Peering out from the edge of a lake. The water is still, but lapping restlessly. What lies beneath? I am eager to know but alone on the edge of the lake. A hood covers my features.

I take a step into the oddly warm water. It laps against my feet, staining my shoes with a dark bloom.

This image is the one that presents itself to me as I start to write this. I try to shake it but the colours become more vivid, the image clearer and sharper. So I write it out, curious as to what it means, how it introduces you and I to this work. So here it is, and here it stands as an opener. 

As I start to write this I am aware of a feeling that is akin to grief, sadness for those who have gone before me,  for all I have been told and taught, and mainly for what I thought I knew. But how did I get to this place? An explanation is needed.

Contents:

• Child Psychotherapy and the Pathology Paradigm
• Us With Them
• An Opportunity to Neuroqueer?
• Neuroqueering in Practice
• Rowena Mahmud
• References

Child Psychotherapy and the Pathology Paradigm

Child Psychotherapy is a discipline that became established in the UK in 1949. To document the history of this profession would involve a much longer deep dive than this work permits. Suffice to say this profession encompasses different perspectives, and has historically been rife with infighting, with passionately held beliefs fiercely contested. 

However, at its heart, it is committed to exploring what may be underneath the surface presenting behaviour of children and young people. It is primarily concerned with the internal world, and how the external world intersects with this. It is absolutely not behaviourism and has the potential to offer a nuanced, multidimensional, thoughtful perspective on individual and collective states of mind.

It also has, to my mind, a problematic view of neurodivergence, in particular autistic experiences. Early in its history, children who would most likely now be recognised as autistic were ‘treated’ under the category of what the psychiatrist Kanner might call ‘childhood schizophrenia.’ (Kanner, 1973, p.129) Luminaries of the profession such as Melanie Klein, Frances Tustin and Anne Alvarez have written extensively on autism as a subject, and are highly regarded within the profession. They have made seminal contributions to psychoanalytic thinking about autistic children and adults. 

However, when reading these contributions it is striking how deeply they are rooted in the medicalized pathology paradigm. Clinicians are viewed as drawing children out of being ‘encapsulated’ in their autistic shell, (Tustin,1972, p.93) and a ‘rescue narrative’ is stamped on clinical studies. For example: ‘Alvarez (2012)…talks about trying to amplify the non-autistic part of the child’s personality in order to bring him/her closer to the universe of normative functioning.’ (Konstantinos, 2019, p.277)

 This is in line with child psychotherapy’s birth from a medical model of pathology, particularly in Freud’s vision. Perhaps this is less pronounced in what I understand to be Jung’s perspective, but that would need another paper to explore.

Even though the psychoanalytic community now firmly distance themselves from Bettelheim’s and Kanner’s oft-quoted ‘refrigerator mother’ concept, there is still a flavour of parent blame in some writings such as ‘…autistic disorders come to be – as Winnicott and Tustin saw it – from an early rupture of the affective communication between baby and mother.’ (Ahumada, 2017, p.1) 

Generally, in this model, being autistic is largely seen as a defence and linked with the inability to tolerate separateness. The onus is placed firmly on the autistic person and how they interact and perceive the world, at the intersection of internal and external experiences. In Konstantinos’s 2019 thesis, his discussions with psychoanalytic psychotherapists illustrated their perspective of autism as a ‘malignant’, ‘stagnant’, damaging, life sucking force, that needed to be ‘treated’ to reveal the child within. (Konstantinos, 2019, p.152) This echoes the depiction of autism by the US based charity ‘Autism Speaks’ in their now infamous tv advertisement, ‘I am Autism’ from 2016.

By positioning autism as a disrupter of the progression of an otherwise ‘normal’ path of development, this could be seen to parallel the capitalist drive for a relentless forward motion, producing and consuming more and more as we develop. Another way of looking at this would be that autistic people pose a problem to a capitalist society because they may not subscribe to this linear, relentless forward motion. For a deep dive into this area please see Robert Chapman’s book ‘Empire of Normality’(2023).

