may have some explanatory or clarifying functions, and is a useful clinical tool, metaphor alone does not constitute science.

Perusal of this specific body of psychoanalytic writing reveals an anti-scientific stance. The offerings of some contemporary psychoanalysts are unscientific, indeed, fanciful, at times confused, self-contradictory, and frankly, incomprehensible (Kenny, 2016). A striking exemplar in the field of infant psychoanalytic theory is Frances Tustin (1981, 1983, 1986, 1990, 1994/2015, 2009), whose work will be examined in greater detail later in this article. Tustin is certainly not alone in this regard. The work of Alvarez (1992, 2012), Engdahl (1994), Mitrani (1995, 2008, 2011), Ogden (1989a, 1989b, 1990, 2002, 2007), Magagna (1987), Bergstein (2009), Dubinsky (2010), Amir (2013), Voran (2013), Eekhoff (2013), and Durban (2017), inter alia, also exhibits these characteristics.

By contrast, the work of scientifically oriented psychoanalysts has provided a rich tapestry of knowledge about infant development that would not have been possible from the application of a positivist scientific perspective alone. Examples include the attachment theorists (e.g., Bowlby, 1940, 1957, 1958, 1960, 1963, 1973a, 1973b, 1984, 1988; Mary Ainsworth [Ainsworth, Blehar, Waters, & Wall, 1978]; and Mary Main [Main, Kaplan, & Cassidy, 1985]), infant researchers (e.g., Beebe [2005, 2006; Beebe & Jaffe, 2008; Beebe, Jaffe, & Lachmann, 2005; Beebe et al., 2010; Beebe & Lachmann, 2014; Beebe, Knoblauch, et al., 2005]; Rustin, 2014; Stern, 1985, 1988, 1994, 1995, 2000; Trevarthen, 1979; Tronick [2002; Tronick & Beeghly, 2011]), and researchers who have attempted a synthesis of psychoanalytic, attachment, and other developmental theories in the treatment of children with autism, gender dysphoria, experiences of loss and neglect (Bonovitz & Harmlem, 2018) and in understanding disorganized attachment and its effect on infant development of parents with an adult attachment classification of unresolved for trauma and loss (D. Diamond, 2004).

The Nature of Infancy

Convergence of Psychoanalytic Concepts With Developmental Psychology and Neuroscience

Despite arguments to the contrary, psychoanalytic theory has always had a developmental and relational perspective, with its emphasis on the importance of the formative nature of experiences that occur in the earliest part of the life span (Kenny, 2014). Originally focused on putative intrapsychic mechanisms, Freud himself and post-Freudian scholars gradually modified early psychoanalytic theory to account for the influence of the social environment on infant development. S. Freud (1940) assigned a central role to the mother in the child’s development, stating that the child’s relationship with its mother is “. . . unique, without parallel, established unalterably for a whole lifetime as the first and strongest love-object and as the prototype of all later love-relations—for both sexes” (p. 65). Freud, and most subsequent psychoanalytic scholarship (e.g., Klein, Winnicott, Bowlby, Blatt, Kohut, Stern), recognized the centrality of the relationship with the mother in ensuring the healthy development of infants, a position that has subsequently been confirmed empirically (Beebe & Jaffe, 2008; Beebe & Lachmann, 2014; Laranjo, Bernier, Meins, & Carlson, 2010; Pinquart, Feußner, & Ahnert, 2012).

The concept of object relations represents another major point of convergence between psychoanalytic and scientific perspectives on infant development. Many scholars, including S. Freud (1900), have noted the profound impact of the child’s first emotional ties on its subsequent capacity to form healthy relationships. S. Freud (1900) contended that “[t]he deepest and eternal nature of man . . . lies in those impulses of the mind that have their roots in . . . childhood . . .” (p. 247). This implicit, embodied knowledge forms the basis of infant object relations that elaborate and consolidate throughout development. Building on Klein’s notion of primitive object relations, Fairbairn’s (1944) concept of the unconscious internal object world, and Winnicott’s observation that babies are embedded in a mother–infant dyad, Bowlby (1958) argued that psychoanalysts agree that the child’s first object relations constitute the foundation of his personality. This fundamental tenet of psychoanalysis has had many incarnations in, for example, Winnicott’s “primary maternal pre-occupation” and Kohut’s “mirroring,” and in empirically validated theories of infant development, for example, Trevarthen’s “primary intersubjectivity,” Stern’s “cross-modal attunement,” and Beebe’s micro-analyses of mother–infant communication.

Thus, attachment theory, an early attempt to empirically examine object relations theory, has played a pivotal role in linking psychoanalytic theory with its social and neurobiological correlates. It re-focused attention onto the primacy of actual relational trauma and the importance of the interpersonal dimension of human relatedness as opposed to fantasy and the intrapsychic environment. Fairbairn’s (1944, 1946) characterization of interpersonal trauma as the internalization of the rejecting object, its transmutation into the experience of oneself (not the other) as bad, followed by repression of those painful internal object relations has been empirically supported in infant research (Beebe, Knoblauch, et al., 2005; Beebe, Rustin, Sorter, & Knoblauch, 2003).

Specific behavioral sequences that underscore different qualities of attachment have been observed between mothers and infants (Beebe et al., 2012). The degree of attunement and mirroring that occurs in dyadic interactions, and how mothers repair attachment ruptures with their infants (Atkinson et al., 2005; Bakermans-Kranenburg, van, Ijzendoorn, & Juffer, 2003) have profound long-term effects on the capacity for self-regulation (Bernier, Carlson, & Whipple, 2010; Feldman, Greenbaum, & Yirmiya, 1999; McClelland & Tominey, 2011), later interpersonal relationships, and even cognitive performance (Lewis, Koroshegyi, Douglas, & Kampe, 1997). Misattuned or abusive early relationships result in various forms of insecure (e.g., ambivalent, avoidant, disorganized) attachment that underscore many forms of psychopathology throughout the life span (Dutra, Bureau, Holmes, Lyubchik, & Lyons-Ruth, 2009).

