Between Their World and Ours: Breakthroughs with Autistic Children (Book Review)

Author:  Zelan, Karen 
Publisher:  St. Martins Press, 2003 
Reviewed By:  Diana Grossman Kahn, PhD, Vol. 26 (2), pp. 52-54

Psychotherapy Can Offer Young Autists What Behavioral Therapies Cannot

In Between Their World and Ours, a carefully disciplined and deeply experienced psychotherapist reports on her psychotherapeutic work of over four decades of treating autistic children. She challenges the assumption that psychotherapy cannot help autists, who can only be trained behaviorally; and critiques use of current rigid diagnostic practices, which are likely to underestimate autistic children’s abilities. The author considers current practices to be a disservice to the likelihood that autists will attain their potential. The author strongly takes issue with an influential dictum of Bernard Rimland (1993), about whom she states

[L]ong an authority on autism, {Rimland] adamantly advises parents in one of his newsletters, “Refuse psychotherapy.” .... He attributes to all psychotherapies those excesses he believes typical of failed psychoanalytic attempts to treat young autists.... Such a recommendation deprives (them) of the help they would receive should the psychotherapy be geared to their particular needs. (p.150)

Although behavioral methods hold sway in this field, Zelan’s book is a demonstration of what psychotherapy can offer autistic children. Most of the book consists of case studies of 9 autists, selected from the total of 45 autists with whom she has practiced, with specialized attunement and intense intellectual inquiry. She explains, ”The feeling of being understood—feeling tuned in to—helps the young autist adapt to society.” Having experienced a pleasurable connection in the one-on-one situation of therapy, he is tempted out of his isolation. And when he is finally willing to connect verbally, this therapeutic relationship can help him find the courage to extend himself with his peers, to be more open with his parents, and to spontaneously take responsibility for improving his social skills. Zelan demonstrates that therapy can help the autist find the motivation and the courage to continually seek new solutions to his own problems, beyond the training others can anticipate he needs. Particularly since prominent autistic defenses are withdrawal and avoidance, psychotherapy can help him be willing to risk learning and making friends.

Interestingly, these 40 years of her work have spanned great changes in knowledge of this diagnosis. Thus the author possesses a rare angle of vision and overview of theory, since she has lived through it. She is able to look back and ascertain what remains, and what has fallen away in theory. Mainly what has been superceded is blame for parents, who were inappropriately labeled “cold, or refrigerator mothers,” by psychiatrist Leo Kanner (1944) in the 1940's (p.15). In contrast, Zelan states that responsive parents are the autist's most important asset. “Far from being the cause of autism, they are unusually sensitive to their children.” She sees them as “reliable and enthusiastic partners in a team effort to evoke discernible changes in their children’s behavior, attitudes, and, especially, their feelings about being autistic” (p. xvii). Zelan demonstrates how the children are well aware that they are different, and the disdain of other children is apparent to them. Therefore therapy also must address these feelings of inadequacy.

Chapter 1, “Diagnosis is not the Person,” strongly challenges diagnostic procedures and tests which are likely to underestimate the potential of autists. She demonstrates in compelling detail how autists are lumped together diagnostically, and thereby deprived of many opportunities to develop. She discusses tests used in diagnosis that she finds problematic, misleading, and invalid. Mistakes of testing can “stigmatize [autists] as mentally deficient” when they simply do not respond to standardized test questions. Zelan reminds us of “their often oppositional, diffident, and uncooperative attitudes” (p.168), which may make procedures and test results invalid. She suggests it would be preferable to estimate IQ by behavior, qualitative means, or observation. The author illustrates this with her own vision:

Diagnosing these young people does not do justice to their individual personalities. ...Every autist I knew forged a distinctive relationship with me, and as I became acquainted with each one I almost forgot their ominous diagnoses and prognoses, often concentrating, as I would with any child, on each youngster’s special, sometimes lovable qualities.... The narratives in this book illustrate a psychotherapeutic approach aimed not only at luring young autists out of their often impenetrable isolation but also at convincing them that they are worthy of the people world. (p. 7)

The author calls for us to “re-examine and rethink our purposes in evaluating other people.” Her purpose in writing this volume is by demonstrating several autists’ breakthroughs to sociability beyond what is ordinarily predicted, she hopes to inspire changes in diagnosis, and in our visions of what they can become. Her plea is that they have a future and that they are able to develop progressively, although not precisely on the normal timetable. She suggests that instead of diagnosing what is wrong with them, we ask, “what experiences challenge autistic indifference and engage (them) in their own recovery” (p. 28)?

