Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part XIV

The Autism Fight
Susan Sheehan, The New Yorker- 12/1/2003

Regina Wagner began to realize that there was something wrong with her son Daniel when he was eight months old. He wasn't sitting or crawling, as her first child, Katie, had done at that age. Over the next year, Regina had more reasons for concern. Daniel didn't make eye contact with her or with her husband, Dan, and he didn't say Mama or Dada. Daniel's pediatrician attempted to reassure the Wagners. "Boys do things later than girls," he said. At eighteen months, Daniel said a couple of words, but he soon stopped. He did not respond to his name. He didn't like to be touched or held. He flapped his hands and feet. At the Sugar Plum Daycare Center, in Bethesda, Maryland, which he and Katie attended five days a week, Katie played joyfully with other children. Daniel remained in his own world and often bit other toddlers who came near him.

In October of 1997, three months before Daniel's second birthday, the Wagners took him to be evaluated at Georgetown University Medical Center's Child Development Center. During the evaluation, Daniel wandered around the testing room, pushing away test materials he was offered. He banged and threw blocks, instead of stacking them. Given a toy car to play with (pushing a toy car over a flat surface is considered an eight-month-level skill), he turned it upside down and spun its wheels. The testing revealed that Daniel's cognitive and behavioral difficulties were "consistent with a diagnosis of Autistic Disorder."

Parents of autistic children rarely forget the details of the day they are first given the child's diagnosis. Dan Wagner remembers asking one of the psychologists, "Are you telling me that Daniel won't be a quarterback at Harvard?" He also remembers her reply: "Well, actually, he may not graduate from high school."

Dan Wagner grew up in Montgomery County, Maryland. His father, a graduate of Harvard, was an electrical engineer; his mother was a teacher. (Both are retired.) "I'm the black sheep in my family," Dan says. "My older brother and sister are college graduates, but I dropped out of the University of Maryland to become a policeman in D.C." He married young, and has a son and daughter by his first wife. (Both children graduated from college; the son is a financial planner, the daughter a film director.) Dan, a tall, lean man of fifty-six with a full head of gray hair, is a homicide detective sergeant. He supervises a group of younger detectives, and his work hours are demanding and always changing.

Regina, a pleasant-looking woman of thirty-eight with brown hair and brown eyes, was raised on Manhattan's Upper West Side. While attending law school at Catholic University, in Washington, she worked as a part-time law clerk at the United States Attorney's office, and met Dan when they worked together on a case. "I never liked dating men my age," she says. After Regina and Dan were married, she took a job as an assistant state's attorney for Montgomery County, where they settled.

The Wagners' third child, Grace, was born a few weeks before Daniel's evaluation at Georgetown; she was a much easier baby than Katie (who had been clingy) and Daniel (whom Regina described as "a lump" during his first few months). Grace looked directly at her parents and smiled. She crawled early and walked early. At twelve months, however, she still wasn't speaking. Three months later, she, too, was given a diagnosis of autism.

DIAGNOSIS
In 1943, Leo Kanner, a psychiatrist at Johns Hopkins University, wrote a paper in which he vividly described eleven children with severe social, communication, and behavioral problems, including extreme aloofness and indifference to other people. He applied the term "early infantile autism" to these children. The medical profession was slow to embrace Kanner's term. As late as 1968, the scientific literature was still using the label "childhood schizophrenia." Kanner originally believed that bad parenting played a role in the origin of autism. He later changed his mind, but other physicians subscribed to the bad mother theory long after Kanner discarded it. When autism was diagnosed in Daniel Wagner, Regina was devastated by the implication, which still lingered in the psychiatric literature, that she was somehow to blame for his condition. The person who was best known for putting the onus on "refrigerator mothers" was Bruno Bettelheim, the director of the Sonia Shankman Orthogenic School at the University of Chicago from 1944 to 1973. After his death, by suicide, in 1990, some of his former patients, now adults, asserted that they had been physically abused by Bettelheim while in his care.

In 1956, a psychologist in San Diego named Bernard Rimland and his wife, Gloria, had their first child. The Rimland baby screamed and resisted being held in the nursery of Mercy Hospital from the very day he was born, and kept screaming and resisting throughout his infancy. The prevailing psychogenic theory of autism made no sense to Rimland: he and his wife hadn't had a chance to do any parenting. In 1964, Rimland published a book called "Infantile Autism," in which it he concluded that autism was not caused by bad parenting but was an organic disorder with a strong genetic component. The book played a significant role in changing the world's perception of autism. Today, autism is accepted as being a complex developmental disorder of the brain that interferes with the brain's normal development.

