The role of relationship in the treatment of autism: perspectives from Relationship Development Intervention and psychotherapy – Colleen Emmens

Introduction
During the time I was studying to become a psychotherapist, one of my grandsons was diagnosed with autism. For his parents, and extended family, from the moment of diagnosis, there began a long and difficult journey, first in grieving for the ‘lost’ child, then in researching how best to treat autism. At the time of my grandchild’s diagnosis, faced with a bewildering set of choices, some claiming to be proven effective, others with unproven promises of magical cures, his parents decided on the most accepted mainstream treatment of a behavioural approach. This is where skills are taught and problem behaviours are targeted.

From the start, these parents found this approach unhelpful in achieving what they wanted, which was to feel connected to their child. By chance my daughter came across a programme called “Relationship Development Intervention”(RDI) (Gutstein, 2000). She was excited by what she read, and although RDI was only about twelve years old at the time, its developmental, and relational approach made sense to her. For me, the RDI programme was intriguing, as it felt a match with the developmental theory and psychodynamic theory I was studying at the time. The opportunity came for me to go to Houston and study RDI, so I ended up studying and working with both psychotherapy and RDI alongside each other.

What I want to do here is to demonstrate why I believe psychodynamic theory has a lot to offer a clinical understanding of ASD. First I will introduce Steven Gutstein, as the founder of RDI. I will then describe an aetiology of autism, in the light of modern research, compared to a brief psychodynamic history, and followed by what autism is. I will summarize the work of Peter Hobson, a researcher and psychoanalyst at the Tavistock who has studied autism for 25 years, and whose studies are at the fore-front of autism research, and from where much of Gutstein’s clinical ideas spring from. Finally, I will compare this work with psychoanalytic theory.

Gutstein and his work
RDI is the result of the work of Dr.Steven Gutstein. He earned his Ph. D. in clinical psychology from Case Western Reserve University. From 1979 to 1987 he served as an Assistant Professor of Psychiatry and Pediatrics at Baylor College of Medicine and the University of Texas Medical School, as well as being director of Pediatric Psychology for Texas Children’s Hospital. He is a founder, and is currently the director of the Connection Center, which is the centre for RDI.

Gutstein describes a lonely childhood during his mother’s cancer and following her death (Gutstein, 2000). He describes feeling like the “eternal guest, tolerated and even welcomed, but always excluded from deep emotional connections” (Gutstein, 2000 p.xvi). In his academic life his passion has been in providing for others the experience of emotional connection. He believes in a capacity for emotional intimacy, no matter what the obstacle. In encountering autistic children he felt a kinship, where, “these individuals, for entirely different reasons were perpetual outsiders in the world of emotional encounters” (Gutstein, 2000 p.xvi).

What you might see
A three year old boy is sitting on the floor at Play-centre, engrossed in a game with train-tracks. He makes no attempt to play alongside or with other children, in fact he appears oblivious of their existence. If you sit beside him you find he is able to talk, but nothing in his talk is about communicating. Instead, he recites whole books, verbatim, to himself. If he hears a spoken word that reminds him of a book he knows, he switches to reciting that whole book. As a baby this child never pointed at things, or brought things to a caregiver to share. He never responded to his name, or used ‘checking’ behaviour with his Mother. He loved to be kissed, and would push his cheek into others’ faces and smile, but never with any shared eye contact. At two, he knew all his numbers, and appeared to know the value of these. He knew letters, and was able to read many logos, which he was obsessive about. This child, with his strange combination of talents and deficits, is autistic.

Aetiology of autism
The current overwhelming evidence is that autism is a global, neurological disorder that likely has multiple causes interacting in subtle and complex ways. (Gastgeb, Strauss, & Minshew, 2006; Mesibov, Adams, & Schopler, 2000; Minshew, Goldstein, & Siegel, 1997; Volkmar, 2000). Gutstein describes how a consensus has been reached by prominent researches, that autism is a “…neurologically based informaton processing disorder which impacts those on the spectrum in very specific ways, regardless of their IQ or language abilities” (Gutstein, 2006, p.2).Minshew, a professor of psychiatry and neurology at the University of Pittsburg, who has spent the last twenty years researching autism, and Marcel Just, (Carnege Mellon University), describe the disorder as a common, heritable neurodevelopmental condition with complex genetic architecture (Minshew & Williams, 2007; Just, et al, 2006) According to these, and other researchers, autism results when the brain fails to form the ability for flexible collaboration (called connectivity) between different brain centres. That is, separate parts of the brain can work perfectly in isolation. In a non-autistic person, it is this neuroconnectivity that provides the opportunity for flexible and original and integrated responses to the environment. The brains of ASD people don’t form collaborative relationships as they develop, instead, unconnected, discrete processing centres are strengthened. The natural course of autism is to get worse over time.

