Tag Archives: psychodynamic psychotherapy

What Does Psychoanalysis Have to Offer the Treatment of an ASD Child?


What does psychoanalysis have to offer models of intervention? There are several features of psychoanalytic theory and technique that can benefit the treatment of ASD children and their parents.

First, the training and experience of psychoanalysts is unique in that it involves developing an intimate, dependent relationship with a person in need, with the focus of attention on that individual’s inner world and also in the interaction between the two analytic partners.  This attention to what is going on in the relationship, in the moment, contributed to by both partners, and understood at a deep level – both symbolically and in the implicit and nonverbal – allows for a different kind of co-creative meaning making. I would consider this to be a unique competence of the psychoanalyst.

Second, psychoanalytic training and experience includes a high degree of “pattern recognition”, for example, an ability to recognize symbolic representations of strong emotions within relationships, and combinations and sequences of emotion and psychological efforts at self-protection or defense. Illustrations of these patterns might include a child’s remark about a tornado followed by an association to the child’s younger brother. Another example might be a child’s attempt to protect him or herself from threatening aggression coming from within by turning away from what is provoking the sense of threat or by retaliating against an imaginary external threat. Refined pattern recognition allows the psychoanalytic clinician to take a less linear approach to the treatment of ASD children in that partial or relatively incoherent symbolic representations are easier to spot and to use in understanding the child’s experience and communicated to the child. This often can be helpful even if the child is not considered to be at a level capable of apprehending such a communication according to other models.

Third, psychoanalytic training and experience requires learning a great deal about yourself, that is, about the clinician him or herself. This self-knowledge might include the clinician’s personal organizing fantasies, for example, to rescue a suffering child. It might include the stressors that challenge the clinician’s sense of him or herself, such as making a mistake or causing pain in another person.  It might also include the individual’s particular reactions to emotional challenges and the characteristic means he or she uses to deal with intense affect – to withdraw, for example, or to try to undo some perceived injury.

Psychoanalytic training also allows for a deeper and more comprehensive understanding of parents – how adults cope with stress, how they transmit early relational patterns from one generation to the other, how they grow. Psychoanalysts learn how to tolerate anguished attacks without taking them personally, how to help a suffering person move from the perception of being a victim to that of taking an active role in recovery, and how to move into a collaborative role with another in the context of threat.

Psychoanalysis “off the couch” is valuable not only to the psychoanalytically trained clinician, but to the team that treats these children. I believe that a team that includes specialists in psychoanalysis or psychodynamic psychotherapy, occupational therapy, speech, and education should treat all children with autistic spectrum disorders. Pediatricians or pediatric specialties are also sometimes needed. It is very challenging to organize a team into a collaborative partnership in which roles are clear and compatible and in which there is adequate communication, but it is possible. It is also challenging – though I also believe possible – to plan such a treatment that is affordable and not an unbearable burden for parents.

Read this blog in Spanish. 

Photograph by Ginger Gregory

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.