The paper discusses the experience of voice in analytic listening, focusing on two vocal phenomena: vocal adhesive identification characteristic of autistic states, and the psychotic split between voice and meaning. A special attention is given to the difference between a lacuna “in the voice” and a lacuna “of the voice”, yielding two modes of intervention: interpretation of the voice, and interpretation through the voice.

This paper will exemplify one possible application of Tustin’s concept in clinical work with adult patients. Some adult patients experience repetitive, fixed states of auto-sensory stimulation that are lacking, to a large extent, a symbolic representation. This results in severe difficulties in attempts to think or to speak about such states. In these circumstances the crucial task of psychotherapy is not developing an awareness of relational patterns, achieved by means of work in transference, so much as supporting the ability to represent or mentalize experience of one’s body. I will refer to Frances Tustin’s formulations as a conceptual foundation allowing to understand the protective function of auto-sensory mechanisms, and then I will present Riccardo Lombardi’s clinical perspective, focused on supporting the fluent flow between body and mind and on clothing sensations in thoughts. An attempt to bridge these two perspectives will be illustrated by an example from the clinical work with an adult patient suffering from addiction to a destructive and largely unmentalized auto-sensory mechanism.
Parasitism has a malignant ring and has been thought of mostly in an intrapsychic way. While this is not without its justification, this perspective could be seen as paranoid from other “vertices” (Bion 1965, pp 90). Bearing in mind the discourse of natural sciences, the paper sees more primitive aspects of what drives parasitism in a “bi-personal field” (Baranger and Baranger, 2008) and attempts a “binocular” (Bion 1962, pp. 86) reading towards that. It is suggested that the womb-foetus link may be used paradigmatically to map parasitic relations which could be emerging from an encounter of autistic parts of the patient and analyst. But fundamentally it is about recognising the still “encapsulated” (Tustin 1986; Bergstein, 2009) parts of our mind that collaborate in the formation of autistic islands, that can confront the parasitic nature of the link.
The author explores the meaning of the earliest experiences of rhythmic elements of reality for the psychic development of the infant. Rhythm permeates all that is living and represents a structuring element of the experience of time and relatedness. In autistic states, any uncontrollable movement represents a threat to survival. As a consequence, the very basis of living life and human relationships is blocked. Natural primary rhythmicity is frozen and replaced by solipsistic repetitive stereotypies. The psychoanalytic process of working with a severely autistic little girl shows the gradual discovery and tolerance of rhythmic elements, which over time led to basic existential psycho-physical experiences, from which further exploration of external/internal reality became possible and brought about genuine learning. In the process, rhythmic elements of human relatedness and reciprocity could not only be explored and experienced, but shared, and ultimately became the source of moments of joyful emotion.
With clinical vignettes illustrating developments from autistic withdrawals to relational nuances within child psychoanalysis, we will present our PRISMA (Protocol for Psychoanalytic Investigation of Signs Mapping Changes in Autism). Nowadays, autism has been surrounded by polemics where psychoanalysis has been losing space as a useful treatment when compared with behavioural alternatives. PRISMA is a psychoanalytic instrument, emphasizing psychic change and subtle nuances that may not always be noticed, but that contribute as a basis for genuine and long-standing structural transformations in autistic children’s and their families’ lives. This instrument helps professionals to be attentive to psychic structural aspects and can help psychoanalysis to demonstrate its potential as a modality for comprehension of mental life and for the treatment of autism. Therefore, it draws our attention to our own countertransferential responses – with conscious but mainly massively primitive and unconscious processes triggering the analyst, as we move along the contact with the patient and with our own primitive states. Within this autistic dimension, we work with the building up of psychic functioning, fostering the capacity for representation and attribution of meaning to experience, rather than the withdrawal from the intensity or fragility of relational links. Our protocol highlights the following areas of development: sense of interest in people or objects, shared interaction, sensory integration, constitution of internal space, symbolic capacity and transferential field.

This workshop will present a therapeutic process of a three-year-old child on the autistic spectrum. It will offer an integrative view into the complex therapeutic process in our multi-professional psychoanalytically oriented day care unit for young Autistic Spectrum Disorder children. Clinical observations from the therapeutic-educational environment will be presented by Orly Shalev. This part will briefly present a multi-dimensional picture of the child in the context of our psychoanalytic-developmental working model. It will be followed by clinical material from a psychoanalytically oriented psychotherapy, presented by Gal Meisels. A short theoretical discussion, reflecting on the presented clinical materials will be presented by Tami Pollak, PhD.

The paper focuses on psychic states in which living and bearing one’s vitality have become hindered or totally obstructed, either as a result of a primary trauma or of a late-onset trauma. The author relates especially to patients who have been severely traumatized and have withdrawn into encapsulated states with schizoid/autistic-like features that create complex challenges in therapy/analysis. The lecture weaves together clinical cases with theoretical understandings and with a discussion of the Kurdish movie Turtles Can Fly, in which many orphan Kurdish refugee children try to survive emotionally the traumatic life they have been going through. The author discusses the complex states of mind of the patients presented and of the orphans in the movie, who are sentenced to life, having lost all their hope and ability to tolerate their own vitality or that of others, due to extreme traumas. Consequently an encounter between themselves and another person, including a therapist/analyst, frequently becomes a flooding experience that is beyond their abilities to assimilate, being experienced as an annihilating threat to one’s emotional existence and being in danger of creating states of a therapeutic and undigestible excess for which the term toxemia of therapy is suggested.

Excerpts from work with an adult patient.

In the paper I describe a hallucination I experienced as a psychoanalyst during a session with an adult patient and search for its meaning.

I relate it to the analyst’s potential ability to experience hallucinations in the sense given by Bion, i.e. to exercise a particular kind of receptivity to the patient’s nameless, unlived experiences. Civitarese wrote that in this state of emotional sensitivity the analyst has access to the patient’s true reality.

I present how an autistic part of the patient was covered up by the well-functioning part of her personality and how I gradually became aware of the manifestations of the autistic part of the patient’s personality through contact with me. I describe how the patient’s primary fears of disappearance and confusion with the object came to be manifested through hallucinosis. I think of the hallucination as a trace of transformation, according to Tustin, an autistic shape into a shape with more psychic qualities, which is a vehicle for communication.