Autism is considered a "spectrum" disorder. Among the disorders on the spectrum are classic autism, the diagnosis that both Daniel and Grace Wanner received, in which children suffer from a triad of symptoms (impaired social interaction, a delay in or a total lack of spoken language, and difficulty with motor skills); Pervasive Developmental Disorder-Not Otherwise Specified (P.D.D.NO.'S., also known as atypical autism), in which a child has some but not all of the deficits associated with autism; and Asperger's syndrome, which is characterized by average or better-than-average language skills but impaired social skills. Autism is four times more common in boys than in girls; Asperger's is ten times more common in boys.

Because of the medical community's long-standing fixation on bad parenting, biomedical research was neglected for decades. Only a few researchers were seriously focusing on autism in 1994, when the National Alliance for Autism Research was established and became the first non-governmental organization committed to biomedical research on the disorder. Last week, federal officials convened a national conference in Washington to unveil an ambitious ten-year plan to address the problem. Among its many goals, the program will provide funding to help identify the disorder's genetic and environmental causes, provide better services for children suffering from it, and train therapists to better help them.

Recent studies suggest that autism spectrum disorders occur in an estimated one in every two hundred and fifty children. Ten years ago, the number was thought to be one in twenty-five hundred. Theories attempting to explain the increase range from citing improved diagnostic tools and public awareness--children once considered "eccentric" might now be labelled autistic--to blaming environmental factors. Much attention has been focused on the possible role of childhood vaccines as a precipitating factor; a recent Danish study found no evidence for that theory.

Autism is believed to involve between ten and fifteen genes. There is currently no in-utero test for autism, as there is for Down syndrome. There is no simple dietary intervention for autism. Every few years, new miracle treatments for autism have been touted and subsequently discredited. Some parents are proponents of "floortime" (getting down on the floor and playing with the child, letting the child take the lead in playing) and others of having the child swim with dolphins, but no studies on the efficacy of such treatments have been published. So far, only one study has provided any real hope for parents.

In the late nineteen-seventies, a Norwegian-born psychologist named O. Ivar Lovaas began a study at U.C.L.A. on sixty autistic children. Children in the study's experimental group received forty hours a week of an intensive, highly structured form of behavior modification called Applied Behavioral Analysis. The therapy was administered by student therapists trained at U.C.L.A. The parents were also trained in therapy, so that supplementary treatment could continue for most of the children's waking hours. Children in two control groups received only ten hours of therapy a week, with no supplemental parent training.

The study was published in 1987. The children in the three groups were compared at the ages of six and seven. Nine of the nineteen children (or forty-seven per cent) in the experimental group completed normal first-grade classes and were promoted to the second grade. In contrast, only one of the forty-one children (or two per cent) in the two control groups was placed in a normal first grade and promoted to a normal second grade.

The theory behind Applied Behavioral Analysis rests on the assumption that autistic children have inefficient neurocircuits--specifically, connections that are not as efficient as those found in normal children. In normal children, a connection may go from A to B, but in the autistic brain the connection may go from A to C to D to E before finally reaching B. Inefficient connections result in more "noise," which is believed to hinder social and cognitive development. Lovaas's therapy takes advantage of the brain's ability to adapt and be retrained. When people learn a particular skill, such as throwing a baseball, they are reinforcing neurocircuits that are specific to that skill. When autistic children are taught a specific behavior through constant repetition, the therapy is training the neurocircuits to respond in a certain way and somehow teaching the brain to receive these signals, which would otherwise be drowned out in a sea of noise. In order to be effective, Lovaas has stressed, A.B.A. therapy must be started early, must be sufficiently intensive, and must be carried out in part by the parents.

TREATMENT
The children Daniel bit at the Sugar Plum Daycare Center had complained to their teachers and parents, and Regina Wagner knew that he would soon be asked to leave the school. She decided to quit her job to care for Katie, Daniel, and Grace at home, while also devoting her time to obtaining A.B.A. therapy for Daniel. It is probably fortunate that she had no idea of what lay ahead. Regina learned of a private non-profit organization, Community Services for Autistic Adults and Children (CSAAC), which provides A.B.A. therapy to young children with autism. Daniel was evaluated by CSAAC (pronounced "sea-sack") in December of 1997 and recommended for the program.