Autistic humans may develop ‘atypically’, not along the well-trodden neuronormative path. They may do things in their own good time, with their own individual spiky profiles. This may confound others, but it doesn’t make it ‘wrong’. What is wrong is the conclusions that professionals and theorists draw about those who divert from a ‘typical’ path. What also seems wrong is the idea that there is a ‘thing’ called autism that is separate from it’s human host. This is a world away from the social disability model of being autistic, where ‘autism’ does not exist in any way as a ‘thing’, rather it is integral to the way in which autistic humans experience the world.

In the psychoanalytic ‘autism as a facehugger’ rhetoric, the analyst is then positioned as the knight charging in to rescue the child from autism’s clutches. She achieves this by the use of her finely honed observations and dazzling interpretations. The psychotherapist then writes lengthy case studies congratulating herself on what hard work it was, how determined and patient she had to be in the face of such arduous emotional terrain, but how she was victorious in the end. Cue many accolades and fawning praise from those inside the psychoanalytic bubble.

 The imbalance of power between child and therapist is not always explored and the analyst’s identity as a healer is once again validated. As Konstantinos writes ‘Autism as a malignant and socially dangerous construct can become a useful language resource for therapists who utilise it in order to highlight the triumphant role of therapeutic intervention. Drawing on this notably emotionally charged repertoire enabled the therapists to advance their therapeutic agendas and also their discrete healing identities.’ (Konstantinos, 2019,p.140)

It is striking how, even in contemporary discourse, there seems an unquestioning allegiance to this pathology drenched model. This is particularly clear in relation to autistic experience, and illustrated by Konstantinos below: 

‘The ‘autism as a pathology’ is firmly pushed into the beholder’s body, this is where the problem resides, not in the interface or relationship between a person and their environment, but wholly internally, within the boundary of their own skin. What is not recognised or acknowledged is the differential power relationships at play, the sense of autistic bodies being policed and held up as incompatible to neuronormative practices, and an uncritical endorsement of a biomedical model.’ (Konstantinos, 2019, p178)

Us With Them

A note about Konstantinos’ work here. Although utilising pathology paradigm language in his work, he cleverly positions the narrative offered by ‘autism experts’, in this case, psychoanalysts, in parallel with an autistic expert by experience, Mel Baggs. Their powerful work can be found here, under the YouTube handle ‘silentmiaow’

This comparison is especially striking, given the chasm between the ‘autism experts’ attitude to their child ‘patients’ and Baggs’ generosity in sharing their interior experience of being with the world, and the world being with them, without this being judged and labelled, as we are used to seeing in many ‘professional’ accounts. Their work disrupts the pathology narrative we imbibe and gives us a glimpse into a way of thinking not seen in a medical textbook.

Again this feels like an opportunity for psychotherapy, if we really are able to sit with the other and be truly alongside them, could this not open up a way of understanding and working with them, in all their humanity and experiences, without needing to suffocate this with a pathologized discourse? 

Perhaps this idea is inherently naive, what it passes over is the marked power dynamic within the relationship between therapist and client, particularly if the client is under eighteen. Without saying a word the power inherent in each of these roles, and how it plays out in a clinical situation cannot be denied, but must be thought about throughout the interaction and any subsequent interpretation of this.

With any way of thinking, including within the neurodiversity movement and psychoanalysis, it is important not to fall into binary states of mind when tackling emotive subjects. Although some subjects are clearly unjustifiable and deplorable, for instance the recent use of electric shocks in the USA to ‘manage’ students in The Judge Rotenberg Educational Center. (Garcia, 2016)

There are other instances where declaring something either completely wrong or completely right, without exploring the nuances and grey areas within can risk closing down an area where learning could take place. This is an attitude that any perspective can fall into, particularly when under stress or acting from a traumatic place. So it is not surprising that players within the neurodiversity movement could potentially slip into this, as, the movement itself, both collectively and individually, could be seen as a phoenix born out of traumatic experience. 

