Tuesday 22 May 2012, byVersion imprimable
Listen to the Autists!
From Hurly-Burly, The International Lacanian Journal of Psychoanalysis, Issue 7,
May 2012, published for the Freudian Field by the New Lacanian School.
In France, Autism has been thrust to the forefront of the public stage following its designation as a “Major National Cause”. The pertinence of the psychoanalytic approach to autism is illustrated in the text below.
AUTISTS are subjects who are to be taken seriously. Those of them that write express themselves to make it known that they are intelligent beings who ask to be treated with greater consideration and to appeal for some respect for the inventions they elaborate as a means of containing anxiety. Do they wish there to be a legal prohibition of those that listen to them, with a view to subjecting them, often without their consent, to learning procedures? Ought they to be forced, or oughtn’t they rather to be listened to?
Opting to listen to them exposes the listener to having to contend with unsettling opinions.
ONE of the most well-known high functioning autists, Donna Williams, takes a
strong stand on the question of the treatment of autism: “The best approach would be one which would not sell short individuality and freedom for the parent’s, teacher’s or counsellor’s version of respectability and impressiveness.”1 Another autist confirms: “the people who were of the greatest assistance were always the more creative, unconventional types.”2 Psychoanalysis is not one, it is multiple; however, psychoanalytic practices all have one thing in common: they are founded on listening, listening to the other person. Entertaining the lawful prohibition of listening to a particular human group bears out an extremely concerning underlying political ideology. Not every form of listening is psychoanalytic, so how will the lawmaker distinguish between the “harmful” psychoanalytic practice of listening and the authorised, benign practice? Besides, is it really his role to promote lines of approach that are deaf to the peculiarities of the autistic subject? This would seem to be at odds
1 Williams, D.,
Nobody Nowhere: The Extraordinary Autobiography of an Autistic Girl,
Doubleday, New York, 1992, p. 180.
2 Grandin, T.,
Thinking in Pictures: Other Reports from My Life with Autism , Vintage Press,
New York, 1995, p. 99.
with the Charter of Rights for Persons with Autism put forward by Autism-Europe and adopted by the European Parliament on 9 May 1996. The Charter calls for recognition and respect for individual wishes, in such a way that autists might have the right to “freedom from fear or threat” and “freedom from abusive physical treatment or neglect”.3 How can this be achieved without listening to them?
All psychoanalytic treatments share the common ground of promoting respect for the singular and its non-absorption into the universal. This is also the unanimous wish of those autists who express themselves. Random control trials geared towards “impeccable” scientific assessment are not the first place to turn when it comes to seeking how to treat autism. Rather one should ask the subjects concerned. They are the ones who have most to teach us. They harbour a precious knowledge about themselves.
Let us take seriously the advice Jim Sinclair gives to parents, advice that is just as pertinent for educators and clinicians. In the name of autists, he states:
The ways we relate are different. Push for the things your expectations tell you are normal, and you’ll find frustration, disappointment, resentment, maybe even rage and hatred. Approach respectfully, without preconceptions, and with openness to learning new things, and you’ll find a world you could never have imagined.4
A cultivated mute autist like Annick Deshays is just as vehement when it comes to demanding a treatment for autists that does not bypass their singularity. On her computer, she writes: “Why this endless discussion over the official documents on treatment for autistic persons when those concerned don’t have any right to the information, and even less to speech?”5 She is opposed to educative methods that draw up an a priori programme of developmental stages to be worked through: “Drawing up a scientific roadmap for the education of autists that would be uniform and unilateral amounts to peddling a regime of protective dictatorship.” She goes on to affirm that, “the first concern should be to find the faculty (or faculties) of each autistic person, before establishing any educational steps.” She considers that “employing behaviourism prompts practitioners to make us ‘simple’ through a formatting that reduces our freedom of expression, and this intensifies our grave problem of identification and humanisation.” She seeks to make herself heard by the specialists to get the following message across: “Tell the decision makers, today, that thinking for us, instead of us, runs the risk of emptying out the ‘substantive marrow’ of our reason for existence.” 6 Against these methods, she advocates “the risk of a dialogue”, the willingness to “tame the fear that isolates”, even inviting us to “taste the humoristic features” specific to the way autists “view life”. All this, she adds, “compels one to work in unison rather than in uniformity, in a dyadic relation rather than with a unilateral purpose.” Like the greater number of austists, she asks to be considered as a subject capable of a creativity that needs to be taken into account: “drawing on modes of knowledge in accordance with our goodwill mobilises a
3 Articles 16 & 17 from the “Charter of Rights for Persons with Autism”.
4 Sinclair, J., “Don’t Mourn for Us” in Our Voice , the Autism Network International Newsletter, Vol. I, No. 3, 1993.
5 Deshays, A., Libres propos philosophiques d’une autiste, Presses de la Renaissance, Paris, 2009, p. 57.
6 Ibid., p. 114, p. 116, p. 121 & p. 124.
potential that is specific to us. […] The more I take part in the decisions that concern me, the more I have the impression of existing fully.”7
Failing to be heard, a good many autists end up resigning themselves to what is forced upon them. However, when the subject is in possession of the means to express himself, he protests. Donna Williams makes no secret of how appalled she is by certain educative techniques. In the nineteen-nineties, she did a placement in a special home for problem children in Australia. She observed two zealous educators in their work with a young autistic girl. Struck by their total ignorance of the child’s inner world, she writes:
I stood there feeling ill as they bombarded her personal space with their bodies, their breath, their smells, their laughter, their movement, and their noise. Almost manically, they shook rattles and jiggled things in front of the girl as if they were a pair of overzealous witch doctors hoping to break the evil spell of autism. Their interpretation of the advice seemed to be to overdose her on experiences that they, in their infinite “the world” wisdom, would bring to her. I got the feeling that if they could have used a tire jack to pry open her soul and pour “the world” in they would have done so and would never have noticed that their patient had died on the operating table. The little girl screamed and rocked, her arms up against her ears to keep their noise out and her eyes crossed to block out the bombardment of visual noise. I watched these people and wished they knew what sensory hell was. I was watching a torture where the victim had no ability to fight back in any comprehensible language. […] They were surgeons operating with garden tools and no anesthetic.8
Without doubt, they were using a classic learning method that consists in presenting a stimulus in repeated sequences, then observing the child’s response and giving a reward so as to reinforce or inhibit it.