Developmental neuroscience has identified the neural correlates of early severe disturbances in the mother–infant dyad (Buchheim et al., 2008). At the behavioral level, traumatized infants display what attachment theorists call “disorganized attachment” that is identifiable by a set of seemingly bizarre responses of infants in reaction to their mothers (Hesse & Main, 2000). The behavior evinces disorganization and disorientation, representing a collapse of behavioral and attentional strategies and possible dissociation that signals the desire to escape when escape is not possible. Early relational trauma, as it is now called, interferes with the maturation of the right brain (Schore, 2001), and continuing trauma impairs later capacity for emotional self-regulation via permanent alterations in the physiological reactivity of the limbic system (Schore, 2009). Thus, we may conclude that the quality of the attachment bond is a complex psychophysiological state that has important regulatory functions that may occur within or outside of awareness (i.e., automatically, or “implicitly” as described in cognitive science; Schuengel, Oosterman, & Sterkenburg, 2009).

Divergence of Psychoanalytic Concepts From Developmental Psychology and Neuroscience

Notwithstanding the strong points of convergence described above, there are also significant divergences between developmental science and psychoanalytic theorizing among some contemporary psychoanalysts, who have demonstrated an enthusiastic acceptance, if not passionate embrace, of the notion that all babies pass through auto-erotic (Nagera, 1964), autistic, symbiotic (Mahler, 1967, 1972; Mahler, Pine, & Bergman, 1975), autistic-contiguous (Ogden, 1989a, 1989b), or undifferentiated, fused, or merged (Fast, 2012; Ogden, 2004) states before emerging with a differentiated sense of self and other. This view has been constantly invoked over the past 100 years in psychoanalytic scholarship and has never been put to rest despite the now abundant evidence to the contrary (Alperin, 2001; Fast, 2012; Flavell, 2004; Stern, 1985, 1988, 1994). Although states of autistic withdrawal have been identified in children with autism (Barthélémy et al., 1992; White & Roberson-Nay, 2009) and other disorders, such as Rett syndrome (Bashina, Simashkova, Grachev, & Gorbachevskaya, 2002), fragile X (Hagerman & Hendren, 2014; Kaufmann et al., 2004), and tuberous sclerosis (Ahlsén, Gillberg, Lindblom, & Gillberg, 1994), such observations in pathological populations of infants and young children cannot be extrapolated to normally developing infants.

The psychoanalytic view that the infant is merged or undifferentiated requires clarification. Two concepts have potentially been conflated in this perception of the infant—those of absolute dependence or helplessness at birth, and the state of purported psychological symbiosis, undifferentiation, or merger with mother. It is possible for the infant to be in a state of absolute dependence with respect to physical and emotional survival at birth, while also possessing, as Klein (1945) argued, and as subsequent infant research has demonstrated (Beebe, 2006; Beebe, Knoblauch, et al., 2005), rudimentary object relations and skills and capacities that render the infant, from birth, a co-constructing partner in the mother–baby dyad. Infants demonstrate autonomy in their interpersonal relationships in the first weeks and months after birth, including the capacity to initiate and terminate social interactions with their caregivers (Beebe, Lachmann, & Jaffe, 1997). Infants can reason about the actions of others and attribute goals and dispositions to agents. After infants realize that they can act intentionally on the environment, they are able to ascribe such behavior to others, possibly due to innate neural pathways for establishing equivalences between themselves and others (Luo & Baillargeon, 2010; Meltzoff, 2007).

Such demonstrated abilities are necessarily in conflict with various psychoanalytic conceptualizations of the infant, which are also at odds with each other. An infant cannot simultaneously be, on one hand, omnipotent (e.g., “Omnipotence is . . . a fact of experience. The mother’s eventual task is gradually to disillusion the infant, but she has no hope of success unless at first she has been able to give sufficient opportunity for illusion”; Winnicott, 1953, p. 93), “self-centred and self-sufficient” (A. Freud, 1946, p. 124), and narcissistic (S. Freud, 1920), and on the other hand, in a “selfless” state (“. . . a beginning non-differentiation of self from other, a selfless state that blankets over all distinctions and that becomes enlightened only in time . . .”; Sheets-Johnstone, 2002, p. 42), or an unintegrated state, described by Winnicott (1945/1975) as “primary unintegration,” and more recently by Symington (2008) in his assertion that infants are “. . . born a messy array of bits” (p. xix).

Contrary to these psychoanalytic theories, psychological and social development at the beginning of life is neither deficient nor incompetent and begins neither in a state of undifferentiation nor with a set of discrete capacities that are not integrated (Kenny, 2013). Newborns demonstrate interpersonal competence commensurate with the limitations of their physical and neurological development (Morgan, 1997). Nonverbal communication and somatic experiencing provide the basis for intersubjectivity (i.e., interrelatedness) in infancy (Trevarthen & Aitken, 2001). Although sociality—observable patterns of interaction, co-operation, and communication among individuals of the same species (Ingold, 1991)—does not emerge until the second or third months of life, and is not at this time directed specifically toward primary caregivers until about the fifth or sixth month, infants intentionally interact with their caregivers from birth in a process of reciprocal mutual influence. Infants are also responsive to social referencing cues (i.e., “the observation and adoption of others’ interpretations of a situation to form one’s own understanding”; Feinman, 1982, p. 445) and adjust their behavior accordingly (Carver & Vaccaro, 2007; Repacholi, Meltzoff, & Olsen, 2008).