In Chapter 2, the author then proceeds to weave an illustrative case study, “Gregory’s Journey. Other chapters continue this case study and those of 8 other autists, taken from her notes of intensive psychotherapy. It is a summation of everything she has learned in those four decades of deeply reflected upon clinical experience. Intriguingly, these chapters are not arranged as individual case studies. Instead Zelan has undergone the labor-intensive and pedagogically more enlightening task of arranging all 9 cases thematically. She intersects parts of the case studies very effectively to show the contrasts and commonalities of each child in regard to the stages of emergence from autistic isolation that can be stimulated by therapy.

Zelan’s case studies illustrate these themes. She begins with the earliest task of making a therapeutic connection, and then proceeds in the order of therapy tasks accomplished. She addresses the development of perspective-taking, emergence of sociability and reflection to ability to take risks to develop new relationships. These case studies are informative as to how to deal with the extreme sensitivity of the autist, and to make a connection with him despite his need to protect himself from overwhelming stimuli by withdrawal. They are rich in examples of how to show a child that he is liked without overwhelming him.

The case studies clearly demonstrate how some autists think. Zelan provides many concrete examples of how a therapist can respond. She purposefully lets the reader in on her inner dialogue on what to say, why or why not, what she tries, and how it goes over with the client. Repeatedly we read how the therapist reviews a number of speculations and hypotheses she has about the autist=s statements and actions. Often she tells us that she deliberately abstains from saying her best hunch to the child, and explains why chooses not to state this interpretation, in terms of the child=s needs or defenses at that moment.

When she does make an interpretation, she reports whether it is successful or not; and demonstrates how she can also learn from being wrong. It is a pleasure to read this open retracing of the process of therapy; it is more inspiring for real life than to read a case study in which all interpretations are correct, and received with validation. Ours is an art in which it takes courage to keep trying when one can only be right some of the time. Tolstoy wrote, “God sees the truth but waits.” Sometimes better judgment leads us to wait with what we know, when that will yield a better result for the client. This is especially important with autists, who are sensitive about mind control, as well as more empowering for other clients.

Chapters 7 & 8, “Self-Revelations” and “Risking Friendship,” are the most interesting, as they show the most advanced development achieved by the author’s patients. The author documents how the therapy relationship can make it possible for the autist to be willing to reach out to others. She explains

To have a true, sensate experience of self, of feeling REAL, one must reckon with the emotional reactions to oneself of an attuned other. Otherwise the self remains underdeveloped—it might even feel “empty”—devoid of the numerous reminders of the particulars of one’s social selfness emanating from a loved, trusted other.(p. 246)

Through the developing relationship with the therapist, the children begin to report their frustrations with other children, and then they may work up courage to ask her for advice on skills to use with classmates, and to take the initiative to modify their own behavior. When the child is thus motivated, and taking the initiative, they are far more receptive than when arbitrarily assigned to "social skills lessons."

Zelan shows how sensitive young autists are to insults from others about their being different: “The idea the young autist has of himself as evil, wacky, retarded, spastic” (p. 237), impedes his being able to reach out to other children. In order to inspire him to become proactive on his own behalf, we need to help him deal with all the epithets, which have been thrown at him by peers, reified by diagnosis, and hurtfully internalized. It is this awareness on Zelan’s part that takes her beyond the formulation of Bruno Bettelheim, with whom she initially worked on her first two cases of autism in the 60's. Whereas Bettelheim had hypothesized that the children feared for their lives, Zelan explains that these children fear being autistic, with all that implies. Therefore to inspire hope that they can become different, i.e., more socially accepted, is very important in treatment.

