Professor Bettelheim is an authority on the capacity to survive extreme situations. His earlier book, The Informed Heart, which was mainly based on his personal experiences and observations while a prisoner in Dachau and Buchenwald, was largely an analysis of what decided whether a person lived or died in a concentration camp. In it he was concerned not so much with the physical capacity to survive brutality and torture as with the psychological factors determining whether a person will be able to resist demoralization in a setting in which he has ceased to be in any way a free agent—a setting, moreover, which is designed to reduce him to a nonentity and, indeed, has no wish that he should go on living.
This same preoccupation with the response of human beings to extreme situations which sap the will to live also pervades The Empty Fortress, an account of his therapeutic work with autistic children at the Chicago Orthogenic School. It is Professor Bettelheim’s thesis that these children have been brought up in families in which they have never been allowed to become themselves, and in which they knew, or rather sensed, perhaps from the very beginning of life, that their parents wished they did not exist. The empty fortress of the title is the psyche of such children, which he likens to a fortress designed to preserve the possibility of a self emerging in an environment that is felt to threaten its existence. Before considering Professor Bettelheim’s reasons for taking this view of the nature and origin of an illness which many psychiatrists believe to be organic, I should perhaps give a brief account of childhood psychosis and of infantile autism in particular.
Although childhood psychosis is a rarity compared to neurosis, its devastating effects both on the child himself and on his family, the therapeutic challenge it presents, and the possibility that it may provide fundamental evidence about emotional and intellectual development, combine to give it an importance out of all proportion to the number of children affected. Descriptive psychiatry recognizes four kinds of childhood psychosis: schizophrenia and manic-depressive psychosis, both of which replicate the adult diseases; the symbiotic psychosis first described by Mahler, in which the child remains in emotional contact with his mother but with her only; and infantile autism, in which the child makes contact with no one. Bettelheim himself would also include among the childhood psychoses infantile marasmus, the wasting away unto death which afflicts emotionally deprived children in institutions. These he likens to the “moslems” of the concentration camps, who resigned themselves fatalistically to the inevitability of death, and faded away.
AUTISTIC CHILDREN are often at first suspected of being deaf or mentally defective, but they do not look stupid nor does their ability to handle things support the idea of an inherent intellectual defect. Their most striking features are their “extreme autistic aloneness,” their self-sufficiency and their obsessive need to control the inanimate objects in their environment. They also display disturbances of speech; some are mute, while the others construct sentences curiously and are incapable of using the word “I” or of understanding the idea of “Yes.”
According to Kanner, who first described the condition in 1943, they come of notably intelligent stock and tend to have parents who are intellectual but inhuman. They are, he said, parents who are “more at home in the world of abstractions than in the world of people…. They treat their children about as meticulously and impersonally as they treat their automobiles…it is possible to speak of them as successfully autistic adults.”
Kanner himself thought that infantile autism was an inherited, organic disorder occurring in families in which a high IQ was also inherited, but Bettelheim is skeptical on both points. He thinks that the incidence of autism is higher than is usually supposed, but that it is only those autistic children with intelligent and well-informed parents capable of seeking out specialized clinics who get correctly diagnosed; while those whose parents are unintelligent and uneducated acquire other diagnoses, usually either schizophrenia or mental deficiency. He also maintains—and this is his essential thesis—that infantile autism is a psychogenic illness receptive to psychoanalytical explanation, the symptoms of which should be regarded as defenses against threats to their identity and as responses to the failure of their parents to welcome them as human members of their family.
Professor Bettelheim’s sense of conviction about this derives from the intensity and intimacy of his contact with autistic children. Prior to the years he spent in concentration camps he had one and sometimes two autistic children living in his house in Vienna, while for the last twenty years he has been Director of the Chicago Orthogenic School, where disturbed children receive residential treatment along psychoanalytical lines. To date he has had forty-six autistic children under his care and he claims therapeutic results markedly better than any quoted elsewhere in the literature.
ALTHOUGH THE CHICAGO Orthogenic School is run along psychoanalytical lines, the children there do not receive analytical treatment in any formal sense, the whole setting rather than particular sessions being utilized for therapy. The children are given every opportunity and freedom to discover themselves as spontaneous agents and to learn that the basic self-enhancing physical activities of childhood—eating, defecating, urinating, walking, talking—are acts which can be performed because they themselves will it and wish it, not because they are behavior patterns on which adults insist. In such a setting they can acquire the trust in other human beings which more fortunate children learn by discovering that their mothers can respond spontaneously to their needs, and the sense of autonomy which derives from learning how to master their bodies for their own sake. (In his theoretical justification of the School’s therapeutic methods Bettelheim follows Erik Erikson in maintaining that the first two stages in the birth of the Self are those of basic trust and autonomy, which correspond to the oral and anal phases of classical psychoanalytical theory.)