A SYSTEMATIC application of these principles is advocated by the Applied Behaviour
Analysis (ABA) method, founded by Ole Ivar Lovaas. It goes on for two years, between thirty and forty hours a week, with children whose consent is not sought even though it is known that the majority of them experience requests in general as intrusive and threatening demands.
Since its invention, psychoanalysis has been disturbing, revealing that man is not his own master, contrary to the illusions of reason. In this respect, it does not bring good news. Nevertheless, psychoanalysis endures in spite of its incessant critics, which bears witness above all else to its vitality. The attacks levelled at psychoanalysis are currently being waged on the terrain of autism, coming in particular from Autisme-France, a parent association whose argument in favour of the ABA method has been taken up by the French MP Daniel Fasquelle. His government bill aims to outlaw “psychoanalytic practices”. Among these practices, he lists “packing”, which was practiced by Esquirol in the early nineteenth century (when it
7 Ibid., p. 118.
8 Williams, D., Somebody Somewhere, Doubleday, New York, 1994, p. 25.
was known as emmaillotement humide [wet swaddling]), half a century before Freud’s birth.
The advocates of ABA recently strayed outside the realms of legitimate scientific controversy by producing a film that has since been strongly condemned by the French courts following a series of complaints from psychoanalysts who were ensnared by the film’s director, Sophie Robert. Her defence counsel tried to argue that were she found guilty, it could also lead to the banning of Michael Moore’s films.
The American director Michael Moore, whose socially and politically committed documentary features have been subject to a number of legal proceedings, has won every time. There must therefore be a few differences between his practice and Sophie Robert’s. A couple of these differences stand out immediately. Moore films himself questioning his interlocutors. Robert does not appear in her films, and at the editing stage she cuts out some of her questions and certain of the answers she receives, which clearly alters the scope of the response. On the other hand, Moore puts his questions to personalities who represent the opinions he is combating, whereas Sophie Robert, who does indeed put her questions to some official representatives, also brings in psychoanalysts who are largely unknown in the public eye and who express opinions that only put themselves on the line.
If someone wanted to use the same procedure of propaganda to object to the ABA method, he could seek out some favourable educator who still uses corporal punishment – which would not be hard to find – even some partisan who harbours a certain nostalgia for the electric shock treatments first used by Lovaas. Now that certainly would be propaganda, because nowadays the method extols the virtues of not resorting to aversive conditioning and punishment. In short, one can deduce that Moore maintains a constant presence in his films because he is proud of what he does. Sophie Robert has chosen to hide herself. Pierre Delion, Bernard Golse, Daniel Widlöcher and Laurent Danon -Boileau have condemned “truncated editing in the service of a cause that remains to be proven”, a tactic that sought to ridicule them.9 The psychoanalysts of the École de la Cause freudienne (Éric Laurent, Alexandre Stevens and Esthela Solano-Suarez) unhesitatingly took the director to court, and the trial court judge ruled that Mme Robert had maliciously distorted their comments.
The partisans of ABA have been campaigning against a psychoanalysis that sometimes they invent, sometimes they caricature. In their view, psychoanalysis heaps guilt on the parents. Taking an out-of-date comment by Bruno Bettelheim as their constant touchstone, a comment which was already controversial in its time, they try to reduce analytic theory to what they call “the thesis of the psychoanalysts”. They unjustly refuse to see that today not a single serious psychoanalyst would support such a thesis.
On the other hand, they assert that autism is a neurobiological disorder, and nothing more. Now, the most conclusive data in favour of this conception is still showing that environmental factors interfere with a possible genetic predisposition. Whilst it is being established that various different intensively applied methods (preferably on a case-by-case basis) have managed to modify the conduct of subjects, it needs to be underlined that there exists no biological treatment whatsoever for autism, and the discovery of cerebral plasticity accounts as much for the efficacy of psychological practices as that of learning methods.
9 Account by P. Delion published in the “Dossier Coordination International entre Psychothérapeutes Psychanalystes s’occupant de personnes avec Autisme (CIPPA), November 2011, p. 39 (cf. www.cippautisme.org).
THE recent Baghdadli Report, a wide-reaching examination of the international scientific literature dedicated to “educative, pedagogical and therapeutic interventions proposed in autism”10, observes that an extreme diversity of methods are being employed with great heterogeneity. It concludes that “currently one cannot propose a straightforward therapeutic algorithm and the recommendations for sound practice are backed up by a very limited degree of evidence”11 – contrary to the publicity being churned out by some.
This acknowledgement of the uncertainty emanating from the current research is not managing to stand in the way of today’s widely held opinion that the priority treatments for autists are educative strategies that can be evaluated. This postulate is generally accompanied by an unquestioning reference to the “normal person” that would mark the completion of the educative process. This gives rise to immediate consequences that on the face of it look self-evident: one should oppose the autistic subject’s “obsessions” and remove his autistic object at the earliest possible moment. Now, the clinical monographs and autobiographical accounts, which are regrettably excluded from the international scientific literature on autism, more often than not give the lie to this supposition.
The parents of Derek Paravicini, in particular his “Nanny”, did from his earliest childhood what most “specialists” advise against, encouraging his musical “obsessions” and his attachment to an autistic object, an electronic organ. “As his musical abilities surged forward, the gap between these and his intellectual and social development was becoming more and more marked.”12 However, all that he acquired went via his islet of ability, finally allowing him, in adulthood, not only to perform concerts, alone or with an orchestra, but to develop “enough of a sense of himself to assert his will, appropriately, in conversation with a stranger.”13
Daniel Tammet’s social autonomy as an adult is even more pronounced than that of Derek Paravicini, and yet he too had “indulgent” parents with regard to his “obsessions”.14 Likewise, both Donna Williams and Temple Grandin were allowed to devote themselves to their “obsessions” and cultivate their attachment to their autistic objects. It thus seems legitimate to wonder whether for them the fact of having eluded treatment by autism specialists was not in fact a great stroke of luck.