Historical Psychodynamic Aetiology
Leo Kanner, the child psychiatrist, who first described and named autism in 1943, originally believed that these children had an “…innate inability to form the usual, biologically provided affective contact with people” (Kanner, 1943, p.250). Donald Meltzer and his colleagues, who offered an intrapsychic view of infantile autistic psychosis, believed it to be related to depression in the mother, with the child not wanting to further burden their depressed mothers, and so dismantling their dependency aware egos (Meltzer, 1975). Alice Miller, who wrote about child abuse and its consequences, believed these children had experienced a history of suffering (Miller, 1991). Francis Tustin, a psychotherapist who spent a great deal of her life working with and studying autism, described autism as “…an early developmental deviation in the service of dealing with unmitigated terror” (Tustin, 1991, p.85). Tustin saw autism as a survival mechanism against a massive traumatic awareness of body separateness. In Contrast, Klein and Mahler saw autism as “constitutional”, or in-born. Melanie Klein described a little boy, Dick, who appears to have been autistic. She wrote that he had “…a complete and apparently constitutional incapacity of the ego to tolerate anxiety…” …” (cited in Hobson, 1990b, p.326). Later, Mahler describes how “the catalysing mothering agent for homeostasis, is inborn, constitutional, and probably hereditary…” (Mahler, 1968).

Kanner later changed his mind, to follow what became the prevailing view of autism, from the 1950s through to the 1970s, largely created by Bettelheim, where autism was thought to have been caused by mothers who were emotionally cold (Bettelheim, 1967). This view has not stood the test of scientific scrutiny. Susan Epstein, suggests that a psychoanalytic view of blaming mothers for causing this disorder in their children, although now seen as having been a cruel and unwarranted mistake, did at least accord some hope that it could be cured, and a fully functioning child could emerge (Epstein, 2000b). However, she suggests that “…historical efforts to explain and cure autism were not the psychoanalytic tradition’s finest hour” (Epstein, 2000a, p.746). She talks about the danger of attempting to fit phenomenology to theory.

In a paper written in 1990, Peter Hobson has reviewed some of the psychoanalytic approach’s ‘credentials’ in thinking about autism (Hobson, 1990b). His aim was to “challenge a more or less prevalent view that psychoanalytic approaches to autism are so fundamentally misconceived as to merit outright rejection” (Hobson, 1990b, p.324). In doing this, his hope was to examine what was of value in a psychoanalytic view.

I want to suggest that in fact Hobson is right, and psychoanalysis does have a major contribution to make in the understanding of, and clinical approach to autism, and that it is psychoanalytic understandings that hold the key.

Theory underpinning much of psychotherapy, would suggest that the kind of ‘wiring’ that is needed for a person to become able to communicate and operate in a complex and dynamic society, occurs in the earliest months and years between a child and their caregiver, beginning soon after birth. We can think about Winnicott’s statement , that there is no such thing as an infant…(1958, p.xxxvii). As a diagnosis of autism is usually not conclusive before a child is well into his/her second year, these neural pathways will already be impaired. For these children, the reasons that we form relationships, the enjoyment of connection and interacting, are not there. Autism is a disability that is defined by a deficit in the essence of relating, closeness and connection. RDI aims to bridge the gap between modern research and clinical practice, in order to ‘reconstruct’ the early foundations that are a prerequisite for success in real-life situations, such as having friends, a partner, and satisfying work. The pathway is a relational one, there is no way to ‘train’ or ‘drill’ children to have appropriate feelings and understanding of relationship. (Hadwin, Baron-Cohen, Howlin, & Hill, 1996; Hadwin, Baron-Cohen, Howlin, Hill, 1997).

What is Autism?
Autism is a pervasive developmental disorder, which shows qualitative impairments in social interactions, imaginative activity and both verbal and non-verbal communication skills. Children with autism tend to have limited interests and activities, and these are ritualised and stereotypic. They have a desire to maintain sameness in their routine and surroundings. Symptoms appear within the first three years of life (Kabat, Masi, & Segal, 2003).

According to Peter Hobson, autism is the “developmental outcome of profound disruption in the usual patterns of intersubjective coordination between the affected individual and others” (Hobson & Bishop, 2003, p.342). Hobson’s theory of intersubjectivity, suggests that without emotional involvement with other people, “…the whole of mental development is terribly compromised” (Hobson, 2002, p.183).

The fact that people with autism do not have these strong emotional pathways in no way distracts from their need for emotional and relational connection, they are still human beings, with the same universal needs (Gutstein & Sheely, 2002).

In their studies, Hobson and his colleagues describe autism as being like a photographic ‘negative’ of normal development, and see it as a chance to simultaneously study “how, in normal development, a young child’s engagement with other persons influences the development of their sense of self” (Hobson, Chidambi, Lee, & Meyer, 2006, p.vii). Hobson demonstrates with careful and detailed research, how children with autism do not have the same degree of shared, involved feeling with others. Someone else’s smile or delighted voice does not give them a feeling of warmth (Hobson, 2002, p.14). This manifests in their being less engaged with others, so that they are oblivious to what others might feel about their achievements, or of others’ attitudes towards them, or to a shared world. They are not so able to ‘read’ and therefore use, the facial expressions and body language of others to make sense of their own world. Although they are able to imitate others, Hobson and his colleagues have shown that they rarely imitate the style or tone of the actions of others, which suggests a reason for their relative lack of guilt or empathy. Hobson writes that “…this compromises their propensity to adopt and conceptualise person-anchored perspectives” (Hobson et al., 2006, p.153).