During both these phases autistic children, in Bettelheim’s view, have been physically cared for by parents who have failed, for a variety of reasons, to respond imaginatively and humanly to them. It is not exposure to cruelty, parental hatred, or material deprivation, but the negative trauma of not being recognized and reacted to, which is responsible for their conviction that “there is nothing at all one can do about a world that offers some satisfactions, though not those one desires.”
As a result autistic children lack any belief that the world wishes them to be themselves. Hence their inability to use the word “I,” the pronoun of self-affirmation, or “Yes,” which indicates an agreement with others which is only safe if one is already sure that one is allowed to be oneself; and their compulsive need to enact “No” by rejecting overtures of affection and refusing to communicate.
The evidence on which Bettelheim bases this conception of infantile autism is contained in the case histories which form the core of his book. Although readers who lack relevant clinical experience or, even more, who are not at home with psychoanalytical jargon, will miss a lot, no one can fail to be overwhelmed by admiration for the heroism and persistence shown by Bettelheim and his numerous co-workers. Not only do these children make enormous demands on the imagination and patience of their therapists, they also hit, bite, defecate, and urinate on them—one staff member required medical treatment for human bites twelve times in a single year—and may continue to do so for years before a trusting, responsive human being begins to emerge. And, as is usual in psychotherapeutic work with children, parents may remove them from the School prematurely and undo years of work.
Although many, perhaps most, psychotherapists would find this work heartbreaking, despair is not an emotion to which Professor Bettelheim is prone, and The Empty Fortress resembles his earlier The Informed Heart in being an illustration of the human will to fight on against apparently impossible odds. In an illuminating footnote he reveals a certain contempt for those who despair and then claim it to be a manifestation of their superior sensibility to do so.
In a strange dialectic process some modern writers (Burroughs, for example) do not seem satisfied to live at the mercy of their untamed primary process thinking, but use drugs to create mental states akin to those of the schizophrenic. Their pride seems to derive from deliberately creating in themselves a state of mind which the mental patient cannot help living in. Having lost contact with reality, or at least the ability to act in accordance with its requirements, but not yet having “lost their minds,” they try to lose it for periods of time by taking drugs. Their stance is that they do so because they reject a world that deserves rejection. Actually they find life wanting, and either they lack the courage to accept this as a temporary deficiency of personality that could and should be remedied, or else they lack the conviction that if this is a bad world it behooves one to improve it. This failure to act on the world or one’s own personality, or both, they try to cover up by claiming it a virtue to escape into a drug-induced dream world.
PROFESSOR BETTELHEIM is also fortified by an enormous faith in his own insight, and, like many other psychotherapists who allow themselves to empathize with psychotic and primitive experience, he writes sometimes as though he had a private line to the Truth. This has led him into what is, to my mind, the one serious defect of this book, a compulsive tendency to assert that he has a deeper appreciation of the active, creative strivings of small children than do other workers in the field and to quote their writings more for the sake of highlighting his own unique perceptiveness than to establish the consensus on which all scientific advance depends. This tendency sometimes leads him into error; I doubt whether there is any real difference between his conception of the infant and its needs and that of Winnicott, the English analyst whose experience comes nearest to his own.
Although The Empty Fortress is primarily a contribution to clinical psychiatry, it is impossible not to read it as a continuation of The Informed Heart, whose subtitle is “The human condition in modern mass society.” Professor Bettelheim more than once compares the struggle of the autistic child to attain identity in a family which denies his need to acquire one, with that of the inmate of a concentration camp struggling to maintain his in a world that is bent on destroying it. One is left in little doubt that he regards both struggles as dramatic examples of the courage required to maintain autonomy and self-respect in the face of the depersonalizing, mechanizing forces of contemporary society—and that he would include the autistic child among the inarticulate heroes of our time.
Bettelheim criticizes even psychoanalysis, from which he derives his main intellectual inspiration, for its failure to appreciate or respect the individuality of the infant in its theory and of the patient in its practice. By conceiving of the infant as a passive creature to whom and for whom things have to be done in order to protect it from trauma and deprivation, it underestimates, he believes, the extent to which it is, from the very beginning, an active, spontaneous person striving for recognition. By conceiving of standard psychoanalytical technique as an end in itself, it may become a rigid procedure to which patients are subjected without reference to their particular personality and needs. In this connection he quotes a telling passage from Anna Freud in which it is clear that the analyst of a schizophrenic girl never considered the possibility that she should or even could take seriously the patient’s suggestion that she abandon classical technique in favor of a relationship which extended into every aspect of the patient’s life. In assuming without question that analytical technique is a set situation to which the patient must willy-nilly conform, the analyst may not only miss the opportunity of curing patients such as psychotics for whom the technique was not designed; he may also be overriding the claims of the self and reproducing the mistake made by the parents of autistic children.
In view of his total dedication to therapy, there is something ironical about the fact that the Chicago Psychoanalytical Society lists him as a Non-Therapist Member.
May 4, 1967