Tag Archives: child’s inner world

A Cast of Thousands


A Case of Thousands

I recently received a neuropsychological testing report on a little patient of mine who has developmental problems in the general category of autistic spectrum disorder. The report was exceptional in its careful attention to detail – in the description of the tests, in the account of the child’s performance on the tests, and in the way it set out the implications that these subtest results had on the child’s learning and more general development. I was very pleased. Then I looked at the recommendation section, and I was disappointed. That is not to say that the recommendations were incorrect. They were detailed and comprehensive. However, they included recommendations for multiple specialists. 

Some of these specialists could provide services at school through the school system; the family is fortunate in that the city where they live makes many special needs services available to children in the school system. However, too many of the recommendations for specialists – such as a CBT therapist and an autism specialist in addition to my psychotherapy with the child – will not be provided by the school. This presents a dilemma for the family. Either the family finds the time and money to pay for these specialists and to take the child to these additional appointments, or the family lives with the worry that they are not giving the child all of what he needs – with long-term negative consequences.

I believe strongly in the team approach to the treatment of children with autistic spectrum disorders (ASD) or pervasive developmental disorders (PDD). However, I also believe in paying attention to the “family economy”, meaning the resources in time, money, and emotional reserve that the family has at its disposal. I have led a number of parent groups for parents of “quirky” children, and I have witnessed the anguish of parents who were trying to make decisions about allocating limited resources to the care of their ASD or PDD child. 

Also, perhaps because my husband is an economist, I am sensitive to the pull of the marketplace and the influence that has on recommendations for treatment. I am not suggesting that all these specialists do not believe that what they are offering is the very best and in fact necessary for the health of the children they treat. I am suggesting, though, that each specialty has a financial incentive to compete for patients. In addition, it is sometimes true that the more defined and therefore narrower perspective of a specialist may have a negative effect for two reasons. The first is that they may be less well prepared to integrate the various aspects of the child’s treatment than a therapist with a more general approach, and the second and related reason is that they may duplicate various aspects of the treatment, sometimes causing confusion and certainly costing more.

I do not hide my bias for a psychodynamic therapist to be at the center of the treatment of these children. That is my training and my conceptual model. However, I have other reasons for suggesting this plan. The first is that children with ASD and PDD essentially have problems with development, and developmental science now teaches that development occurs in the context of a relationship. Of all the therapeutic disciplines, psychodynamic therapy is the one that primarily emphasizes the therapeutic relationship. The second reason is that psychodynamic therapists aim to make meaning of the particular child’s experience, and to do that they must search for the unique personhood of that child and try to join it. This begins, as it does in normal development, with a shared focus of attention and proceeds to the sharing of complex experiences of affectively charged symbols. It is only through the energetic building of  a position of mutual understanding and collaboration that the therapist can help the child build new developmental capacities. 

The dynamic therapist, though, must not limit herself to the verbal narrative and symbolic play of these children. Instead, she must learn – especially from her O.T. colleagues, but also from child trauma researchers – how to help the child regulate himself, and then work with the parents to help them continue the work at home. She must focus relentlessly on the child’s agenda and support it by recognizing and joining it, then nudging it slightly forward by making contributions of her own, in a repetitive but flexible manner. This approach shares a lot with the DIR floor time method; I have learned a great deal from floor time practitioners. 

The therapist must also comment on the relationship between herself and her patient, and acknowledge patterns that may repeat themselves with parents, teachers, and peers. She must network with the parents and other caregivers and clinicians as frequently and consistently as possible. Through these therapeutic interventions, the therapist and child make links between the child’s inner world – emotions and fantasies – and his body (physiological arousal state and experience of body in action), and between his inner world and the outside world of objects and other people.  In essence, the psychodynamic therapist can fulfill many of the roles of other specialists, while keeping the meanings of the child’s inner world always in mind.  This is what I hope to do in the Cornerstone project beginning in September and what I also try to do in my own clinical practice. While I am learning more and more about ASD and PDD from current research in these fields, I don’t call myself an autism specialist, because what I am learning about these children applies and enriches my work with all my patients.


Read this blog in Spanish.