Regina then approached the Montgomery County Infants and Toddlers Program, which provides services and funding for autistic children under three years old. She was told that Daniel, instead of receiving funding for A.B.A. therapy, would be eligible for forty-five minutes of speech therapy, forty-five minutes of play therapy, and forty-five minutes of occupational therapy (skills like holding a cup and scribbling with a crayon), for a total of two and a quarter hours of therapy every week.
Believing that the success of A.B.A. is contingent on early intervention, the Wagners decided to hire a special-education lawyer to file an administrative complaint seeking to get Daniel into the A.B.A. program right away, and borrowed ten thousand dollars from Regina's parents for the attorney's retainer fee and for the initial work he did. The Wagners' suit began in February, 1998, and lasted until August, 1999. During that time, Daniel received only an hour or two of weekly speech-and-language therapy for six months; the costs were paid for by Dan Wagner's insurance. A speech-language pathologist said that Daniel had improved in his ability to "imitate" words and phrases, that is, to repeat words in a parrot-like manner without appearing to understand them. As for actual speech, at home Daniel usually said just one word--it sounded like "wah" to Regina--but he sometimes babbled.

Life in the Wagner household was dismal. Daniel often spent eight hours a day dangling a piece of string in front of his eyes. Sometimes he put the string in his mouth. He screamed if it wasn't precisely the way he wanted it, and he screamed when his parents took it away. The Wagners never gave Daniel string. He fabricated his own by tearing threads off a towel, a blanket, or a carpet fringe. He also tore up books, putting the torn pages in his mouth, making spitballs out of them, and sticking the spitballs on the television screen. "I hated it when Daniel destroyed books," Regina says. "I bought the same books again and again for Katie to read. They meant something to her."
When Regina tried to go out with Daniel, he flung himself on the pavement. He kicked and scratched her when she tried to pick him up. If the Wagners did get their children to a playground, Daniel screamed if he was put on a swing or a slide. He preferred to sift endlessly through the pieces of cedar mulch below the equipment.

Sometimes Regina couldn't get Daniel into his car seat, because he arched his back and flailed; on more than one occasion, she had to cancel his doctor's appointments. Once, when Dan, Regina, Katie, and Daniel were waiting to check out at a Home Depot, the cashier ran out of change. Daniel started to scream and to punch himself in the face. Other customers glared at the parents. Regina felt terrible. The Wagners couldn't eat at McDonald's, and because Daniel was intolerant of waiting it was often hard for them even to order food at a drive-through window. "I became a prisoner in my house," Regina says. "Dan had to do most of the grocery shopping. He soon knew which supermarkets were open until midnight and which were open all night."

It was hardest for Regina when Dan, with his rotating job schedule, was working the midnight-to-8 A.M. shift. As Daniel got older, he became more violent toward Regina, and he started to bang his head against a wall. He rarely slept through the night. He often woke up between 2 A.M. and 6 A.M. and wanted to watch television. "He would grab my fingers and slam them against the TV," Regina recalls. "When I refused to turn it on, he bit me and pulled my hair and scratched me and kicked me. I had to call Dan at work. He told me to stay calm. He promised me he'd let me take a nap after he got home and before he went to bed for a few hours." Regina suffered from sleep deprivation and from her son's remoteness. "Daniel had no real idea who I was," she says. "He treated me like a piece of furniture. He imitated the words of the `I Love You' song from `Barney & Friends,' but he didn't know what the words meant. He never said, `I love you, Mommy."'

In May of 1998, three months after the Wagners brought suit to obtain Applied Behavioral Analysis therapy for Daniel, an administrative-law judge ruled against them. On January 19,1999, while an appeal of that ruling was pending, Daniel turned three. The Wagners sought funding for A.B.A. therapy from Montgomery County Public Schools, which is responsible for educating children from ages three to twenty-one. The school district agreed to fund an A.B.A. therapy program for Daniel through CSAAC. By then, however, the CSAAC program was full, and Daniel was put on a waiting list. He could not start A.B.A. until August of 1999, the same month the Wagners learned that they had lost their appeal. The Wagners now owed the special-ed lawyer an additional twenty thousand dollars.

On Tuesday, August 31, 1999, Regina and Dan Wagner wheeled Daniel's stroller into CSAAC's offices in Rockville, Maryland, for an initial three-hour workshop. The CSAAC team included a psychologist, a special-ed teacher, and several therapists, including a twenty-year-old woman named Bonnie Dayhoff, who had been administering A.B.A. therapy since she was sixteen and a junior in high school.