Here is where psychoanalytic concepts such as Klein’s ‘depressive position’ could illuminate what may be affecting the discourse, that is, a position that allows for ambivalence rather than a binary stance. It is this kind of cross-fertilisation of ideas that may well be useful. Binary thinking is an area I have tried not to slip into when writing about this, as I try and sift my way through my own thoughts and emotions. As Konstantinos argues, promoting the dichotomy of an ‘us and them’ position could well lead to a ‘stuckness’ for all involved. The questions remain, is there a space beyond this that we can occupy, is it even conceivable, and if so how do we get there?

 I wonder if Ashburn and Edwards are imagining a possible way forward when they write about an interpersonal state of mind described as ‘productive conflict’ (2023, p.23). This uncomfortable area requires both participants to listen to the other and refrain from shutting the conversation down, an agreement may not be reached but each participant can feel heard and may be able to take aspects of the others experience with them.

However, many professionals may entrench themselves even further in their views, clinging to their beliefs in the face of experience to the contrary. In online spaces participants may ‘dog pile’ on those that, although well-meaning, may inadvertently use pathology based language, and then be widely condemned for this. What I would argue is being played out here is rooted in trauma and projection, which forecloses a more thoughtful and less attacking space. 

So, can there be an emergent ‘Us with Them’ (Konstantinos, 2019, p.286) social or even transitional space created? This brings to mind the concept written about by Jung of the ‘transcendent function’ (Jung, 1960, p.69) which appears as neither one standpoint nor the other, but is one created by, and is more than both. Jung’s writing tended to focus on this as a psychic phenomena utilised for individuals on the quest for individuation, and working on the interface between the conscious and unconscious realms. 

However, it can also be applied to a more collective phenomenon. Can we, as a society, allow a third area to develop, in which we can step into a more collaborative, democratic space? This may well be rhetorical as, again, power differentials need to be addressed, we do not enter this arena as equals, but as an autistic minority and a ‘professional’ privileged group. There are of course intersections between this, and there is also the ever present ‘double empathy’, (Milton, 2012, p.883) or even ‘triple empathy’ problem. (Shaw et al, 2023)

This may not be anywhere close to a solution, but I think that all we can do as individuals is investigate our own mindsets, be aware of our own emotions and thought processes, take responsibility for these and allow a process to evolve within and between us. As Baggly states, ‘I am just interacting with the water, as the water interacts with me.’ (Baggly, 2007)

An Opportunity to Neuroqueer?

With exceptions, child psychotherapy presently seems to operate under the grip of ableism and can be used to promote a neuronormative bias. This has the potential to not only let down neurodivergent children and their families, as detailed above, but perpetuates a narrow, medical narrative which threatens to choke any buds of alternative thinking at their root.

 It may be that this could be linked to how the discipline of child psychotherapy is currently embedded in CAMHS (Child & Adolescent Mental Heath Services) in the UK. As a part of the NHS, and subject to government funding and restrictions, as a discipline it has had to fit into this pre-prepared mould to obtain continued funding and survive within this system. As part of the National Health Service a medical model is a pre-requisite, a model that answers to Western societies urge for individuals to engage in productive activities, in order to be seen as ‘healthy’ or fulfilling their potential. (Konstantinos, 2019, p.145)

I also wonder if child psychotherapy’s current, rather paternalistic position toward neurodivergent lives (this extends to other forms of neurodivergence, not only autism) is a product of how psychoanalysis was first founded. Frealand (2022) argues that in order to push psychoanalysis as an objective science and uncouple it from criticisms relating to his Jewish heritage, Freud, and those following him, encouraged a heteronormative narrative which pathologized those whose identities stood apart from that, including along racial, class and gender lines. For a detailed discussion of this, please see Frealand’s excellent 2022 thesis, referenced below. By projecting this shadow into minority groups, such as neurodivergent identities, psychoanalysis could have potentially lost a richness of contributions which have never been realised.

In terms of the profession’s public facing discourse, there seems to be a lack of reference to the concept of neurodiversity, and any reference to autism is relentlessly couched in person first discourse, that is, ‘with autism’. In many published papers in the field the ‘autism as a tragedy’ narrative proclaims itself.