We know that Leo Kanner was not far from asking himself the same question as he considered what became of the eleven children from his first article when he
10 Baghdadli, A., Noyer, M., & Aussiloux, C., Interventions éducatives, pédagogiques et thérapeutiques proposées dans l’autisme, French Ministry for Health and Solidarity, Direction générale de l’action sociale, Paris, June 2007.
11 Fuentes-Biggi, J., et al., Spanish Ministry of Health and Consumer Affairs, “ Guía de buena práctica para el tratamiento de los trastornos del espectro autista”, in Revista de Neurología,
43 (7), 2006, pp. 425-38.
12 Ockelford, A., In the Key of Genius, The Extraordinary Life of Derek Paravicini,
Hutchinson, London, 2007, p. 214.
13 Ibid., p. 242.
14 Tammet, D., Born on a Blue Day: Inside the Extraordinary Mind of an Autistic Savant: a Memoir, Simon & Schuster, 2006, p. 62.
followed them up twenty-seven years down the line.15 Two of them had managed to elude the healthcare institutions and socially integrate, and it is clear that a permissive upbringing and the cultivation of their “obsessions” helped them a great deal. As concerns Donald T., when he turned nine, his parents sent him to live on a tenant farm some ten miles away. Kanner writes, “When I visited there [three years later], I was amazed at the wisdom of the couple who took care of him”. Far from making him conform to systematised apprenticeship programmes, “they managed to give him goals for his stereotypies”.
As for Frederick W., at the age of thirty-four he was employed in an office, doing routine work operating duplicating machines. According to Kanner, he had benefited from an adjustment to the conditions of his life, similar to the adjustment Donald T. had enjoyed: “in the framework of the Devereux Schools […] he slowly was introduced to socialised pursuits via his aptitude for music and photography.”16 The nine other children observed by Kanner in 1943 had a far less favourable destiny. At the end of his report he writes:
One cannot help but gain the impression that State Hospital admission was tantamount to a life sentence, with evanescence of the astounding facts of rote memory, abandonment of the earlier pathological yet active struggle for the maintenance of sameness, and loss of the interest in objects added to the basically poor relation to people. In other words, a total retreat to near-nothingness.17
Here, within arm’s reach, lies some essential knowledge on the therapeutics of autism. Kanner notes that the maintenance of sameness and the interest in objects bear out precious psychical activities, and that suppressing them leads subjects back to near-nothingness. Donald and Frederick on the other hand show the advantage an autist can draw from his “obsessions” and his islets of ability. Now, knowledge such as this gets rapidly buried under layers of developmental studies centred on the ideology of the “normal person” who is supposed to have neither an excessive attachment to objects nor a behaviour that maintains sameness. Worse still, biological approaches would suggest that these children are too afflicted for their strangeness to merit any attention or possess a function. The specialists are not predisposed to admitting that the “sick” can harbour any knowledge about their troubles that would be worthy of interest.
Birger Sellin has had harsh experience of this: when his account was seen to diverge from the prevailing lines of knowledge on autism, a press campaign was launched seeking to cast doubt on the authenticity of his writings. One of the reasons for the determination shown by some against the use of Facilitated Communication with autists draws from the same sources: the discourse of science does not sit well with the singularity of the subject; it always seeks to silence it.
15 Kanner, L., “Follow-up Study of Eleven Autistic Children Originally Reported in 1943” in Journal of Autism and Childhood Schizophrenia, Vol. I, No. 2, 1971, pp. 119-45.
AS a matter of fact, the highest successes in the social functioning of autistic subjects have not been obtained by the application of learning techniques, nor by treatments marked out by stages of development, but by the path of singular approaches that show great diversity and whose progression has not been blocked by any knowledge the care teams might possess about autism.
The psychoanalysts are not alone in having grasped that the best aid that can be brought to an autistic subject is not that of technicians of the psyche but that of educators and therapists who are capable of blotting out their a priori assumptions so as to make room for the other’s inventions. In this regard, the Rogers-inspired play therapy conducted by Virginia Axline with Dibs may be cited as an example.
Axline did not set about treating Dibs by figuring out in advance the path her patient would have to take. On the contrary, she endeavoured not to say anything to him that might indicate a desire on her part to see him do anything in particular. She contented herself with communicating with him, trying not to force herself through into his inner world, but seeking to comprehend the specificity of his system of references. “I wanted him to lead the way”, she writes, “I would follow.”18 Her prime concern was that he would not feel any obligation to read into his therapist’s thoughts to orient himself in the treatment. She did not want to offer any preconceived solutions and was sufficiently audacious to entertain the idea that any “meaningful changes” would have to come from the subject himself.19 The application of this method led her to one of the most striking successes ever in therapy for an autistic child.
This remarkable testimony, which was known the world over in the nineteen-sixties, no longer falls within the methodological framework of scientific discourse. It did however benefit from exceptional conditions because the sessions were recorded in their entirety. But this is by the by, the international review of the literature on autism mentioned above is unaware of its existence. Axline’s experience, so they seem to suggest, must now be considered null and void.
How then are we to proceed with autistic children? Parents, educators and therapists who ask themselves this question today find themselves faced with a multitude of propositions. However, this diversity falls into three main orientations: the behavioural methods, the cognitive- behavioural methods, and the psychodynamic methods. All of them have proven to be incontestably capable of modifying the behaviour of autists. So where does one take one’s bearings from?