A significant part of A.B.A. therapy is conducted with the therapist sitting in a child's chair facing the child. Daniel was told to "sit down." It took three therapists to get Daniel into a chair. Once seated, he was told to stand up, which required the therapists' help. The "sit down" command was given a second time. Daniel was again "prompted" into the chair--the therapists helped place him in it. Each small step in A.B.A. is repeated and prompted until the child masters the step; then the physical prompts are gradually phased out.

Another step was to get Daniel, who tended to slouch in the chair, to "sit good." He was inclined to fidget, and was told to keep "hands quiet." He was praised for "good sitting" and for "quiet hands," and he was rewarded. The reward might be an M&M, a cracker, or the chance to play with a toy. Daniel had seen an Elmo Guitar on "Sesame Street" and there was one in CSAAC's clinic room. Someone gave it to him and he appeared interested in it. "One thing Daniel really had going for him was that he was easy to reinforce," Bonnie Dayhoff recalls. "He wanted certain objects. And, when we all clapped for him, he looked around the room. He clearly liked applause. Not all autistic children care."

After Daniel had a brief break, a therapist demanded his attention by saying, "Look at me." He was praised for "good looking." A three-piece puzzle was put on a table between the therapist's chair and Daniel's. The therapist handed him one piece of the puzzle, a pig, and said, "Put here." She took his hand and showed him where to put the piece. This was repeated a number of times. Each time Daniel put the piece in the wrong place, she again demonstrated where it went. When he put the piece in its correct place, she praised him and rewarded him with a treat. Daniel likes sweets and was willing to work for M&M's. After he put the first pig in correctly, he picked up the second piece, a pig of a different color and shape, and put it in correctly, and did the same with the third pig.

"I could tell from the first day that A.B.A. was going to work for Daniel," Regina says. "He responded to structure. He seemed eager to learn. He lit up like a light bulb when he did the puzzle. He had never done this before. I was so happy I was practically crying." Because Daniel had "receptive" language (he could understand words spoken to him) but negligible "expressive" language (he could speak only a few words, such as "All gone" and "No more"), CSAAC's goals for him in the 1999-2000 academic year included knowing and saying the letters of the alphabet, numbers, and the names of colors.

In September, CSAAC began to send therapists it had hired and trained to the Wagners' home. Four young women came for morning and afternoon sessions with Daniel for an average of thirty-six hours a week for a year. Dan Wagner built a therapy room for Daniel in the basement of the Bethesda town house where the Wagners were then living. At first, Daniel resisted entering the room and sometimes tried to escape, pulling the therapists' hair, hitting them, and scratching them, but he soon became more willing.

At the beginning of each session, Daniel was told to "sit down" and was reminded to sit properly. He was helped with the puzzle. He was praised. "So smart," "Very good," or "Wow," the therapists said, and they clapped, and they rewarded him with candy. Everything Daniel was taught was repeated a number of times in a session, and during subsequent sessions. Each therapist recorded Daniel's correct and incorrect responses to each skill that was attempted. Daniel's "behaviors" were also recorded. He was easily distracted and often threw himself on the floor, perhaps to try to avoid therapy: it was the first time in Daniel's life that demands had been made on him. The therapists are trained to avoid making eye contact with children who are "tantrumming." It is hoped that, if the child learns that disruptive behavior brings no rewards, his tantrums will diminish and perhaps stop. If the child quiets down, he is praised for "good quiet." It is believed that autistic children rock, spin, or stare--or, in Daniel's case, fixate on a string, make spitballs, and twirl the tails of toy animals--in order to stimulate themselves, because they don't find appropriate behavior sufficiently engaging. Many autistic children continue to "stim" for months or years, but the behavior in some who do well in A.B.A. tends to decrease, as Daniel's did, at least while he was involved in therapy. Initially, his behavior improved outside therapy. "Daniel independently went into the therapy room to do a puzzle and called `Mommy' so that I would come and look at it," Regina says. "I called Dan at work to say, `He did it!' I could see glimmers of a child coming out of a dense fog."

Compliance is also a tenet of A.B.A., and Daniel slowly became more cooperative. After six months, he was less aggressive with the therapists, he responded to the "come here" instruction between sixty and ninety per cent of the time during a session, and he had fewer tantrums--an average of seven a week. As the therapy progressed, Daniel quickly learned to say simple words. When a therapist told Daniel what a ball was, or a boat, or a cat, he was able to say the words clearly and he didn't forget them. At the end of his first six months, he began to respond to the question "What is it?" not just by saying "Ball" but by saying, "It's a ball." He had more trouble pronouncing words with more difficult blends; for example, the "br" in "bread." His progress in receptive and expressive language skills was described in a February 23, 2000, report as "tremendous."