 There are notable exceptions to this. For example ‘Listen to the autists!’ (Maleval, 2012). This was published originally as a reaction against the use of ABA ‘therapy’ in France and makes a case for psychoanalytic psychotherapy as a modality that listens and respects the autistic experience. This may not be an opinion shared by all, but it is worth mentioning as a relevant paper.

I want to make a distinction here between writing focusing on autistic ‘states’ and ‘autism’ as an integral part of a human being. A great deal of psychoanalytic literature deals with an autistic state of mind, which seems to be a very different concept to writing about a human being who is autistic. I think it is important that distinction is made, as it could potentially lead to a gap in understanding, if the writing meant to describe a transient state of mind is taken to mean a way of being and experiencing that is inherent.

While as a naïve, anxious as hell and (unknown to me at the time), autistic psychotherapy trainee, I came across a fellow trainee who was several years ahead of me in the training, and therefore my senior. She explained to me that as a child psychotherapist I would need to explain to the parents what was going on in their child’s mind, ‘because they don’t know, and that’s what we are here to do.’ I waited for the self-deprecating laugh to indicate sarcasm. It never came. I mumbled something and made my face express agreement. But this is not how I felt inside.

 The arrogance of this statement floored me. Bearing in mind there were bound to be defences at play for this trainee, defences against not knowing and uncertainty, it is an attitude that, unfortunately, comes up regularly in the psychoanalytic canon. It is this frame of mind that potentially does child psychotherapy a dis-service and what has led me to imagine something other.

So what is this ‘something other’?

Could child psychotherapy live, and perhaps thrive, within a social model of disability, or at least acknowledge the existence of this model? Could it’s practitioners work toward a vision of true inclusion and engagement? Could psychotherapists (who don’t already do this) truly work as co-creators and facilitators, rather than, as my colleague above, positioning themselves as infallible experts deigning to grace families with their presence? I hope the answer is yes.

This wouldn’t stop at neurodivergent children but would ask practitioners to look at themselves and engage in a reflective practice of neuroqueering (Walker,2021, p.168). Could therapists ask themselves why they practise therapy? Are they there to help children conform to societal norms? That’s not what I imagine for example, alternative thinkers such as Jung or Bion would have advocated for. 

Taking the compass as being able to work with trauma on a very deep level, could therapists let go of their own assumptions about what constitutes a secure and achieving child, and let them find their own way? That is, be truly ‘child-led? For example, a ‘successful’ outcome of therapy may be thought that a child is attending, engaging and learning in school. But what if this actually describes a highly masked young person who is complying in this setting? Perhaps the more successful outcome for that young person would be to access learning which is not housed in a mainstream school.

In an age where CAMHS is barely functioning, is this not an opportunity to re-imagine a broken system, neuroqueer our thinking and serve our children and young people in the best way we possibly can?

In its essence, I think child psychotherapy has the potential to be fundamentally neuroqueer. In its nature it is not a ‘quick fix’, but requires circumscribed space and time to be with another, think about, explore, and reflect on what maybe underlying another humans suffering. This is not housed in a behaviourist, objective viewpoint but requires the therapist to draw deeply on their own wounding , as Jung quotes, ‘The meeting of two personalities is like the contact of two chemical substances: if there is any reaction, both are transformed.’ (Jung, 1933, p.49) 

In child psychotherapy non-linear thinking is used as standard, i.e free association, and nothing is taken for granted. It is a deep practice of listening to another and holding a space for unknowns to unfold. It is holding a stance of curiosity when the network and wider society may demand certainty. That in itself is subversive, particularly in a capitalist society that demands constant productivity and immediate solutions.

Neuroqueering in Practice

What would neuroqueering look like in practice?

Fundamentally, much like approaches such as the NEST approach, and low arousal concepts, the change starts with ourselves as reflexive practitioners. Child psychotherapy training requires a deep and prolonged engagement in a reflective space to get to know oneself. This involves at least three times weekly therapy for the length of time of the training. Therefore, shouldn’t we be very well placed to approach others with an open mind, offer a deep humanity, an understanding as ourselves, and an ability to tolerate the unknown?