Babies are from birth imitators, observers, learners, communicators, and interpersonal partners (Giles & Rovee-Collier, 2011; Lyons-Ruth, 1991; Rovee-Collier & Cuevas, 2009; Stern, 2000). They are not hapless victims of the terrifying emotional states envisioned by Bion (1962; schizoid mechanisms), Winnicott (1974; fear of breakdown, “primitive agonies,” “unintegrated states,” “falling forever,” p. 104), Klein (1975; persecutory anxieties), Tustin (spilling, falling, dissolving), or Mitrani (2011; “elemental terrors,” “dread of dissolution,” p. 21). Rather, the newborn infant engages in lengthy periods of alert inactivity, during which significant learning about the world occurs through the infant’s calm engagement with their surroundings (Bower, 1971; Bower, Broughton, & Moore, 1971).

Case (1988) identified four emotional states in the newborn—contentment, distress, engagement, and disengagement. From birth, neonates strive for physical and social equilibrium and, if attained, respond with quiescence as indicated by an endogenous smile or social engagement. If the neonate experiences disequilibrium (i.e., discomfort), he or she responds with irritability or fussiness, disengagement, or disgust. Restoration after disequilibrium (e.g., being offered a nipple when hungry) is followed by states of relief and contentment (Young, 2011). Thus, the psychoanalytic theories of infancy that are the subject of this article have paid insufficient attention to the important function played by normal developmental experiences in a safe environment in psychic development.

Neonates are born with a well-developed visuo-motor system and, from the outset, show a preference for human faces over other forms of visual stimuli (Fantz, 1963). Visual experiences are not only important in sensorimotor and cognitive development, they also play a crucial role in social and emotional development. The first forms of human contact are tactile (mother–infant skin on skin immediately after birth) and visual—infants and mothers engage in the “intense mutual gaze” (Blass, Lumeng, & Patil, 2007) through which reciprocal mutual influence in the dyad begins. This mutual gaze triggers endogenous opiates in the child’s brain (Edalat, 2015), which is now understood as the neurochemical correlate of Kohut’s (1971) “mirroring”; Mahler, Pine, and Bergman’s (1975) “optimal mutual cueing”; and Trevarthen’s (1979) “shared intersubjective affect states” between mothers and their infants.

Further, infants prefer human voices over other forms of auditory stimuli (Friedlander, 1970), and the smell of mother’s milk over the milk of other lactating mothers (MacFarlane, 1975). Neonates are also cognitively active; they seek sensory stimulation and begin almost immediately to categorize the social world (Gibson, 1983, 1992). Infants actively engage in constructing their experiences and understanding the world into which they are born. As well as having well-developed sensory systems, there is also some integration of visual and auditory systems at birth because infants look toward the source of sound (Bower, 1974).

All of these capacities are supported by the rapid neural development of infant attention (Striano, Reid, & Hoehl, 2006). Infants are capable of stimulus orientation and sustained attention toward novel stimuli, during which time they resist peripheral distracters, a capacity that supports memory encoding (Richards, Reynolds, & Courage, 2010). Hence, although the first 2 months of life are “pre-social, pre-cognitive, pre-organized” (Stern, 1985, p. 37), this is a period of rapid organization and cognitive and affective learning, out of which a sense of self slowly emerges. Infant research has confirmed that “. . . human social relatedness is present from birth . . . [and] does not lean upon physiological need states” (Stern, 1985, p. 44), a position taken by the British object relations school (Balint, 1949; Fairbairn, 1946).

Neonates also engage in active intermodal mapping, a process that unites perception with execution of a motor plan, thereby permitting imitation from birth (Meltzoff & Moore, 1977, 1994) and the beginning of “like me” perceptions, which form the basis of social cognition (Meltzoff, 2007a, 2007b; Meltzoff & Brooks, 2008). By 6 weeks of age, infants show deferred imitation. When confronted with a nonresponsive face, they will reproduce a tongue protrusion they had imitated 24 hrs earlier, purportedly in an attempt to ascertain whether the passive face before them is the same as the face of the person whom they had imitated the previous day. Imitation rapidly becomes more complex, with cooing games indicating the presence of social expectations by 2 to 3 months of age (Caron, 2009). Infants in the first 2 months of life actively engage and negotiate with their mothers around their sleep–wake and feeding/eliminating cycles. Infants whose caregiver/infant relationship was disrupted after the first 10 days of life showed dysregulation in the organization of basic biological functions, leading to the conclusion that early regulation of biological functions is the outcome of mutual negotiation between the infant and his caregiver (Sander, 1988).

The infant is born with a strong tendency toward psychic coherence and a need for agency. These initial capacities are required for survival and adaptation and motivate other systems, such as the attachment system (Ghent, 2002). These dynamic, self-organizing characteristics, together with appropriate experiences in the social and physical world, account for the development of psychic structure (i.e., mind) that comprises consciousness, memory, affects, cognition, language (Demos, 2007), and internalized object relations that develop as a result of repeated experiences of relatedness with primary caregivers, which have been aptly named “representations of interactions that have generalized” (RIGS; Stern, 1985), a process that Bowlby (1973a) described as the development of a “working model” of attachment (see, for example, Beebe et al., 2003; Beebe, Knoblauch, et al., 2005). These internalized representations include the encoding of strategies for affect regulation and restoration of biological homeostasis. Both regulated and unregulated affective experiences with caregivers are encoded and stored in procedural memory and determine the individual’s characteristic response to affect dysregulation. The encoding and learning of dysfunctional interpersonal (i.e., attachment) relationships express themselves in subsequent failures of self and other interactional regulation that, if uncorrected, will eventually manifest as disturbances in the personality and symptom formation.

Thus, far from being fused, merged, unintegrated, undifferentiated, selfless, omnipotent or “radically egocentric” (Piaget & Cook, 1954), the infant enters the world with self-other equivalences that are innately specified and experientially elaborated (Meltzoff, 2007a, 2007b). Intersubjectivity is primordial, not developmental. Varga (2011) concluded that “. . . neonatal imitation reveals the equi-primordiality of our own sense of an embodied self and a sense of others . . .” (p. 631). Neonatal imitation, as embodied perception, is intersubjective (Gallagher, 2001). Infants are interdependent and interactive with their caregivers and engaged with the intersubjective world from birth.