THE behavioural approach deserves to be looked at in some detail, because the
healthcare authorities currently favour this approach. ABA does not burden itself with studies on the autistic child’s functioning, nor on his specificity. In conformity with the methodical hypothesis of behaviourism, it considers the psyche to be a black box that it does not seek to open. It situates itself at the degree zero of any grasp of the psychology of autism. It is a method that treats learning, it is not a mode of knowledge about autism. It operates essentially by breaking down learning tasks into
18 Axline, V. A., Dibs: In Search of Self: Personality Development in Play Therapy,
Houghton Mifflin, 1964, p. 44.
19 Ibid., p. 47.
component parts, then reinforcing the acquisition of each element of the task through conditioning.
According to the specialists of this method, many institutions that take it as their reference only apply its rudiments. It is true that this method is hard to implement in its full rigour. It necessitates one qualified person, individual treatment, and practitioners working preferably in pairs. Furthermore, one of the parents has to be part of the team. The ideal state of affairs is continuous treatment from the time the child awakes to the time he is put to bed. A minimum of thirty hours per week is required. The availability required of the parent seldom turns out to be compatible with professional activity.
ABA confines itself to tackling behaviour that it sets about normalising, without seeking to penetrate its functions and without concerning itself with affective life. Not only does it permanently confront the autistic subject with requests that are felt to be intrusive and menacing, but its willing ignorance of cognitive functioning often leads it to advocate techniques that most other specialists deem inappropriate. This multi-purpose pedagogical method leads one to suppose that what holds true for most individuals, namely that “unpredictability and novelty enhance reinforcement”20 must also be true for autists. With that, the ABA partisans unhesitatingly extol the virtues of “surprises” that are supposed to be “in general, highly agreeable and motivating”. Now, this prescription clashes with the unanimous opinion of high-functioning autists who have experienced the reassuring function of the maintenance of sameness. “I didn’t care for surprises”, writes Gunilla Gerland, “not in any part of life. I didn’t want to be taken unawares, ever. If I was to stand a chance of overcoming certain events, I had to be prepared.”21
On the other hand, advising ABA educators to put enthusiasm into their voice22 shows a marked failure to recognise the contributions from psychoanalysis concerning the anxiety-provoking character of the voice.23 Indeed, most clinicians agree that a contrary attitude is preferable, underlining after Hans Asperger that it is better to speak in a “calm tone of voice”24 if one wishes to make oneself heard.
In this context, which induces situations of conflict, it becomes necessary to give the ABA educators advice, not to moderate the psychical interventions, but to incite them only to make such interventions if they feel capable of taking them on board. They are taught:
Don’t give instructions that will lead to a fight if you aren’t able to assume it (getting him to sit down, trying to keep visual contact, making him sit quietly or getting him to say “Hello” or “Goodbye”). It’s up to you to decide whether it really is important and whether you are ready! In other words, never
20 Leaf, R. & McEachin, J., (eds.) A Work in Progress: Behaviour Management Strategies and a Curriculum for Intensive Behavioural Treatment of Autism, DRL Books, 1999.
21 Gerland, G., A Real Person: Life on the Outside , transl. by J. Tate, Souvenir Press, London, 1996 [translation modified to accord with the French edition].
22 Leaf, R. & McEachin, J., (eds.) A Work in Progress…, op. cit.
23 Maleval, J.-C., L’austiste et sa voix, Seuil, Paris, 2009.
24 Asperger, H., “‘ Austistic Psychopathy’ in Childhood”, translated by U. Frith, in Frith, U., (ed.) Autism and Asperger Syndrome, Cambridge University Press, 1991, p. 48: making “requests in an automaton-like and stereotyped way, for instance, speaking softly in the same sing-song that they use themselves”.
demand anything if you aren’t prepared for the consequences it can lead to and which might necessitate physical intervention.25
In short, the ABA educator doesn’t hide the fact that he has to be ready for a fight for the other’s good.
From this perspective it follows that the specificity of the autistic subject’s functioning is essentially grasped as an obstacle to the educative work. There is never any mention of his anxieties, and his interests are barely taken into account, because neither are directly observable psychological notions. On the other hand, they try to combat his isolation, his distractions, his anger, his self-stimulation and his refusal to cooperate. In sum and substance, it is a matter of making the child obey by leading him to share the educator’s views on the developmental norms of the person.
Admittedly, ABA practice does force one to take into account certain cognitive difficulties, but the autist is required to overcome them more than the educator is required to adapt to them. Above all, the specificities of his affective functioning are ignored. This method pays scant attention to the autistic child’s differences: one size fits all. Furthermore, techniques of similar inspiration are being used, notably in Canada, to re-educate delinquents. “This pedagogical process is applicable to all ages and all populations. […] It is simply good teaching.”26
This method leans on the implicit hypothesis that all human beings share the same functioning. The specialists are now affirming that they apply it in the raising of their own children, in their relationships with “friends and significant others”, as well as when “coaching baseball, soccer or dance”.27 Nothing can resist it: it can improve social skills, professional performance, language acquisition, independence, hobbies, &c. In fact, the adherents to the behavioural approach haven’t shrunk from lending it further support by asserting that autism doesn’t exist: it was merely an error by Kanner. They don’t mention the fact that Asperger, unaware of Kanner’s work, made exactly the same “error” the following year.
One of the objections often levelled at the ABA method lies in its use of aversive conditioning. This technical term designates what in everyday language is readily termed “punishment”. Having ascertained that these aversives are efficient, the behaviourists ask: why not employ them in all their rigour?
The supporters of this method do not hide the fact that Lovaas began his research in the nineteen-sixties by administering electric shocks to autistic children to reduce their self-harm behaviour. The results were conclusive.28 They stress that the subsequent abandonment of these punitive methods was due to the influence of ethical considerations exerted by social pressure, and not in the name of science. They bring up the notion of “political correctness”. One can detect a certain regret on their part to have been forced to give up such efficient methods.