How Steven Gutstein views autism
What Gutstein came up with was an understanding of autism as consisting of areas of ‘core deficit’ that are present in every person on the autistic spectrum, (although there are individual differences within this) and which result in impaired social and emotional function, and the huge obstacle to quality of life, that is autism (Gutstein, 2000; 2004;2005 ).

Declarative (experience sharing) communication
Gutstein (2000), drawing on the work of Camaioni, (1997) distinguishes between two kinds of communication, declarative and imperative. Declarative is the kind of language we use to share experiences, our ideas, feelings, goals, intended actions, predictions, memories, plans etc. An imperative form of communication is what we use as a ‘means-to-end’; for example, acquiring information, testing or demonstrating knowledge, asking for someone’s service etc. Declarative language often has a rich non-verbal component and invites a type of response from the other which is never rote or scripted. Autistic people have an inability to share their experiences and feelings, so use little or no declarative language.

Referencing
Referencing refers to the ability to ‘borrow’ another’s perspective, in order to help resolve uncertain situations, or to find reassurance. We might check out if the other is approving or disapproving, or if they are finding us boring or interesting. People who are autistic are often able to learn to recognize and label various facial expressions, but they are not able to ‘borrow’ or ‘read’ the other’s perspective during an interaction (Gutstein 2000).

Regulating
Gutstein (2000) describes the back-and-forth ‘dance’ in interactions with others. This dance is always spontaneous, unpredictable, and reciprocal. Autistic people can learn to follow procedures and scripts, but not to ‘dance’ (Gutstein 2000).

Episodic (autobiographical) memory
Autistic people may have very good or even excellent procedural memory, but lack autobiographical, or episodic memory. This is very different to remembering details. It involves extracting from memories what is personally meaningful to the self, and using this to reflect on the past and anticipate the future. This allows us to avoid negative consequences, and repeat positive ones (Gutstein 2000).

Flexible thinking
Autistic people are able to understand rule-based, black-and-white thinking, but are not able to adapt their thinking quickly, accept what is ‘good enough’ or see grey areas. They struggle when it comes to being able to ‘go with the flow’ if plans change, and find it difficult to adapt to these changes (Gutstein 2000).

Hobson’s work
Hobson’s ideas follow on from a prevailing opinion that babies are born pre-programmed to acquire cognitive function and language. Hobson believes (along with a lot of psychotherapy theory) that this capacity develops through the baby’s interaction with other people over his/her early months and years of life. He views emotional engagement between the baby and caretaker as the vital part of mental development, and sees autism as a neurological condition that demonstrates the profound impact of what happens when this interaction is inhibited (Hobson, 2002).

Hobson arrives at his theories via several routes. The first of these is a clinical method of observation. For example, he cites the careful observations of Kanner’s early descriptions of autism, and the essence of detachment and inaccessibility of an autistic child.
To broaden the picture Hobson turns to experiment. By setting carefully designed tasks for groups of children with autism, and matched groups without autism, the picture becomes clearer.
In a third approach Hobson looks to psychoanalysis, which has a primary concern with “…the close connection that exists between what happens within an individual person’s mind and what happens between one person and another” (Hobson, 2002, p.22). Hobson credits this avenue as “casting light” on the kind of mental functioning that his observations and experimentation around autism have revealed (ibid). Hobson sees psychoanalytic research as responsible for alerting us to the developmental importance of the role of the caregiver in an infant’s ability to think.
Hobson sides with the view that the mother and infant are mutually engaged with each other in a genuinely reciprocal way; that is, they both modify their own reactions according to feedback from the other. For example, a baby may be delighting in the anticipation of a game of peek-a-boo, and smile towards a mother, in a way that suggests “we are sharing this” (Hobson, 2002, p.43). Hobson sees this kind of early communication as “providing a kind of scaffolding for the introduction of language itself”(p.43).

Hobson suggests that although autism is rarely diagnosed within the first year of life, there are possibly clues before this that something in a baby’s development is awry. Recorded interviews with parents have shown that those infants who were later diagnosed as having autism, showed less greeting and waving, less raising their arms to be picked up, and they were less liable to direct anger and distress towards people. They also failed to point at objects to share, or to bring an object to an adult to share.
Whereas typical babies are emotionally connected to people, and play their role in the communicative ‘dance’, for autistic children there is “something profoundly lacking in their orientation towards people…and… in their emotional engagement” (Hobson, 2002, p.59). It is against a backdrop of autism, Hobson believes, that we can understand the richness of what normal development entails.

He further suggests that we develop language “in order to affect the hearts and minds of others” (2002, p. 85). For autistic children, who do not “relate to the world-according-to-the-other” (p.88), there will likely be deficits. In fact, many children with autism never learn to talk, and Hobson observes that if the purpose of language is to communicate and share, for them acquiring language may appear pointless, except maybe in a simple form as a way of getting needs met. When they do acquire language in a more sophisticated form, autistic people have an oddness, in that they tend to understand only literal meanings, and fail to pick up on the subtleties of what the speaker really means.