Furthermore, the infant is born with the capacity to experience positive (rewarding) and negative (punishing) affects, which he or she encodes both neurologically and in memory (Weinberg & Tronick, 1996). The infant is motivated to increase positive affects, decrease or manage negative affects, and minimize affect inhibition. These motivations enhance learning of environmental contingencies that lead to positive and negative affects and help them to organize behavior to influence outcomes (Tronick, 2002; Tronick & Beeghly, 2011). Infants appear to be just as attracted to the expectation of a pleasurable outcome as they are motivated to avoid the negative affect experienced with too much incongruence, dissonance, or the inability to discover the contingencies related to outcomes, and adjust their own behavior accordingly (Papousek, Papousek, & Koester, 1986). Infants develop knowledge about themselves, their world, and their relationships nonverbally, nonsymbolically, and implicitly and use this knowledge in communicating with primary caregivers. Communicative competence precedes language. Indeed, “prior to language . . . the origin of mind is dyadic and dialogic (Beebe et al., p. 807). Adult intersubjectivity is built on infant intersubjectivity; i.e., all linguistic forms of intersubjectivity continue to depend on pre- or nonlinguistic forms” (p. 813).¹

Psychoanalysis offered unique insights into emotional development and the causes of psychopathology without the benefit of a science of brain/mind upon which we rely today. Inevitably, our understanding of infants has evolved in light of research that does have that benefit.

To summarize then, infant research has identified five key capacities in infants that do not support the psychoanalytic conceptualizations of infancy from this coterie. They are as follows:

Newborns are interpersonally competent (they are not merged or fused with mother).

Infant development proceeds in a process of continuous unfolding of increasingly complex organization (not in a stage-based way with points of fixation or regression).

Infants are interdependent and interactive with their caregivers (not driven by instincts or governed by fantasies or terrifying states).

Patterns of interaction build object-related psychic structure that are internalized as representations of interpersonal interactions (objects are not intrapsychically derived).

Infants strive for affect regulation (not for drive gratification) and learn environmental contingencies that produce positive or negative affects.

Frances Tustin and the Case of Autism

We shall now turn our attention to Frances Tustin, in whose honor an international conference is conducted bi-annually. The quintessentially Tustinian title of the 2014 conference was “Spilling, Falling, Dissolving: Engaging Primitive Anxieties of the Emerging Self,” the aim of which was to “. . . examine and extend the seminal work of Frances Tustin on the understanding and analytic treatment of autism and autistic states across the diagnostic spectrum and throughout the life cycle” (European Psychoanalytical Federation, 2014).

A few words of clarification of the term autism are required. Eugen Bleuler (1951) first used this term to describe a state of “active turning-away from the external world” that he observed in schizophrenia. He qualified subgroups as follows: “The most severe cases withdraw completely and live in a dream world; the milder cases withdraw to a lesser degree” (Bleuler, 1951, p. 397). By contrast, Bleuler perceived autistic thinking to be a normal process, akin to a state of day-dreaming that had its own logic; it “. . . mirrors the fulfilment of wishes and strivings, thinks away obstacles, conceives of impossibilities as possible, and of goals as attained” (Bleuler, 1951, p. 399). S. Freud (1911) described an autistic state with the following analogy:

A neat example of a psychical system shut off from the stimuli of the external world, and able to satisfy even its nutritional requirements autistically (to use Bleuler’s term), is afforded by a bird’s egg with its food supply enclosed in its shell . . . (p. 219)

Later, S. Freud (1921) made a distinction between autistic and narcissistic phenomena, stating that “. . . Bleuler (1912) would perhaps call them ‘autistic’—mental acts . . . in which satisfaction of instincts is partially or totally withdrawn from the influence of other people” (p. 69). These meanings were subsequently adopted by Mahler, Tustin, Ogden, Mitrani, Magagna, and others.

Contemporaneously, the syndrome of childhood autism was first formally articulated to be different from mental retardation and schizophrenia-type presentations in children by Leo Kanner (1943) in a work describing a case series of 10 children titled Autistic Disturbances of Affective Contact. Subsequent research has captured the distinguishing social/interpersonal characteristics of autism through careful, structured observation. For example, one study compared children aged between 2 and 8 years who were diagnosed with either autism or intellectual disability and found that the primary distinguishing features between the two groups were autistic children’s greater desire to be alone, ignoring other people, poor social interaction, and stereotyped sensorimotor behaviors (Barthélémy et al., 1992). Children with an ASD have higher psychiatric comorbidity across a range of disorders compared with the general population and with children with an intellectual disability (Brereton, Tonge, & Einfeld, 2006).

Tustin’s (1983) use of the concept “autistic” was broader than Kanner’s use of the term “autism.” It draws on Bleuler’s original conception, describing conditions of withdrawal across the psychiatric pediatric diagnostic spectrum as a result of “. . . disorderly rearing practices, . . . detectable brain damage, . . . hospitalization or surgical intervention in early infancy, or other interruptions to early ongoing infantile development” (Tustin, 1986, p. 50).

Notwithstanding the differences in the understanding and use of these terms, available descriptions of the children to which this term applied for both Kanner and Tustin bear notable similarities. Indeed, Tustin (1983) conceded that Melanie Klein’s patient, Dick, would “certainly have been diagnosed as autistic . . . akin to that described by Kanner” (p. 50).

Yet, there was an immediate parting of the ways. Kanner’s book formed the basis of the subsequent scientific study of autism, of which Tustin remained essentially ignorant while, for more than 40 years, she pursued what I will argue to be implausible and empirically unvalidated theories. These theories have been uncritically incorporated into subsequent child psychoanalytic thinking and treatment to the present day (see, for example, Akhtar, 2003; Berg, 2012; Bergstein, 2009; Busch de Ahumada & Ahumada, 2015; N. Diamond, 2013; Mitrani, 2008; Mitrani & Mitrani, 2015).