However, they put forward pertinent reasons for doing so, affirming that punishment is a highly abusive procedure and therefore necessitates careful control.29
25 Leaf, R. & McEachin, J., (eds.) A Work in Progress…, op. cit.
27 Leaf, R., McEachin, J., & Taubman, M., Sense and Nonsense in the Behavioral Treatment of Autism: It Has to Be Said, DRL Books, 2008, p. 10.
28 Lovaas, O. I., & Simmons, J., “Manipulation of Self-Destruction in Three Retarded Children” in Journal of Applied Behavior Analysis, Vol. 2 No. 3, 1969, pp. 143-57.
29 During a 1973 research study that demonstrated the efficacy of the ABA method for normalising behaviour, punishment was used, but the staff were trained in its use “so as to
They add that, “We have witnessed circumstances in which ‘professionals’ abused punishment to a point that would be considered mistreatment”. Moreover, they note that it is a procedure that is too easily used, which is resorted to in “an emotional way”, such that its “incorrect use” runs the risk of harming the reputation of ABA. The mention of “incorrect use” of punishment in a book explaining the reasons why they put a stop to it is significant: it reveals that there is a persistent notion of correct punishment in the method’s logic. Moreover it is asserted that it was used in a “correct” manner in 1973 thanks to the training the staff received under the watchful eye of several supervisors, including Dr Lovaas.
This is not without consequence on the day-to-day practice of ABA. In the opinion of its specialists, it is frequently implemented by professionals who are not sufficiently competent, never having been trained at UCLA.30 Thus, many of them have only a very rough understanding of it, one which amounts to the notion that the child has to do what he is told. When his refusals test the educator’s patience too far, the temptation is strong to go beyond positive conditioning alone and draw on other conditioning methods, which are certainly not advised, but which had been proven to be scientifically efficient. The specialists at UCLA admit that some professionals still use aversive methods, but they try to be reassuring, saying that they are not necessary and that the vast majority of professionals only use positive behavioural approaches.31
However, even when it avoids aversives, the ABA method remains a practice that does violence to the autistic child by not taking his anxiety into account, by ignoring the importance of his sameness, by striving to separate him from his autistic object, by asking him to adapt to the therapist, and by affording him the least possible opportunity to isolate himself. The child’s “difficult” behaviour and his frequent initial refusal to cooperate are not examined, nor are they grasped as modes of communication or ways out of specific difficulties. The child is essentially told to obey. The practitioners take the risk of using subordinative learning that hinders access to independence.
The results produced by ABA resemble the method itself: they are dehumanising and purely statistical. Case accounts are extremely rare. Never has a high-functioning autist reported coming out of his withdrawal through a systematic application of constraint-based learning.
MANY different methods have learnt lessons from the observation that autists understand the world in a different way from other children. Such methods seek to take into account the specificity of the cognitive functioning of autistic subjects, which leads them to put in place educative strategies that are not “multi-purpose” but adapted to the subject’s mode of functioning. TEACCH, PECS, MAKATON, and others, aim to build a shared reality, more often than not by encouraging a structuring
ensure the procedure was correctly employed”. Leaf, R., McEachin, J., & Taubman, M.,
Sense and Nonsense in the Behavioral Treatment of Autism…, op. cit.
30 Leaf, McEachin and Taubman write critically of how they have often observed programmes put in place by individuals who have never had any links with UCLA, but who claim to replicate its model.
31 Leaf, R., McEachin, J., & Taubman, M., Sense and Nonsense in the Behavioral Treatment of Autism…, op. cit.
of the environment and an implementation of a communications system using pictograms. By listening to the cognitive peculiarities of autists, the educators who draw on these methods sometimes find themselves led to examine affective functioning in such a way that they can become less assertive of the necessity of cutting the child off from his autistic object and his sameness.
Thus, contrary to the adherents of the ABA method, a supporter of TEACCH (Treatment and Education of Autistic and Related Communication-Handicapped Children) can affirm that austists need their stereotypies, and that they have a right to them.32
Nevertheless, in cutting the learning methods off from meaning and motivation, not only are these methods hard to implement across the board, but acquisition remains artificial. The results obtained sometimes make a strange impression on the outside observer. When in the nineteen- nineties Oliver Sacks visited a special home for the education of autistic children in the US which was mainly inspired by the TEACCH method, he noticed that many of the kids had learnt to function more or less well, but he couldn’t shake off a certain uneasiness. He writes:
They had certainly learned, many of them, to “operate” after a fashion, to show at least a formal or external recognition of Social convention – and yet the very formality or externality of their behaviour was itself disconcerting. I felt this especially at one school I visited, where children would stick out rigid hands and say in loud, unmodulated voices, “Good morning my name is Peter… I am very well thank you and you” without any punctuation or intonation, affect or tone, in a sort of litany. Would any of them, I wondered, ever achieve true autonomy?33
Indeed, it is not enough merely to get them to acquire knowledge, to which their high capacity for memorisation lends itself, they still have to be afforded the possibility of integrating it. Here it is necessary to underline with force that authentic learning is quite distinct from “breaking in” the subject: to the acquisition of a line of behaviour, authentic learning adds the subject’s assimilation of its meaning.
The three major treatment methods for autism lean on fundamentally different conceptions of what it means to be human, which means they clash with each other from the very outset. However, they have each accumulated experience of practice with autists and are thus able to present therapeutic results. It would therefore be interesting to examine the potential existence of certain points of agreement, beyond their clear points of divergence. As a matter of fact, there are many.
First of all, the different methods have each contributed to put paid to the notion of the incurability of autism. They each insist on the fact that autism is not an irremediable handicap and that a socialisation of these subjects is possible – at the very least for some of them. Today, no one would object to the benefits of sending the autistic child to school as soon as he is capable of adapting to ordinary schooling – on condition that he not be rejected by the other pupils. The necessity of individualising the treatment is always stressed – even by those methods that lend themselves to it poorly. Finally, it may be useful to call to mind that, for the informed specialists, the consensus is that we are still in the dark as to the cause of autism: neither poorly
32 Peeters, T., Autism: From Theoretical Understanding to Educational Intervention , Wiley-
Blackwell, London, 1998.