In his research, Hobson compares autistic deficits to other barriers in communication. He explores what happens when mothers who are diagnosed with borderline personality disorder relate to their infants. Hobson found that these mothers were “less sensitive and more intrusive towards their infants than were the other mothers” He believes that the vital importance of interpersonal relationship, and its impact on the developing mind has been overlooked until recently (except among psychoanalysts).

Hobson also explores the case of congenitally blind children, and the curious frequency with which the clinical features of autism occur in these children (Hobson, 2002, Hobson, 2003, Biship, 2005). Hobson found that even for those children who were blind and did not show autistic features, their engagement with people was still severely affected. They had “the kinds of difficulty in social engagement that are typical of autism” (Hobson, 2002, p.192). Hobson concludes that this study provides further evidence on the serious nature of barriers in personal relations.

Similarly, in examining the findings of Michael Rutter (et al., 1999) of infants exposed to the terrible conditions in the orphanages of Ceausescu’s Romania, Hobson found that the appalling treatment of these babies, and the subsequent adoption of some of them into caring homes, revealed some unexpected findings, which dovetailed his own research with blind children, that this level of deprivation led to behaviours that were characteristic of autism (although these children also displayed behaviours a-typical of autism, such as making spontaneous efforts to communicate).
His hypothesis of autism as an intersubjective deficit, that happens between an affected person and others, accounts for the findings from these studies, as well as indicating the essential role of intersubjective experience in a developing self.

Hobson believes that “thinking cannot become a flexible and creative medium for human intelligence without passing through the minds of others” (2002, p.210-11). A vital part of experiencing oneself as a person is to feel a person among others. He writes: “In the course of our social interactions, each of us is pushed or pulled or nudged or drawn or wrenched towards the psychological position of the other”(ibid).
A part of this emotional responsiveness occurs in the action of “imitation”. Hobson believes it is the propensity that young children have to imitate their parents, that is “basic to our intellectual prowess” (Hobson, 2002, p.215). Hobson (et al’s) many experiments have demonstrated that although autistic children can easily imitate an action, they are not able, or moved, to imitate the quality or the style in which the person performed the action (eg. was it gentle or rough?) Matched groups of non-autistic children automatically did this.
This has implications for developing an understanding of a self. If a child is unable to identify with the characteristics of someone, and make them their own, they are unable to access a vital process that is happening all the time, and which involves continuous shifts into the roles and attitudes of others.
In spite of this, many autistic adolescents have “a very painful and moving awareness that they are not like other people” (Hobson, 2002, p.226). With the understanding that typical adolescents are “deeply preoccupied with how they compare to their peers” (ibid), Hobson and his colleagues administered an interview to two matched groups. Their results showed that although the group without autism, but with mild retardation, describe themselves as part of a richly social world, autistic adolescents did not describe themselves in the context of their relationships. Hobson believes that without a propensity to take on the attitudes of others, a process involving identification, we cannot “acquire the special human form of self-reflective awareness” (p.238). Hobson concludes that

An implication is that facilitating the development of communicative skills among
individuals with autism may involve more than teaching specific forms of behaviour, and
instead require a focus on affective relatedness in order to foster more person-centred
engagement (Hobson, Lee, & Hobson, 2007, p.329).

.
Gutstein
In his first book, Gutstein (2000) describes his dissatisfaction with the results he was achieving in his work with autism. Although his patients made good eye contact, were tolerated by their peers, and received excellent grades for conduct, it felt as if something very important was missing.

Even for these highest functioning children, their abilities were not enough to have a real caring friendship with another child…None could, on their own, maintain the topic of his conversation with a pal, or share a tender moment. Some key element was missing that kept them from learning the critical parts of friendship
(Gutstein, 2000, p.xvii).

Gutstein began studying and consulting with world experts in the fields of child development and neurology. One of his fundamental discoveries was the difference between what is called instrumental interactions, and those which are referred to as experience sharing. His research showed that Autistic Spectrum Disorder (ASD) people could function well for instrumental purposes, (where interaction serves as a means to obtain a desired object or outcome), even displaying behaviors usually considered missing in people with ASD, such as eye contact and showing affection (Gutstein, 2000).

Experience sharing involves sharing a part of oneself with a partner. It is the reason we desire and enjoy the company of others. Gutstein concluded that what he had been working on with his patients was an instrumental style of development, and what was being left out was experience sharing. Referring to Hobson’s work, Gutstein began to understand autism as a range of neurological disorders that children are born with, which “…collectively interfere with the type of information processing that makes Experience Sharing so simple for the rest of us” (Gutstein, 2000, p.xix). Autistic people are not able to link their own feelings and experiences to the continuing stream of emotional information that surrounds them. This limits their capacity to perceive others’ emotions, or to enjoy and participate with others in a meaningful way.

Realizing that social skills were still being taught in an instrumental way, Gutstein returned to the literature, believing that an effective clinical treatment would parallel typical children in the way they develop this capacity. Working alongside his wife, Dr. Rachelle Sheely, (also a Ph.D. in Clinical Psychology, with a primary interest in autism), Gutstein created RDI.