Frances Tustin commenced her professional life as a teacher but subsequently trained as a child psychotherapist at the Tavistock Clinic, London, between 1950 and 1953. She died in 1994 at the age of 81 years. Tustin was exposed to the work of Esther Bick and John Bowlby, both of whom had been influenced by Melanie Klein. Consequently, Tustin’s own work took a Kleinian turn, although Bion, her analyst for 14 years, and Winnicott were also influential. For example, Tustin was impressed with Winnicott’s distinction between the “unintegration” of the autistic child compared with the “disintegration” of the schizophrenic child, suggesting the former experienced inhibited development and the latter regression to an earlier stage of development.

Tustin (1986) distinguished between autistic and schizophrenic children, using “the terms confusional or entangled rather than schizophrenic” to refer to the child’s state of “confused entanglement with his mother” (p. 53). From her clinical experience with such children, Tustin derived her categorization of two types of childhood psychosis, each with two subtypes. The first—“entangled” or “confusional”—could be primary (i.e., have no precipitating factors) or secondary (i.e., as a reaction to physical or emotional trauma). This latter group was noted to share similarities with Melanie Klein’s schizophrenic children and Mahler’s notion of pathological symbiosis in symbiotic psychotics (Mitrani & Mitrani, 2015). According to Tustin (1986), the schizophrenic child is minimally object-seeking; in contrast, the autistic child lives in a “sensation-dominated world from which he seeks sensations rather than objects” (Tustin, 1986, p. 54). Humans are not clearly differentiated from inanimate objects and are experienced only in terms of “hard and soft sensations.” Because entangled children have no boundary between self and object, they are only capable of “adhesive” or “intrusive” identifications. They are undifferentiated and cannot distinguish between “me” and “not me,” hence have only “flickering moments of separateness” (Tustin, 1986, p. 55) such that “. . . each awareness of bodily separateness from mother reactivates the unhealed primary wound of bodily awareness” (Tustin, 1986, p. 43).

Autistic children are described by Tustin as “encapsulated” or “shell-type,” which denotes a psychophysical protective reaction that could be global (i.e., signaling continuous encapsulation), akin to Kanner’s autistic syndrome or Freud’s bird’s egg that characterizes children who have no capacity for relatedness, or are segmented. Segmented children have echolalic speech and idiosyncratic contact with the object world. While the segmented group has some interaction, albeit confused, with the environment, Tustin’s continuous encapsulated group are withdrawn, inaccessible, and nonverbal in contrast to entangled/confusional children who are hyperactive and chaotic but have some language. Neither group has the capacity for play. Their interaction with physical objects, such as keys, toy cars, or other play items, had a “bizarre and ritualistic quality . . . the child has a rigidly intense preoccupation with them, which is not a feature of fantasy play . . .” (Tustin, 1981, p. 103). Furthermore, such objects are not used by these children for their intended purpose but rather in sensation-dominated ways that interfere with mental development. Tustin (1986) labeled these items “autistic objects,” which can apparently be either soft (more in the nature of Winnicott’s transitional objects) whose purpose is to “. . . mop up the experience of woundedness” (p. xv) or hard (e.g., swords, spears, pens, poles), the latter group supposedly representing the penis.

Encapsulated children are said to interact with hard but not soft “autistic objects,” although Tustin offers no explanation for their preference. Entangled/confusional children interact with “confusional objects” and both hard and soft “autistic objects.” Tustin (1981) asserts that “. . . soft confusional objects support the delusion of being enveloped in a veil, a fog, or a mist” (p. 133), while the role of soft and hard objects is to protect the child against the dread of annihilation, described as “the threat of dissolution of the sense of being and dread of spilling out or of falling infinitely . . . [these feelings are] connected with the experience of an untimely abruption from the post-partum psychological womb” (Spensley, 1987, p. 126), which catapults the child into a world of bizarre objects, in particular the fear of black holes (i.e., loss of self) and “nameless dread,” rendering life random and meaningless. These children purportedly protect themselves from meaninglessness through the use of autistic defenses that

. . . obliterat[e] perception, freez[e] up feeling, paralys[e] thought, blot out and amputat[e] fantasy, and avoid communication by fixing attention onto sensations created by holding onto hard objects—all of which are aimed at diverting awareness away from sensing the unthinkable dread. (Mitrani & Mitrani, 2015, p. xxx)

Both entangled and encapsulated children interact with “autistic shapes” which Tustin (1986) claimed were created by repetitive contortions of the child’s own body, a perversely pathological (i.e., autistic) form of (normal) “auto-sensuousness.” Tustin viewed these activities as asymbolic.

Tustin was unable to maintain a clear behavioral (symptomatic) distinction between her two proposed subtypes of childhood psychosis and eventually decided that the real distinction lay in causation—psychogenic for entangled children and physical and/or emotional trauma for encapsulated children. Tustin (1986) asserts that “. . . psychogenic autism is [caused by] . . . the narrowing of perception through terror” (p. 190), but the perceived damage is illusory and is due to unconscious fantasies that activate these maneuvers to defend against the terror. Both forms of childhood psychosis represented attempts to avoid the “unbearable awareness of bodily separateness” (Mitrani & Mitrani, 2015, p. xxv). If awareness of separateness occurs before the development of “psychic skin” (i.e., Bick’s, 1968, metaphor for separateness or body awareness; Meltzer’s, 1975, metaphor for a trusting dependence on mother; Tustin’s, 1981, metaphor for a sense of identity, including body awareness), the child will allegedly develop encapsulated-type psychosis, in which he or she vanishes into a sensation-dominated “autistic shell” that constitutes a shelter from the external world. In Tustin’s (1986) words, the child has