33 Sacks, O., An Anthropologist on Mars, Seven Paradoxical Tales, Knopf, New York, 1995.
adapted learning, nor malfunctioning in information processing, nor the unconscious desire of the parents, nor genetics, are in a position to explain its genesis.
The points of agreement listed above are significant, but they pale in comparison with the scale of the points of divergence.
The ABA method essentially confines itself to tackling behaviour that it strives to normalise without seeking to penetrate its functions and without consideration for affective life.
On the other hand, the TEACCH programme is finely acquainted with the autist’s cognitive functioning, and puts in place techniques that take it into account. However, from this perspective affective life and the work of protecting against anxiety remain impenetrable.
The psychoanalytic approach to the autist is more heuristic because it does not block off any of the realms of human functioning.
THE psychoanalytic approach is the only one capable of offering an understanding not only of affective functioning but also its consequences on the cognitive dimension. It is the only approach that can account for the function of the autistic object, the primacy of the sign, and the strangeness of enunciation. It is the only approach that isolates, behind the diversity of different types of behaviour, what is constant in autism. In short, it draws on a knowledge of the ensemble of subjectivity (albeit partial and provisional), whereas the ABA method reduces the child to his behaviour and the TEACCH programme only grasps the cognitive consciousness of the subject.
The approaches that take into account subjectivity have major consequences for the treatment. By refusing to focus on just one part of the subject’s functioning, they do not block off the possibility of listening, in a non-restrictive way, to what he expresses, thereby enabling them to lean on his own inventions. Moreover, they valorise the autistic child who is not seen as a retarded manipulator, but an intelligent child shackled by his anxieties.
The rich experience that has accumulated in institutions whose methods draw on the psychoanalytic approach clearly encourage us to note that an autistic subject
often learns, and learns better, at a tangent rather than when he is directly confronted with the task at hand without any possible way out. Even when he seems to be absent, he is observing and listening through the intermediary of
other children and will then be able to reproduce what he has seen others do.34
At the Antenne 110 in Brussels35, as in other institutions for which the Freudian discovery constitutes a major orientation, the work with autistic subjects seeks not to
34 Boudard, B., “Un ‘programme’? Pas sans le sujet” in Halleux, B., de (ed.), Quelque chose à dire à l’enfant autiste: Pratique à plusieurs à l’Antenne 110, Éditions Michèle, Paris, 2010, p.140.
35 The International Network of Children’s Institutions (RI3) is a Freudian Field network created by Jacques-Alain Miller in 1992. It is currently comprised of three member institutions: Antenne 110 and Le Courtil in Belgium and the CTR in Nonette, France, along
apply a predetermined technique to one and all, but to invent one way of proceeding for each subject.
We take the child as he is, with his potential and his incapacities, but also with his privileged object – it might be a stick, a length of twine, a piece of circuitry, a Walt Disney character, &c – and we invent tools, strategies to hear, displace and generalise this privileged focus of interest and progressively lead the child towards a learning process. By virtue of this, the child’s interest is attracted by the work that is requested, which becomes motivating in and of itself and a source of satisfaction.36
A simple clinical example, which relates the kind of observation that has been repeated again and again in such institutions, illustrates this everyday experience:
When Hubert first arrived at the Antenne, he really was not ready to join in pedagogical learning: in the logopedics class he would not respond to the questions, did not listen to the instructions, and shared nothing of what he knew. He always held a stick in his hand, a favourite object with which he would constantly tap out a beat. Rather than give this behaviour the limited status of a mere dysfunctional stereotypy to be eliminated at the outset, we hypothesised that his interest in the stick had a function, and we used it as a point of departure for an individualised work project. This next enabled Hubert to take an interest in the striking of the bell in the Genval church, and then in the hands of the church clock, which made him want to learn to tell the time, and for that he learnt the numbers with the logopedics specialist, first from 1 to 12 (the clockface), then from 13 to 24 (the 24 hours of the day), then up to sixty (sixty minutes per hour), &c. And so, the workshops which for a few weeks had the goal of going to examine the church, the bell and the clock, allowed a path to be traced from the child’s favourite object to learning the numbers, and then the letters, and moreover gave rise to his taste and motivation for pedagogical learning.37
Certainly it should not be claimed that acquisitions obtained in this way occur without any constraints. In this respect, Antonio Di Ciaccia promotes the necessity of a “gentle forcing”, an indication confirmed by the autists themselves. One mother of an autistic child observes:
If I don’t insist beyond what is reasonable, there is no result, because things don’t get going. However, even when she opposes it, Anneclaire really does have a demand for all kinds of teaching and learning, and she doesn’t do it on her own. I observe this paradox without understanding it. […] It takes an outside impulse for her to start getting things underway. Once she’s going nothing can stop her, and if I stop then everything stops right there.38
with the associated institutions: Podensac, L’Île Verte, La Demi-Lune, the Aubervilliers Day Hospital (France), and Le Prétexte (Belgium). These institutions accommodate autistic and psychotic children, teenagers and young adults. They are oriented by Freud’s oeuvre and the teaching of Lacan.
36 Ibid., p. 140.
37 Ibid., p. 141.
38 Damaggio, N., Une épée dans la brume. Syndrome d’Asperger et espoir, Anne Carrière, Paris, 2011, p. 74.
“Gentle forcing” is not distinguished from constraint-based learning by its degree of firmness, the difference lies in their very nature. “Gentle forcing” draws on the subject’s interests; constraint-based learning draws on the educator’s knowledge. The former finds its roots in the subjective dynamic, whereas the latter ignores it.
Consented learning mobilises a subjective dynamic that in constraint-based learning is either missing or drives against the work. Certainly, it cannot be doubted that as a rule constraint-based learning techniques manage to improve the subject’s IQ and his cognitive capacities. Despite their diversity, all of these techniques prove to be relatively efficient on this point. They contribute to the acquisition of social skills, which are sometimes unceremoniously inculcated.