Relationship Development Intervention (RDI)
Rather than providing instruction in skills, RDI is designed to engage the child with a parent in on-going interactive ways, which are fashioned to follow a progressive developmental path. Psychotherapy theory might refer to this as empathic attunement (Kohut, 1977). Prior to beginning this work, there is a careful assessment, over several days, to ascertain where the child might be on that pathway, their particular strengths and limitations, and the parents’ strengths and obstacles.

An emotional feedback system
Competence in experience sharing is something which happens in a gradual systematic fashion in typical development, with mastery of early abilities being the springboard for new challenges (Hobson, 2002; Rogoff, 1990; Sroufe, 1995). For typical children, there is parent-infant emotional feedback, which helps parents regulate this sequence (Fogel, 1993; Sroufe, 1995; Tronick, 1989). However, with ASD children, there is an absence of this emotional feedback, so that parents are unable to gauge their infant’s emotional state, and the infant is unable to use or interpret their parent’s emotional expressions.

RDI teaches parents to use simple activities to promote this feedback system. For example a parent might use a gentle rocking game such as ‘row-your-boat’. A client, Anna, had become adept at building shared anticipation, with her child, Sam. In games of ‘ring-o-roses’ on the trampoline, she delayed the “all-fall-down” until Sam, glanced at her exaggerated, wide-eyed smiling face. Eventually, after many games like this, he had an almost matching expression on his own face, until they fell down together. In their daily life, Anna included Sam in simple activity, such as helping her carry the laundry basket to the laundry and put the clothes into the machine. She was able to build anticipation around holding up clothes and dropping them in. As Sam’s understanding about the world developed, she pretended to drop in something silly, eg a cup or a saucepan, and they laughed together about how silly that was. All of this was about their becoming an ‘us’, not about getting the laundry done efficiently!

Apprenticeship in co-regulation
Parents of typically developing children act as, what Gutstein (2005) calls “senior co-participants in interactions with their children” (p.9). They carefully regulate the degree of support their child needs to participate with them in an activity, so that both experience enjoyment and success. They allow them just enough of a role. ASD children fail to master this co-regulation system. RDI teaches parents to “…carefully pace their demands for co-regulation…” (Gutstein, 2005,p.10). They need to ensure that their child is maintaining their on-going social referencing, while supporting their children in developing a sense of self efficacy, and to share in social interactions. Success in this motivates children to want to be co-participants in these encounters.

Sam’s Dad would spend time playing simple ball games with Sam. At first Sam would get the ball and run off with it, but a few months later, he was very much part of the game, he knew his role, his siblings were included, he could follow the rules, and there was look of delight and competency on his face. There was no longer any suggestion of him running off with the ball.

Participating in dynamic systems
Social relationships involve constant changes and challenges, with new information creating a disruption to a child’s existing cognitive state. Typically developing infants thrive on this variety and benefit from it, using it to develop more sophisticated ways of understanding and organizing their experiences. For example, they adore playing games such as ‘peek-a-boo’. ASD children do not want to play these games and lack the ability to take part in activities where there is change and novelty. Rather, they seek static, predictable activity where they know what will happen. (Video and computers are examples of static and predictable activity, and many ASD children are obsessive about these).

A particularly delightful game Anna invented involved Sam sitting on a ledge that divided their lounge and dining room. Anna sang a chant, while holding both his hands,

“Here’s my little Sam
sitting on the ledge
I think he wants a ….”

At this point Anna would say, after a pause to build anticipation, “kiss” or a “hug” or a “tickle” or a “raspberry” (etc) and would act out the action. The game ended with a “fall down” where she gently pushed Sam so that he fell onto the sofa amidst great hilarity. During this game, there were many shared excited glances. It contained enough predictability to keep Sam feeling competent, and therefore engaged, while introducing unpredictable changes. I was delighted to watch how engrossed Sam was in the game, as tolerating these differences is a real sign of progress. It was at this stage, I believe, that Sam began to understand that it was more rewarding to be involved in a game with his Mum, than a game by himself.

RDI parents learn to add these unpredictable moments in small, manageable amounts, usually into known games, then gradually to build this up, allowing the child the opportunity to take this up and become an active participant.

Developing declarative communication
ASD children tend to almost exclusively use an ‘imperative’ form of communication, which is instrumental, that is, directed towards having one’s needs met. Typical language consists of a larger proportion of ‘declarative’ language, (around 80%) which is language that shows an intent to share with others something of one’s experience (Camaioni, 1997; Tomasello & Farrah, 1986).

RDI parents learn to emphasize a declarative language style, and to slow down and simplify their language to enable their child to process what they have said and think about their reply. Parents are taught not to over-talk, or use prompting techniques such as questioning to elicit responses from their children. eg. Instead of “Pick up your bag”, they might say, “Uh-oh, your bag is on the floor!”. And instead of “Go and clean your teeth” they might say, “Yuk, your teeth are really dirty”.

Constructing optimal learning environments
Without the advantage of having mastered the foundations of experience-sharing in their infancy and toddler years, children with autism are hugely vulnerable to objects and activities in their environment that distract them and compete with social partners for their attention

RDI parents learn to simplify their environment, as well as the general pace of everyday life. There needs to be time throughout the day to practise their newly emerging experience-sharing skills. Gradually, parents are able to increase the amount of environmental ‘noise’ to a level that is more like the real world.