. . . jumped out of his skin with fright, and . . . feels skinless and disembodied. The skin has been replaced by the “armour” of his autistic practices, which help him to feel protected from the terrors of falling, of dissolving, of spilling, of losing a sensuous object as part of his body . . . (p. 301)

In the case of John, when mother’s nipple was withdrawn, John experienced this “. . . as loss of part of his body and not as the loss of the mother and her breast” (Tustin, 1983, p. 126). The point of this case report seems to be that the child cannot mourn the nipple in the normal sense because the nipple was not encountered by him in the normal sense as an external object but only as a set of sensations. However, he is mourning the loss of the nipple qua set of his own oral sensations. This mourning is then dealt with defensively by substituting for the nipple the “hard autistic objects” that provide new desirable sensations. His grief is thereby rendered unconscious and more visible to the observer than felt by the child. The putative stage of primary narcissism, if not reached and transcended, will interfere with the capacity to acknowledge others and grieve their loss. Nonetheless, Tustin asserts that the perceived loss of the body part precipitated a period of intense grief. “Anyone who sees the mournful eyes of an autistic child will not question that he is grief-stricken” (Tustin, 1983, p. 126). How can Tustin reconcile this claim with her statement that autistic children are unable to experience loss and are therefore unable to mourn the nipple because it had not been experienced as an object but rather as a set of sensations? We are now left with the question regarding the grief for a lost body part, as we are told that autistic children do not have body awareness (i.e., psychic skin).

Ironically, Tustin has often commented on the concrete (i.e., asymbolic) mode of communication observed in autistic children, but nonetheless assures us that every gesture and sensation has a latent (i.e., symbolic) meaning waiting to be understood and interpreted. She concedes that the task of decoding their chaotic behavior is difficult, but that “flowing along” with one’s countertransference will reward the therapist with understanding.

From “Pathological” Autism to Pathological Theorizing

The approach described above to the understanding and treatment of autism was, for many years, founded on the premise that “pathological autism” was a regression to a phase of so-called “normal primary autism,” a phase of development initially hypothesized by S. Freud (1914) and subsequently elaborated by Margaret Mahler (1967), who was impressed with Freud’s notion that primary narcissism and autoeroticism preceded object choice in the developing child. Tustin (1986) acknowledged that the use of the term “autism” to describe normal states of development was problematic because the word “autism” became “. . . so contaminated with pathological associations that it can no longer be usefully used for normal states. . . . Thus, I have come to use the term ‘auto-sensuous’ for the earliest states of normal infancy, and autism for pathological ones” (p. 128).

Notwithstanding, Tustin’s (1983) conceptualization of auto-sensuousness as part of normal development is still in error because it signifies, according to her, a “. . . a psycho-physical state . . . in which the child has not yet differentiated his body from that of the mother . . . his primal sense of ‘me-ness’ is bound up with feeling merged with his mother” (p. 128). However, one can only feel merged with someone whom one understands to be other than oneself. This understanding is what gives content to the feeling. One does not, after all, feel merged with oneself. In her reasoning on this score, Tustin has neglected to distinguish ontological moments of merger, in which the infant has slipped into actual nondifferentiation with mother, and the epistemological grasp of merger. If one is ontologically merged, then one cannot epistemologically feel merged, as, in effect, one simply is not, in one’s actual selfhood, other than mother.

As discussed above, Mahler’s and Tustin’s conceptions of infantile states in normally developing infants as merged, autistic, or symbiotic have been repeatedly empirically discredited (Legerstee, 2005; Legerstee & Haley, 2013; Papousek et al., 1986; Rustin, 2009; Seligman, 2008; Stern, 1985, 2000). Although Mahler finally recanted her theory just before her death in 1985 in light of the overwhelming evidence to the contrary, this has not prevented other psychoanalytic theorists from continuing to endorse this view. For example, Tustin (1986), Ogden (1989a, 2004), and Mitrani (1995) continued to advance the idea that the infant begins life in an “autistic shell,” an “autistic-contiguous,” merged, or fused state despite abundant evidence that babies have rudimentary interpersonal competence from birth.

Tustin (1994/2015) finally acceded that the regression theory of autism was incorrect, that is, “. . . there was no normal infantile stage of primary autism to which the pathology of childhood autism could be a regression” (p. 4). However, she replaced it with a theory that was equally unsustainable, which stated,

. . . a[n] ubiquitous factor in their early infancy had been the perpetuation of a fused, undifferentiated situation with a mother who, after the baby was born, had felt herself to be a “non-person,” . . . 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 [he] became aware of [his] bodily separatedness from mother, had seemed like the loss of part of [his] 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 . . . realise[d] that, in seeing this perpetuated state of unified “at-oneness” with the mother as a normal situation in early infancy, we had been extrapolating 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 realise that the infantile state that was being re-evoked in the clinical situation was an abnormal one . . . autism is a protective reaction that develops to deal with the stress associated with a traumatic disruption 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 traumatic disruption of this and the stress that this arouses (p. 12) . . . I have come to see autism as an infantile version of post-traumatic stress disorder (p. 13).

There are two possible readings of this revised account noting that what is described as “pathological” or “abnormal” is the “perpetuated state of unified at-oneness.” The ascription of pathology could apply to the perpetuation of unification or to the state of unification per se. Hence, allowing that Tustin continues to hold that there is a normal kind of unification, in autism, (a) there is an abnormal kind/degree of unification (note “the child had felt so unified with the mother . . .”), and this leads to an abnormal perpetuation of unity, or (b) there is an abnormal perpetuation of unification, perhaps because of the mother’s response to the infant. In either case, the breaking of unity is traumatic, resulting in an autistic retreat to deal with the trauma. Recall that Margaret Mahler had retracted her view of normal infancy as a dual unity prior to 1985. Notwithstanding, Tustin clings to this notion in her new formulation of autism, but now with the understanding that it is a pathological state. However, she now talks about “. . . this perpetuated state of unified ‘at-oneness’ with mother . . .” (Tustin, 2015, p. 12) as if it were the perpetuation that was pathological, not the state of unified at-oneness per se.