The opportunity to neuroqueer starts within our own mind-body and emanates from there. It involves bringing a critical, playful stance to perhaps long held and cherished theoretical frameworks, an inquisitive questioning of what structure the authors are advocating, and a reappraisal of what we are taught.

It is not a call to throw the baby out with the bathwater, but an invitation to us all as individuals to question everything we have been told, taught or imbibed, all that we have absorbed seemingly by osmosis, and mull it over in our minds. What are the unspoken/unwritten assumptions that this person/paper/ lecturer is operating from? If it is the pathology paradigm, how can we interrogate this?

This begins with us. We ALL have the opportunity to question and peer beneath our beliefs to really investigate why this idea is in place, what function does this theory serve? This can be a gruelling process and true soul-work, as it cuts to the intersection of our professional identity and personal, ethical standpoint.

One thing that neuroqueering does not seem compatible with is the notion of becoming a ‘blank screen’ psychoanalyst, that is, a quasi-objective reflective mirror that the human you are in partnership with can apparently see themselves reflected in, without being distorted by your identity. I would reject this notion as not only potentially retraumatising as a technique, (as discussed in many other works including, Wilkinson, 2006) but also an impossible and undesired aim. Perhaps there is a way to hold the transitional/transformational space for your fellow human, as a particular circumscribed area for them to unpack their world and unfold within, whilst embodying yourself in an authentic way.

 It brings to mind the recent conversation in the ACP (Association of Child Psychotherapists) magazine (Frealand, 2023, p.16) highlighting the experience of a queer child psychotherapist in training. In Frealand’s work he speaks of how trainees have had their identities ‘directly invalidated’ by the culture of the training. This feels a thorny situation to be in when our ‘calling card’ is that we are clinicians supposedly able to engage and explore nuances and complexity, but if the very training that we ‘grow up in’ promotes an antiquated, rigid idea of what is ‘normal’ development and how to return those we work with to that path, then this is clearly problematic. 

As Frealand recounts in his thesis on social identity within the training, (2022, p.7) often those questioning the neuronormative bias of child psychotherapy are told this is a problem rooted in themselves, and this is located as an individual issue. This then misses any chance for the profession to grow and learn in this respect, as it would require an acknowledgement that this is an issue for the wider culture of psychotherapy, and how it nurtures its trainees.

It seems a re-evaluation of the theories behind child psychotherapy is needed, by this I mean investigating if these bodies of work implicitly, or explicitly, support the pathologizing of alternatives to heteronormative identity and other social identities, including neurodivergent, class and racially diverse ones? 

It is important to note the hazards of speaking to this issue. As Frealand quotes Ahmed (2017, p.37) in his thesis ‘..when you expose a problem you pose a problem’ (2022, p.25).  The establishment may double down in defensiveness, locating the issue outside of the accepted discourse and lampooning the questioner with accusations about how psychoanalytic they are anyway, it is they who are the ones who are not thoughtful or nuanced enough. 

By doing so this forces the dissident into a proverbial corner. Is there a way out? Is there a way to incorporate ‘clinical technique with social identity’ (Frealand,2022,p.49)? That is, to not feel restricted by the narrative of the ghosts of psychoanalysis, but to find freedom in neuroqueering yourself as a clinician. Is this possible?

This neuroqueering perspective is not an easy or safe one. It is inherently destabilizing. It could usefully be thought about in connection to many social identities, class and gender politics, feminist thinking and race, both within child psychotherapy, and beyond. As Frealand (2022,p.95) evocatively puts it, can our thinking become ‘less leashed’? I believe psychotherapy has the potential to subvert social norms and can do this with flair if we let it, and let ourselves emerge into it. Perhaps what emerges from it, for ourselves and those we work with, is something not yet known.