Chapter 6, “Theory of Mind Problems,” takes a time-out from the case studies to contest the assertion that these children lack a theory of mind (Frith, 1989). As in regard to her critique of diagnosis as currently practiced, Zelan is incensed at this assertion because it underestimates autists in a way that can lead to severe impoverishment of expectations and designed programs. It seems she has inserted this theoretical chapter here in the middle of the case studies, because the reader has now read some of her evidence that autists do have a theory of mind, and she can refer to it in her argument. Thus informed, the reader will understand the significance of further evidence in the last two clinical case chapters that follow.

Chapter 10, as its title, “What to Do,” indicates, covers a full array of practical advice for parents and teachers, including some hints for therapists as to how to approach and interact with these children. “I will make specific suggestions about how to help you autistic child learn and use language, play more freely, and above all, socialize more congenially,” the author states. The first section prepares parents for diagnostic assessment, and counsels them to list the child’s assets to present to the diagnostician as well. Explicit resources are suggested, such as Autistic Behavior Checklists, including the addresses of where to send for these resources. Parents are advised to contest the evaluation and seek a second opinion if they feel that it underestimates their child.

The author discusses the importance of non-verbal communication; and she coaches parents on how to respond in such a way as to build a bridge to later verbal communication. She specifically describes how to use language aids, play, board games, pretend games, and thinking games to stimulate and make contact with their children.

Chapter 11, “Hopes for Autistic Children,” summarizes the basic approach to be taken to the autist, pointing out that the same principles apply at home, at school and in therapy. They are: 1) Understanding the nature of their withdrawal as a protection against overwhelming stimuli; 2) Recognizing the importance of hope; 3) Liking the child; 4) Setting appropriate expectations; 5) Permitting him his aloneness time, not barging in on his necessary time in his own world; and 6) Not foreclosing on their future with premature negative pronouncements. The author reprises her view of autism:

[O]ur respect for the autist’s perspective, our... empathy for his condition, is what lays the groundwork for luring him away from his private world and into the “people world.” Showing ... that we care about what he does, thinks, and feels.... helps prepare him for the idea that he is capable of participating in his own recovery. (p. 358)

She again defines the “corrective emotional experience,” of psychotherapy with these children as essentially to begin with an experience of attunement, which has as its goal not the uncovering of the unconscious, but the strengthening of the ego and the ability to live in his social world. She states.

The child who tolerates attentive empathy in individual psychotherapy—who

learns to do it—experiences or re-experiences an attunement that ordinarily reverberates between parent and small child. This is not to say that the psychotherapist functions as a mother.... Nor should a therapist baby him, return him to infantile pleasures. This is the last thing a young autist needs. Infantilizing him.... would debilitate his struggling ego. Rather, he needs to develop the social and emotional skills.... appropriate to his chronological age. (p. 360)

Zelan shows us how we can have a new encounter of psychoanalytic knowledge with
the special needs of the autist’s defensive system. Utilizing the classic concept of mechanisms of defense, we can find psychoanalysis very applicable to understanding these children. Therapist responses and techniques, Zelan shows us, can be creatively adapted and flexibly utilized for their particular defenses.

Since she believes that the best hope for an autistic child is a responsive family, there- fore she recommends that psychotherapy be focused on overcoming his social reclusiveness, and not on dwelling on his ambivalence to those close to him. She gives examples of this principle, which can be informative to psychotherapists interested in what modifications of technique will make therapy most useful for autists. Instead of interpreting symbolic fantasies, she found that “the intensity of the inner struggle seemed to abate .... as I encouraged him to feel good and hopeful about himself.” I think this is a crucial focus with the autist who feels so despised. There appears to be a resonance with self psychology approaches in this view.

Zelan’s vision of an attitude toward autistic people with appreciation of their individuality is in the tradition of humanistic psychologists such as Robert Coles, offering a larger perspective. She concludes with a plea: “If only we would focus as much on the worked-with and lived-with child as we do on the theorized and tested child” (p. 387)! She urges us not to relegate them to labels which deny their variety and potential. The case studies challenge us to reassess and to revalue psychotherapy for them—the treatment which can, if appropriately adapted, make a great difference in their lives.

Rimland , Bernard (1993). Treatments to be avoided. Autism Research Institute Newsletter..
Kanner, Leo (1944). Autistic disturbances of affective contact, Nervous Child 2: 217- 250.
Frith, Uta (1989). Autism: Explaining the enigma. Cambridge, MA: Blackwell, 1989.

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