Tustin claimed that this revised theory was so fundamentally different from previous understandings that it necessitated a dramatic change in therapeutic technique, requiring the abandonment of so-called regression therapy in favor of one that focused on trauma. Indeed, following this new formulation, Tustin (1981) opined that autism was a posttraumatic stress disorder.

One may wonder why such a problematic theory continues to spawn a dedicated following of Tustinian acolytes while the science of autism (discussed below) has developed apace. One explanation is the difficulty experienced in reliably identifying the diagnostic social deficits characteristic of autism in children younger than 2 years (Maestro et al., 2002), leaving the field open to speculation and theorizing. A second possible explanation is that Tustinian scholars have made no attempt to understand or integrate evidence-based psychoanalytic constructs or developmental neuroscience into their lexicon despite repeated calls for this to occur (Fonagy & Target, 2003; Fox & Reeb-Sutherland, 2010). Delion (2011) describes a number of attempts at synthesis, re-iterating Daniel Widlöcher’s caution against confusing different levels (i.e., psychoanalysis and neuroscience) of synthesis. Third, the search for specific biomarkers for ASDs continues, with a range of factors—genetic vulnerability, mitochondrial function, oxidative stress, environmental factors, and immune deficiency, all potential candidates (Goldani, Downs, Widjaja, Lawton, & Hendren, 2014). Alonim (2014) argued that

. . . as long as we do not have clear biomarkers to diagnose autism, we shall have to rely on our clinical observations (p. 270) . . . while clinical knowledge depends on scientific knowledge in order to better explain what works, what does not work, and, most important, why (p. 271).

The problem, of course, resides in the definition of clinical observation. Alonim (2014) discusses existential anxiety, failure of the development of the self, and a traumatic reaction to awareness of bodily separateness as possible putative causes of autism, none of which can be clinically observed in the infant.

The Scientific Study of Autism

Contemporaneously with the theorizing of this group of child psychoanalysts regarding the etiology and treatment of autism, the scientific community was also attempting to define and treat this devastating but not uncommon cluster of symptoms. The first and second editions of the Diagnostic and Statistical Manual of Mental Disorders (1st ed.; DSM-I; American Psychiatric Association [APA], 1952, and 2nd ed.; DSM-II; APA, 1968, respectively) described autism as a “schizophrenic reaction, childhood type.” In the third edition of Diagnostic and Statistical Manual of Mental Disorders (3rd ed.; DSM-III; APA, 1980), the diagnosis “infantile autism” was introduced, which, in 1987 (Diagnostic and Statistical Manual of Mental Disorders [3rd ed., rev.; DSM-III-R; APA, 1987]), was modified to “autistic disorder,” a classification that survived until 2000 (Diagnostic and Statistical Manual of Mental Disorders [4th ed., text rev.; DSM-IV-TR; APA, 2000]). In the fourth iteration of DSM, autistic disorder was listed as one of the five pervasive developmental disorders (PDD) that included Rett’s disorder, childhood disintegrative disorder, Asperger’s disorder, and PDD (not otherwise specified). However, since 1987, the three groups of symptoms that defined autistic disorder have remained; these are impairments in social interaction and communication and restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013), the nomenclature changed to ASD and the disorders in this spectrum take their place in the group of neurodevelopmental disorders alongside intellectual disability, communication disorders, ADHD (attention deficit hyperactivity disorder), motor disorders, and specific learning disorders.

Psychoanalysts lament this medico-behaviorist diagnostic scheme that speaks not at all to the interests and concerns of the child psychoanalyst; specifically, that autism has now become reified into a syndrome and the broader adjectival sense that had to do with forms of inner experiencing are no longer apparent. Notwithstanding, scientific investigation has revealed many aspects of this disorder not addressed by the child psychoanalytic community.

For example, comorbidities are common in ASD; accordingly, in DSM-5, the diagnosis is accompanied by specifiers such as with or without intellectual disability, language impairment, or epilepsy, and whether it is associated with known genetic, medical, or environmental conditions, such as advanced parental age, low birth weight, or fetal exposure to valproate.² Heritability, based on twin concordance studies, has been estimated at between 37% and 90% (APA, 2013). Furthermore, a large number of cases are associated with known genetic mutations, although estimates vary between studies (Moss & Howlin, 2009). These include Fragile X syndrome (between 21% and 50% also have a diagnosis of ASD), Down’s syndrome (18% with ASD), Rett’s syndrome (25%-40%), and Prader–Willi syndrome (25% with ASD; Moss & Howlin, 2009; Sacrey, Bennett, & Zwaigenbaum, 2015).

There is a recurrence rate of between 8% and 18% in later born siblings in families with an autistic child (Sacrey et al., 2015). Boys are 4 times more likely to be diagnosed with ASD than girls (Ozonoff, Goodlin-Jones, & Solomon, 2005). The heterogeneity of ASD and the many comorbidities (e.g., up to 80% of children diagnosed with ASD have an intellectual disability; Christensen et al., 2018), which are rarely discussed in the psychoanalytic literature on autism, can significantly affect the clinical presentation and response to treatment or intervention. It is possible that the two types of childhood psychosis identified by Tustin may be discriminated by the presence or not of a co-occurring condition such as intellectual disability or genetic disorder. In addition, ASD is a lifelong condition; symptom severity appears to be worse during the preschool years but may improve over time (Ozonoff et al., 2005), although the majority of people with autism are unable to live independently. This established trajectory for ASD is problematic for the psychoanalytic theory of autism and for (unsubstantiated) claims of cure.