However, the all-important question posed by these purely educative methods of the treatment of autism is precisely the one that Sacks raises: is there any gain in autonomy?
IT is plain to see that any gain in autonomy is not strictly correlative to cognitive
improvement. Those who have managed to take a decisive step in this regard testify to the fact that autonomy is the result of a choice that cannot be taught. It only comes about through a major decision that produces a subjective mutation. For this, it is necessary that the decision not be hindered by those around the subject. Not only must the subject agree to take the risk of loosening his grip on his mastery of the world, but also it is imperative that he not have to contend with an overprotective Other who obstructs this.
Gains in independence cannot be taught: they can only come about as decisive acts for which the subject must take responsibility. For Donna Williams, she first had to accept to take the risk of revealing her inner world by publishing her first book: she tells us that for her this was a test that was not free of anxiety. Temple Grandin did not hesitate either to take risks by opening herself to the world; she relates precisely how her quest for autonomy was punctuated by choices cemented by crossing different symbolic thresholds. A turning point in Daniel Tammet’s existence likewise occurred when he took the decision to do something “new and challenging” by going overseas.
For a long while Daniel remained very dependent on his family, but when he turned eighteen, at the end of his secondary school education, he felt the need to do something to get away from his child’s bedroom. He wanted to go and work in another country, and replied to a recruitment ad for people interested in voluntary work. He tells his parents. They are doubtful of the pertinence of his project, but rather than considering him an overly vulnerable invalid, rather than rushing to dissuade him, they take the risk of not discouraging his initiative.39 Somewhat unexpectedly, Daniel gets through the selection process and is posted to Kaunas in Lithuania for a one-year mission. His parents worry whether their son will be able to live such a long time so far from their home. But Daniel insists on taking what he sees as a big step forward in life. He is delighted at the prospect of going to teach English to foreigners. “There was anxiety, of course”, he writes,
39 Tammet, D., Born on a Blue Day…, op. cit.
about the trip and whether or not the placement would be successful. But there was something else as well: excitement, that I was finally taking charge of my life and my destiny. Such a thought took my breath away.40
Nearing twenty years of age, he does not hesitate to leap into the unknown. He makes a break with his life of security, taking the risk of an act whose consequences could not be calculated in advance. In spite of his “difference”, he adapts very well to his work in Lithuania. He makes a few friends there among the women who come to his lessons. He finds himself in a position to take a major new decision, out of step with his previous conformist attitudes, which confirmed a modification in his subjective position. He dares to telephone a gay association. “That phone call was one of the biggest decisions of my life and one of the most important too.”41 It was the first step on the road towards accepting his homosexuality. He assumed it fully a little while after arriving back in the UK by living with Neil, a partner he met via Internet. His parents are not against it. Thus Daniel reckons, quite rightly, that the support of his family “has been a very big reason for any of the success” he has had in his life.42
Indeed, it needs to be stressed that this support was enlightened support, accepting risk, making room for unknowing, and able to bet on the subject’s responsibility. They put in place the conditions that allowed their son to bring about a decisive subjective mutation, breaking from the security of a routine world and gaining access to one of the most successful ever stabilisations of autism.
However useful and well -intentioned learning methods may be, they come up against limits. As the Baghdadli report observes, their efficacy is generally limited to the acquisition of a specific skill targeted by the intervention under study, such that it does not imply a significant change in the functioning of the person who benefits from the intervention.43 There is no cause to doubt this observation, and yet too many studies stop here, leaving little hope for the future of autistic children. Their methodological refusal to take into account clinical monographs and biographies of autists, which harbour a knowledge that allows one to go further than this refusal, clearly constitutes an epistemological obstacle. “When we look too long through the spy-glass of scientific omnipotence”, Jacqueline Berger keenly observes, “our certitude-crammed minds unlearn human unpredictability and its creativity.”44
THE learning methods cite in their favour eloquent statistics that bear out their
efficacy. Without going into endless discussion about their interpretations and what is actually being grasped by their figures, we should underline above all that it is incontestable that results of at least equivalent efficacy can be obtained by other methods that are more respectful of the subject.
If we focus only on accounts from mothers who have managed to bring their child out of his autistic withdrawal through empirical methods of different inspiration,
40 Ibid., p. 119.
41 Ibid., p. 129.
42 Ibid., p. 217.
43 Baghdadli, A., Noyer, M., & Aussiloux, C., Interventions éducatives, pédagogiques et
thérapeutiques proposées dans l’autisme, op. cit., p. 261.
44 Berger, J., Sortir de l’autisme, Buchet-Chastel, Paris, 2007, p. 31.
it appears quite plainly that the improvements obtained by gentleness and play are no less significant that those acquired by violence and coercion.
When the Copelands discovered in the nineteen-sixties that resorting to “reward-hugs and punishments-slaps” with their daughter sharply improved her behaviour, they thought they had found the long-sought key to the treatment of autism.
She screamed terribly the first time they tried it, making her touch everyday objects for which she had shown fear. And those were more than could be numbered. At times the task seemed impossible. They would grip her firmly by the wrist and every time she resisted, they smacked her. It had to be done. Gradually, as the exhausting weeks dragged on her resistance was definitely becoming less. 45
Now, the improvements that Anne Idoux- Thivet achieved more recently with her son are no less significant, and yet she always refused to use “the carrot and stick” routine, practicing instead a “ludotherapy” oriented by her child’s reactions, anxieties and shows of curiosity.46 In short, a comparison of the two contrasting accounts makes it clear that what can be obtained through violence can be better obtained through play.
Another mother of an autistic child, Hilde de Clercq, came to the following observation after considering the diversity of methods. We can only agree with this assessment: “It is much more agreeable, for everyone, to follow the way these children think and to stay positive, than to force them to adapt and constantly have to contend with behavioural problems.”47 To do so, taking into account their ways of struggling against anxiety is essential, which is precisely what the learning techniques neglect.