I leave you with a quote from Konstaninos’ thesis:

‘Therapists, including myself, remain torn between their culturally prescribed positionality and a need to act outside that, for the benefit of the individual…. it requires a leap of faith and perhaps an act of rebellion if one wants to escape the normative character of the helping professions. Even in the most simple but core facets of life we have been trained to monitor for deviant symptoms, to reach for positive change and to strive for restoring things to their normative appearance. For this one needs to ask profoundly “who defines then?” and “whose voice is to be heard?” In particular, therapists could develop new instruments of self reflexivity based on the use of their discursive practices. By drawing more attention to the way culture saturates their thinking and acting they could possibly extend their practices beyond their fundamentally normative character.’ (Konstaninos, 2019, p.289)

I step into the water. As it laps around me I persist until the water covers me. Somehow I breathe. The lakes surface is now unbroken. Only ripples remain. As my eyes adjust, I see am not alone. 

Rowena Mahmud

References

Ahmed, S. (2007). A phenomenology of whiteness. Feminist Theory, 8(2), 149–168.

Ahumada, J. L., Ahumada, L. C. B. d. (2017). Contacting the Autistic Child: Five Successful Early Psychoanalytic Interventions. United Kingdom: Taylor & Francis.

Alvarez, A. (2012). The Thinking Heart: Three levels of psychoanalytic therapy with disturbed children. London: Routledge.

Ashburn, M and Edwards, J . (2023) I Will Die On This Hill: Autistic Adults, Autism Parents, and the Children Who Deserve a Better World. Kingsley: London

Autism Speaks. ‘I am Autism’ (2016) https://www.youtube.com/watch?v=9UgLnWJFGHQ

Frealand, N. (2023) Child Psychotherapy Matters Spring 2023 Issue 283, 16-18

Frealand, N. (2022) How have child and adolescent psychoanalytic psychotherapists experienced and understood the role of social identity in training, and how might this relate to their practice? University of EssexTavistock & Portman NHS Foundation Trust https://repository.essex.ac.uk/33494/

Garcia, E. (2016) The school that uses shock therapy on autistic students. The Independent Friday 16 July 2021 21:13 BST https://www.independent.co.uk/voices/autism-shock-therapy-trump-biden-b1885595.html

Jung, C. G., Baynes, C. F. (1933). Modern Man in Search of a Soul. United Kingdom: Harcourt Brace.

Jung, C. G. (1960). The transcendent function. In The structure and dynamics of the psyche (Vol. 8, pp. 69, 75). London: Routledge & Kegan Paul.

Kanner, L. (1973). Childhood Psychosis: Initial Studies and New Insights. United States: V. H. Winston.

Kenny, D. T. (2019). Faulty Theory, Failed Therapy: Frances Tustin, Infant and Child Psychoanalysis, and the Treatment of Autism Spectrum Disorders. SAGE Open, 9(1). https://doi.org/10.1177/2158244019832686

Konstantinos, G. (2019) Constructing autism inside and outside the clinic: Exploring relationships between psychoanalytic psychotherapists’ and activists’ discourses. University of Hertfordshire.

Maleval, J.C. (2012) Listen To the Autists! Hurly-Burly The International Lacanian Journal of Psychoanalysis, Issue 7.

Milton, D. (2012) “On the ontological status of autism: The ‘double empathy problem’.” Disability & society27.6: 883-887.

Smith, A., Aut, N., Hughes, J., Wilshere, K. The NEST approach: Supporting Autistic young people with meltdowns. https://drive.google.com/file/d/1n6KOJklw2YTkRUijDteEu3FsgWPtvdpw/view)

Shaw, S. C., Carravallah, L., Johnson, M., O’Sullivan, J., Chown, N., Neilson, S., & Doherty, M. (2023). Barriers to healthcare and a ‘triple empathy problem’ may lead to adverse outcomes for autistic adults: A qualitative study. Autism, 0(0). https://doi.org/10.1177/13623613231205629

Tustin, F (1972) Autism and Childhood Psychosis. London: Hogarth

Walker, N. (2021). Neuroqueer Heresies: Notes on the Neurodiversity Paradigm, Autistic Empowerment, and Postnormal Possibilities. United States: Autonomous Press.

Wilkinson. M (2006) Coming into Mind: The Mind-Brain Relationship: A Jungian Clinical Perspective. London: Routledge