Several prodromal signs and symptoms have now been identified in at-risk infants. These include atypical neurobiological markers such as generalized cortical enlargement (Hazlett et al., 2011), increased temporal lobe white matter (Herbert et al., 2004), and reductions in brain connectivity (Belmonte et al., 2004) that result in delays or deficits in neural network efficiency, which in turn are associated with sensory (e.g., atypical use of objects, unusual visual exploration, diminished attention to faces) and motor (e.g., postural instability, delayed sitting, reduced arm movements) deficits. In contrast to psychoanalytic theories of autism that assert catastrophic problems with bonding and individuation, these early-appearing neurodevelopmental deficits appear to underpin the key behavioral deficits in emotion regulation (e.g., reduced positive affect and increased distress), social interaction, and communication, which in turn impair subsequent interactions with the environment. The trauma-like symptoms referred to by Tustin are now thought to be due to a sensory processing disorder that includes acute sensitivity to sensory input, both from within the body and from the external world. Thus, autistic-like symptoms may be defenses against over-stimulation; these include withdrawal, controlling, rigid, and obsessional behavior, and resistance to change in familiar routines (Gensler, 2012).

A number of interventions (e.g., Early Start Denver Model [children aged between 18 and 30 months], Dawson, Rogers, & Munson, 2010; Early Social Interaction Project [toddlers aged 16-20 months], Wetherby, Guthrie, & Woods, 2014) that specifically address the identified deficits in ASD have been effective in increasing IQ and adaptive behavior and reducing the symptom constellation typical of ASD. Programs that focus on individualized parent coaching and parent-mediated interventions with their children result in improved language performance and functional verbalizations, increases in responsivity, initiations, social orienting, and shared smiling (Brian, Bryson, & Zwaigenbaum, 2015).

These approaches are a far cry from child psychoanalysis in which the parents hand their child over to the analyst for treatment. Tustin skates quite close to blaming mothers for their child’s autism. Although she rejected the misconception that mothers of autistic children were cold and aloof, she referred to mothers’ post-natal depression and emotional unavailability as partly causal of autism (Tustin, 1990), failing to realize that the emotionally unresponsive, autistic behavior of their infants may have resulted in depression, grief, and emotional withdrawal in their mothers. Current research (cited above) shows that failure to closely involve parents in treatment and to teach them evidence-based strategies to assist their autistic children is a significant cost-effective opportunity for change lost.

There have been voices of dissent within psychoanalytic circles, admittedly few and often too soft to rise above the din made by the attempted excavations of primitive or autistic states within the personality. Howlin and Rutter (1987, in Howlin, 1998) were early critics. Baron-Cohen and Bolton (1993) warned that play therapy would be ineffective with children with few language skills and that complex, symbolic interpretations of the child’s play would be anxiety-provoking and counterproductive. Campbell, Schopler, Cueva, and Hallin (1996) were more forceful in their objections stating that “. . . psychoanalysis as a treatment for autism has limited value . . . unless therapy is combined with direct practical advice on how to deal with problems, the outcome may be disastrous” (p. 5). Barrows (2004) further highlighted the elephant in the psychoanalytic room by stating that

. . . psychoanalytic psychotherapy is not generally regarded as an appropriate form of treatment [for autism] and is even . . . potentially damaging . . . [S]ome autistic children who have been seen in psychotherapy have shown very little progress, despite intensive input over many years, and have not recovered their capacity to play. (pp. 175-176)

This is no doubt due to their limited intelligence, restricted or absent language, and incapacity for symbolization (Fonagy & Target, 1998).

Others (e.g., Reid, 1999; Rhode, 2000) argued that there is a subgroup of autistic children who may benefit from child psychoanalytic psychotherapy—those who adopt autistic defenses to cope with the overwhelming trauma of physical and psychological separation from their mothers (Bick, 1968; Tustin, 2009). How any assessment could accurately discern the members of this subgroup from the heterogeneous population of children with ASD is an open question. Reid (1999) named the condition autistic posttraumatic developmental disorder, but it enjoys no currency in mainstream psychiatry, pediatrics, neurology, or developmental psychology.

What has allowed a failed therapy to survive and thrive despite a strong body of research and practice that demonstrates its ineffectiveness? Below are some of the main reasons for the longevity of Tustin’s approach to childhood autism:

A hagiographic adherence to a faulty theory of infant development by Tustinian acolytes

Application of faulty theory to therapeutic intervention

A failure of the processes of observation, unencumbered by theory

Restricted membership to cult-like enclaves that create closed feedback loops, whereby there is an injunction against dissent from within the group and reluctance to admit new ideas, theories, or practices from without

Groupthink—a term coined by social psychologist Irving Janis (1972)—is an extreme form of conformity that tends to occur in homogeneous groups, when a powerful and charismatic group leader (like Melanie Klein, Esther Bick, or Frances Tustin) is insistent on strict adherence to their own approaches and interpretations

Failure to apply the scientific method, in particular, unwillingness to subject one’s theories and practices to scientific scrutiny by independent researchers, including the assessment of replicability.

Conclusion

Tustin (1994/2015) concluded her 1994 paper with an exhortation to avoid “insularity” and seek consistency in “views about the aetiology of childhood autism [so that] we shall be able to talk to each other better” (p. 17). These are salutary words indeed from someone who obfuscated the study of normal infant development and autism for four decades. The field of child psychoanalysis would do well to heed the criticism of Fonagy and Target (1998) that “[c]hild analysis’s claims to legitimacy rest heavily on case reports that, however moving or dramatic, tend to resist objective assessment and controlled scrutiny (p. 88).” It is time that this subdomain of child psychoanalysis oriented its compass toward the scientific method, integrated with and informed by evidence-based psychoanalytic constructions of infant development, developmental psychology, and developmental neuroscience.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

ORCID iD

Dianna T. Kenny

Author Biography

Dianna T. Kenny is professor of psychology at The University of Sydney, Australia. She is a developmental and educational psychologist, psychotherapist, marriage and family therapist, and family dispute resolution practitioner. She is the author of eight books and over 200 peer reviewed journal articles (see ).

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