RDI Theory and Psychotherapy
Because RDI is built on a relational model, my argument is that it has many parallels within psychoanalytic theory, and that many of the concepts that are proving to be useful in an effective clinical treatment are fundamental concepts in psychotherapy.

I see an essence as being similar to an object relations view. In object relations theory, the self is seen to exist only in relation to other selves (objects), which may be internal or external. Internal objects are formed from early interactions with parents, for which infants are ‘hardwired’, and the patterns of these interactions are what form the “prototypes for all later experience of connection with others” (Mitchell & Black, 1995, p.116).

The famous Winnicott statement, that “There is no such thing as an infant, …wherever one finds an infant one finds maternal care, and without maternal care there would be no infant” (Winnicott, 1958, p.xxxvii), feels at the heart of this work. Because an autistic child is unable to make use of maternal care (Hobson, 2002), it is almost as if there is no infant.

William James described an infant’s reaction to the world as a “booming buzzing confusion” (cited in Modell, 2005, p.556). From an object relations view, a human infant is predisposed to respond to this environment and to find meaning that shapes their world, in the affective responsiveness of its caregivers. I argue, that because the autistic child is unable to make use of the care-giver to navigate their world, (Hobson, 2002), that they remain in a state of anxious confusion.

In RDI, it is recognized that before we can begin work on the developmental objectives, it is necessary to establish an activity, or activities that will function as a soothing phenomena for these children. For example, with Sam, we invented a gentle rocking game, that we called ‘Tick-Tock’ where he lay on the floor and Anna held his legs and rocked them side to side. The game had a simple repetitive chant, and this became a reliable way to sooth. In RDI this is referred to as “regulation”, but I also think of it in terms of what Winnicott called, “transitional phenomena”. Winnicott said that transitional phenomena, “…shall exist as a resting-place for the individual engaged in the perpetual human task of keeping inner and outer reality separate yet inter-related” (Winnicott, 1953, p.90). He observed that sometimes a tune could act as a transitional phenomenon, (cited in Roiphe, 1973) and it was as if the familiar, rhythmic, dependable chant and actions, became associated with comfort from his mother, and so therefore “…a defence against anxiety” (Winnicott, 1953, p.90).
For Winnicott’s client, and for my client, it was as if this resting place allowed him the space to engage in the task of beginning to relate to his Mother and his world. Winnicott referred to this as the “potential space between the individual and the environment” the use of which is determined by early life experiences, and that having this space is dependent on “experience which leads to trust” (Winnicott, 1967, p.370-72).

Hobson described how the infant is disadvantaged when caregivers are less able or willing to engage with an infant. With an autistic child, it is the other way around, in that it is the child who is less able to engage with the parent. However, the end result is the same, in that there is an absence of “experience leading to trust”. In our work with this client, being able to establish this simple, calming rhyme, was the beginning of trust. From this point we could move on towards “playing”.Winnicott said of play, that it is:

universal, that it belongs to health: playing facilitates growth and therefore health; playing leads into group relationships; playing can be a form of communication in psychotherapy; and, lastly, psychoanalysis has been developed as a highly specialized form of playing in the service of communication with oneself and others” (Winnicott, 1971, p.41).

In working/playing with autistic children, there is not a natural flow of play, we need to pay attention to detail in a concrete way, in order to facilitate the kind of responses that are easy and natural for non-autistic children. Progress in the beginning is slow and involves a huge investment of emotional energy and commitment. As children become more connected and begin to enjoy being actively involved with a parent, there is a feeling of connection and “play”. From this point, as Winnicott says, “there is growth, and therefore there is health” (ibid).

Winnicott saw the ability to “use the object” as being related to this capacity to play. However, he believes that this is not inborn, but is dependent on a facilitating environment. “To use an object the subject must have developed the capacity to use objects” (Winnicott, 1969, p.713). He describes a maturational sequence, where first there is object-relating. In object relating the object has become meaningful, but “the experience of the subject is of an isolate” (p.712). Next, there is “the most difficult thing…the subject’s placing of the object outside the area of the subject’s omnipotent control…in fact recognition of it as an entity in its own right” (p.713).

This sequence defined by Winnicott feels to have a parallel in RDI. In the beginning we strive for brief moments of connection, which we recognize in the shared excited glances that gradually begin to occur as anticipation builds in games like ‘peek-a-boo’, or in shared “One-two-Three…, GO” games. When this begins to happen regularly, it feels as if we have achieved ‘object relating’, and that the parent is now meaningful to the child. With this established, we then move towards Winnicott’s “most difficult thing…” and RDI’s dozens of carefully crafted tiny steps that make up a “facilitating environment”, and which need to happen before there can be “object use”.

Winnicott wrote that, for certain patient groups (borderline), there needs to be a concern with the development of a capacity to use objects He describes the ‘joy’ of allowing a patient to arrive at creative understanding, by waiting rather than attempting ‘clever’ interpreting (Winnicott, 1969). He believes that for interpreting to have an effect, the patient must have the ability to use the analyst, and that in our work we need “to be concerned with the development and the establishment of the capacity to use objects and to recognize a patient’s inability to use objects when this is so” (p.711).