All methods for treating autism have their successes and failures. This diversity results in part from the considerable differences in the functioning and the expectations of the autistic subjects. However, they do not share the same ethical stance: for the behavioural and cognitive- behavioural methods, the source of change is essentially situated in the hands of the educator, seconded by the parents. On the other hand, for the methods that take into account subjectivity, it is a matter of stimulating and accompanying a dynamic of change inherent to the child. The psychodynamic methods bet on the subject’s responsibility, which can lead to his independence along paths that are to be invented and not pre-programmed. (Who would have trusted in Donna Williams’s imaginary companions or Temple Grandin’s squeeze machine?) The educative approaches effect a choice: they work with a child who must be steered onto the road to normalised development that is supposed to be valid for all and sundry. More often than not, they do manage to improve his autonomy, but they struggle to aid his independence. Among the many high-functioning autists who relate how they came to autonomy and then to independence, none of them show to have benefited from intensive educative methods. All of them however report that they invented highly original methods as a way of making their autistic functioning compatible with the social bond.
45 Copeland, J., For the Love of Ann, Arrow Books, London, (Revised Edition) 1976, p. 47.
46 Idoux-Thivet, A., Écouter l’autisme. Le livre d’une mere-autiste, Autrement, Paris, 2009.
47 De Clercq, H., Mum, Is that a Human Being or an Animal?, Sage Publications, 2003.
PSYCHOANALYSIS in the twenty-first century is not the caricature that Autisme-France are fighting against. Most of its detractors are unaware that certain psychoanalysts (admittedly, on this point they are still in the minority) consider that autism is not a psychosis, that contrary to Frances Tustin’s opinion the autistic object can serve as a precious support in the treatment, that signifying or Oedipal interpretations are to be proscribed, and that “gentle forcing” is necessary to give rise to learning. What then does psychoanalytic practice consist of? The crux of it is the capacity to accompany the subject in his original inventions so as to ward off anxiety.
Learning methods sometimes lead an autist to autonomy, but never to independence from his family. Moreover, these methods postulate, misguidedly, that ongoing monitoring will be constantly necessary. Countless singular experiences give the lie to this assertion. The different accounts from autists testify to the fact that never has an autist gained independence without benefiting from a benign listener who respects his inventions.
It is coherent that those who are striving to efface the speech of the autists are the very same who are applying themselves to a caricatured propaganda campaign to ensure bad press for the psychoanalysts’ arguments.
In March 2012, the French Haute Autorité de Santé (HAS) published good-practice guidelines for educative and therapeutic interventions with autistic children and adolescents. To bring them out, it promotes a conception of science that is limited, according to its own indications, to methodologies inspired by “biological and pharmacological trials”. No space is given to clinical method (despite the fact that the latter is supported by monographs that are far more appropriate to the study of human phenomena) for the reason that such method “does not allow for the generalisation of results”. The fact that it is second-to-none when it comes to the study of subjectivity does not fall within the coordinates of present-day scientific discourse. For the HAS, the reductive universality of the numerical figure takes precedence over the approach to singularity. The autist’s subjective functioning is conspicuously absent from its recommendations.
For example, it is remarkable that one of the most specific creations of these subjects, the autistic object, is completely ignored. Likewise, there is no mention of the importance of the work of sameness that was so forcefully stressed by Kanner at the outset. Paradoxically, the first recommendation consists in “respecting the singularity of the child/adolescent and that of his family”. This is hammered home insistently: the quest for the child’s adherence is paramount, he should be allowed to take part in decisions and his tastes and interests should be taken into account. “He should be recognised in his dignity, with his history, his personality, his pace, his own desire and tastes, his capacities and limits”. Better still:
So as to gather the opinions of the children/adolescents who do not express themselves verbally or who present serious or deep mental retardation, professionals are advised to take into account the child/adolescent’s non-verbal expression of adherence or opposition, notably through observation, and by referring to knowledge garnered from his close ones and/or other professionals who share his everyday environment and can thus contribute to deciphering his expression.
These are all excellent indications, and the psychoanalysts subscribe to them. Indeed, they have always ventured to apply them. Unfortunately, in the HAS recommendations, these indications feature as negations because they are incompatible with the ABA method. Were they to be taken seriously, they would at the very least lead one to be severely on one’s guard with respect to the pursuit of this practice. It is therefore paradoxical and incoherent that the ABA method is so strongly recommended by the HAS, on the sole basis of a “scientific presumption” of efficacy.
Here we have fresh confirmation of the fact that the discourse of science is bereft of ethics. It leads to a recommendation of one of the most violent techniques, the same that denies the very existence of autism, the same that its promoters deem to be just as appropriate for delinquents as for autists, the same that in their own expressed opinions functions better when it includes punishment, the same that is most strongly fought against by high- functioning autists (Michelle Dawson, Donna Williams, Annick Deshays), the same that produces good, normalised kids who will be forever dependent, and very same that does not respect the Charter of Rights for Persons with Autism in its appeal not to expose them to “fear or threat” or “abusive physical treatment”.
The HAS points out that the ABA method is currently venturing to attenuate its violence by seeking out the individual’s interests and even taking his desires into account. Could it be that this method, which yesterday was still banishing all psychology, might today be renouncing its own fundaments? One more effort, and soon it will be Freudian.
The HAS advocates unlimited evaluation at all stages of treatment and in connection with most of the individual’s functions. It veers towards managing what is human through a conditioning that promises autists the best of all possible worlds. A more favourable future would aim at dialogue and collaboration between those methods that respect their specific cognition and those that take into account their inventions and the singularity of their affective life.
Translated from the French by Adrian Price
Originally published in Lacan Quotidien, Issue 155, 14 February 2012, pp. 1-8; revised edition published as Maleval, J.-C., Écoutez les autistes !, Navarin, Paris, April 2012.