Modell describes the means by which a patient is “raised to a higher level of relatedness” as depending on both the patient’s strengthening of self, and the ““borrowing” of the analyst’s consciousness” (Modell, 1990, p.122). Modell refers to Sterba’s contribution to this concept of “borrowing”, stating that the “analyst serves the learner as a vicarious form of consciousness until such time as the patient is able to master his own consciousness” (p.124). Similarly, Anne Alvarez, a child psychotherapist at the Tavistock, has suggested, that for very depersonalised patients, the therapist may have to carry the feeling, and that it does not matter who has the feeling first, that the patient may be testing whether or not it is safe to have feeling states at all (Alvarez, 1993, p.117). These concepts feel like a match to RDI, where we encourage parents in the beginning to have their own emotional responses alongside their autistic child, rather than attempting to illicit a response from the child.
I argue that for some patient groups, a facilitating environment would have some resemblance to RDI, in that there is a need for something new to grow. In RDI this capacity is being built from the beginning, and although the techniques used cannot directly apply to psychotherapy clients, there is still an important reminder of a maturational sequence; that is, that object use cannot occur before there is a foundation of object relating, and a “gradual build up of the individual’s capacity to play” (Winnicott, 1969, p.711). In her work, Alvarez has suggested that sometimes, rather than thinking about “helping patients reintroject parts of themselves “…something may need to grow for the first time” (Alvarez, 1993, p.120-21). In its relational approach, and intricate developmental steps, first towards what could be described as object relating, then towards object use, I argue that RDI is adding support to Winnicott’s theory, and to Alvarez’s observations.

An intersubjective view
While object relations theorists have observed the primacy of personal relatedness, intersubjective theorists talk about a dynamic systems theory, which works towards illuminating interweaving worlds of experience. “For us an intersubjective field – any system constituted by interacting experiential worlds- is neither a mode of experiencing nor a sharing of experience. It is the contextual precondition for having any experience at all” (Orange et al 1997, cited in Stolorow, Orange, & Atwood, 2001, p.371). Stolorow describes an “embeddedness” of an individual’s world “with other such worlds in a continual flow of reciprocal mutual influence” (Stolorow, 1997, p.338). This is a fit with Gutstein’s understanding of the back-and-forth dynamic ‘dance’ of relationship as always spontaneous, unpredictable, and reciprocal. .Autistic people, although they can learn to follow procedures and scripts, are not able to ‘dance’.

Stolorow views the child-caregiver system as fundamental in the organization of a child’s experience (Stolorow, 1997, p.339-340). Jessica Benjamin describes how “very early on we find that recognition between persons – understanding and being understood, being in attunement – begins to be an end in itself. …By our very enjoyment of the other’s confirming response, we recognize her or him in return” (Benjamin, 1990, p.37). She describes the development of a “capacity for mutual recognition” (p.37). As a child begins to recognize a mother’s subjective experience, she/he moves from a “retaliatory world of control to a world of mutual understanding and shared feeling” (Benjamin, 1990, p.40). Similarly, Fonagy describes how it is “the consequence of being active observers of the functioning of other minds as well as being the subject of their observation” that we become aware of our own subjective state (Fonagy, Steele, Moran, Steele, & Higgit, 1993, p.982).

These descriptions of Stolorow, Benjamin and Fonagy reflect what Gutstein and Hobson describe as missing in autistic people. Referring to Hobson’s work, Gutstein explains how the capacity of autistic people to enjoy others is limited by their incapacity to link their own feelings and experiences to a continuing stream of emotional information.

RDI, psychoanalysis, and understanding autism
Throughout this paper. my central argument has been that RDI could be interpreted as a psychoanalytic approach, and that it is psychoanalysis that has provided the necessary theory and research to support a programme that aims to make the kind of cognitive changes needed to allow autistic people a quality of life.

In RDI there is a similar profound respect for the child-caregiver system that is an integral part of much psychodynamic understanding. RDI implements this belief in working to empower parents to be the therapists for their child. In comparison, for a psychotherapist, even with their knowledge of a relational and empathic system, the tiny amount of time they could spend with a child would be insignificant in light of their enormous deficit and need. In RDI there is a complete ‘re-do’ of the early years, and Gutstein has suggested that there are thousands of hours of time to be made up (Gutstein, 2000). RDI equips parents with the knowledge and skills to parent their child. It has been my privilege in working with these families to witness the “joy” that is part of their reconnecting in a relational way to their children, which reminds me of the joy that Winnicott talked about. I see a parent’s absolute delight when their autistic child begins to ‘nag’ in the ‘annoying’ way that non-autistic children do, for their parent’s attention, with that robust, insistent, “Mum! Mum!…MUM!!” Their joy at seeing their child become curious about other children and want to play, to see the beginning of empathy when another child is upset, and their child makes appropriate attempts to help, and to see their child want to share their own triumphs. An RDI parent becomes acutely aware of the experience and feeling of connection, and of these mile stones which go un-noticed in the development of a non-autistic child. It is deeply moving to watch video of these families working with their child, and witness child and parent revelling in each other’s company.

In contrast to earlier mother blaming psychoanalysts, Hobson’s (2002) work has been guided by an understanding of autism as a neurological disorder. Although he has not been involved in the development of a clinical programme, his detailed and extensive research, and multi-disciplined approach have yielded crucial insights into the disorder, which Gutstein has been able to take up in the development of RDI. These studies are on-going, with recent research suggesting the vital importance of imitation and identification in typical development. Interestingly, Freud said that “ a path leads from identification by way of imitation to empathy, that is, to the comprehension of the mechanism by means of which we are enabled to take up any attitude at all towards another mental life” (Freud,1921, p.110, fn 2).

In both psychotherapy and RDI, there is a fundamental recognition of the nature of how real communication “involves affecting and being affected by someone else” (Hobson, 2002, p.259). In Fairburn’s words, “what man seeks most deeply is emotional contact with his fellow human beings” (cited in Symington, 1986, p.238). Gutstein’s belief in this capacity for emotional intimacy, no matter what the obstacle, has been the compelling force behind his life’s work in confronting the deficits of autism.

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My name is Colleen Emmens I have been a primary school teacher for most of my life, where I developed a specialty area in early literacy and in working with young teachers. Later, after a gap of ten years at home having become a mother of four children, one of whom had ASD, I became passionate in working with what could be described as children at risk of ‘falling through the cracks’ of the school system. As my children became teens and adults, I began further part time study in related fields, and following a teaching stint in Asia for two years, decided to return to university where I completed a Masters in Health Science, majoring in psychotherapy. During this time, one of my grandchildren was born severely autistic, and through this, began my interest in autism, and my study to become a consultant in a programme called Relationship Development Intervention, or RDI. I am constantly struck by the parallels between working with RDI and with psychotherapy, and the power that relationship has to heal. I also believe that autism demonstrates what psychotherapists know, that is how vital the role of relationship is in normal development. I now work both as a psychotherapist, and with families affected by autism.

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8 Responses to The role of relationship in the treatment of autism: perspectives from Relationship Development Intervention and psychotherapy – Colleen Emmens

  1. Mensch says:

    Fascinating stuff. Is there a website for RDI in New Zealand?

    Also, is autism being over- or mis-diagnosed these days? What are some of the common mistakes people make when classifying all and subdry as autistic spectrum?

  2. Colleen Emmens says:

    Hi, thanks for your comments. The website in NZ is our website, http://www.pathwayprogrammes.co.nz. It is currently in need of some work, which we are doing, but haven’t finished. RDI is constantly changing as more and more work and research is done. The web site for RDI itself is http://www.rdiconnect.com

    I think diagnosis is an issue, it can either missed, ie not diagnosed, or diagnosed as an anxiety disorder, or some other mental health problem, especially at the high functioning asperger end: or sometimes mis-diagnosed. My only experience if a mis-diagnosis was with a child who had been born with a severe visual impediment, which is something that Hobson draws attention to. Generally, though, the deficits in ASD are very distinctive.

  3. A reader says:

    This is fascinating stuff.

    Let me see if I understand correctly.
    1. Autsim is about neurological deficits.
    2. These deficits mean that the autistic cannot relate to another person.
    3. RDI has figured out ways to repair those deficits by encouraging the development/growth of the deficient neural pathways.

    If that’s correct, it occurs to me that behavioural treatments might be barking up the wrong tree. (To mix my metaphors) behavioural work might be making the rich (imperative) richer and leaving the poor (declarative) as poor as before!

  4. Colleen Emmens says:

    YES! We now understand that the imperative path is generally not a deficit for ASD. A behavioural approach reinforces this, which might make for a higher IQ, but as Gutstein says, IQ is not a measure for quality of life. In contrast to what has often been written about autism, people with ASD are still human beings, and like all of us, they want to feel connection to others.

  5. A reader says:

    Thanks for you response, Colleen.

    Can you you help me to think about this: autistic people are unable to relate to people but that is not to say that they don’t have feelings, is that right? It can look from the outside as though the autistic is something of an automaton, but that’s not what it’s like on the inside?

  6. Colleen Emmens says:

    Yes, people with Autism do have feelings, and in many cases can tell you what the feelings are that they are experiencing. What they struggle with is, within a group or even one on one situation, they can’t ‘read’ the emotonal information, and link their own emotional experience to what is happening in the here and now. For most of us this is so automatic, we don’t even think about it. But for someone with autism, these dynamic situations are difficult, if not overwhelming, therefore are often avoided, in preference for what is static and predictable, (eg. computer screens).

  7. Jenny Albinelli says:

    Colleen – very intriguing article. RDI claims, then, that autism can be CURED? Are there any ‘before and after’ clips on the web that show the dramatic change?

  8. Colleen Emmens says:

    Hi Jenny,
    Yes, RDI does move children off the spectrum. I have been hesitant about putting “before and after” clips on the web, as I don’t know how these children might feel about having the “befores” floating around the internet later on. I was given permission by parents to use some for the presentation that I did recently of the work.

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