By then, Daniel was able to snap beads to one another, stack rings, and complete wooden puzzles of up to ten pieces. He knew all the letters of the alphabet. He was gradually acquiring abstract concepts. After the therapists taught him the words "triangle," "rectangle," "circle," and "square," and put two-dimensional and three-dimensional shapes on the therapy table, he was able to "put with same." Daniel learned hundreds of nouns and was proficient at putting them in correct categories--animals with animals, and vehicles with vehicles. "Not all autistic children learn so fast and not all are able to generalize," Regina says.

Therapy moved from Daniel's therapy room to other rooms in the Wagners' house. Daniel was able to use his words spontaneously to request some items he desired. He often said, "Want apple juice, Mommy," and, still more often, "Want computer." Daniel had first seen a computer in the office at the Sugar Plum Daycare Center and had been attracted to the mouse, which he didn't need to be taught how to use. He and Regina shared a computer--Daniel had seen her send countless e-mails to lawyers and subsequently to CSAAC personnel. He was able to do kindergarten-level computer programs when he was four.

Daniel's therapy also moved outside. When the therapists first started to take him on walks, he would try to run into the street, or "body drop," falling to the ground, or kick and scratch. Eventually, he learned that if he walked a few steps without throwing a tantrum he would receive M&M's. After a few weeks, he walked. That meant he could go out of the house--and that Regina and Katie and Grace (in her stroller) could go out of the house--and to the playground. After several months, Daniel was able to go down a slide alone. And he was so occupied with the six hours of daily therapy that he often forgot about the string, and he was tired enough afterward to sleep through the night, and let his parents sleep.

The above text covers the first four pages of this thirteen page article. For the remainder, visit the archives of the New Yorker Magazine at www.newyorker.com/archive.

Clinical Implications of Ego Psychology
David Rapaport (1954)

I assume that in talking about ego psychology here I can take it for granted that it is familiar to most of you and therefore I will discuss mainly some clinical implications. However, I would like to spend the first third of my presentation on certain concepts of ego psychology, so that I can afterward talk more easily about things clinically important. What is ego psychology? In general, it is a term used in contrast to and complementary to id psychology. The great discovery of psychoanalysis was a thoroughgoing psychic determinism in all behavior. This consideration of motivation had a huge impact upon psychiatry, psychology, and clinical psychology. In the course of the search for the motivation of behavior, we forgot or neglected for a long time our interest in matters not motivational. In the amoeba, whatever motivating state exists is going to create pseudopods. It will reach out, pull in, etc. But it has a nucleus which does not change with motivation. Human behavior has many features comparable to the nucleus of the amoeba: for instance, what we today call inborn ego apparatuses, namely, motility, perception, memory, and the threshold apparatuses. The latter define the point at which the organism is ready to discharge a certain tension. My first point, then, is that ego psychology deals with the apparatuses we use in reaching the goal of a motivation. However, this is not all ego psychology has come to represent.
     Again we have to look back on what we have learned from psychoanalysis and what has become commonplace in psychiatry, psychology, etc.; namely, if a human being behaved in a certain way we have been looking first of all for his motivation and have come to disregard the fact that behavior is determined not only by unconscious motivation but also certain reality conditions. For example, a cigar can be just a cigar and not primarily a penis symbol. We are infected with a kind of thinking: something peculiar a patient does is immediately interpreted in terms of dynamics, to the neglect of environmental conditions. It is a difficult job to create concepts which take account both of intrapsychological motivations and reality adaptation. How difficult this is will be clear to you if you consider for a moment the aims of treatment. What is the aim of psychological treatment? Is it to liberate an individual from his defenses? We all would agree that liberation from crippling defenses is the aim of our work. In the meantime, however, there is also something we keep in the back of our minds, and some of us may even keep it in the foreground: the patient needs to find his place in society and lead a useful, productive life. What is our goal? Is it liberation of the person or is it fitting him into something? This is a kind of choice which probably should not be made by us. Maybe it could be compared with the choice of the young Hungarian nobleman who was waiting for his wife to deliver. As he was waiting the nurse came and brought out triplets. He put his finger to his nose, pondered, and finally said, pointing to the one in the center, "I'll choose this one." Should we lay down the law and say to the patient, "You've got to quit doing rebellious things and be a good boy?" Maybe the patient's only way to survive is to be rebellious and the only way he can serve as a useful person is to be a very sick, reckless person and the way in which to give him help is to help him feel reasonably comfortable as a reckless, rebellious person. Once you start out that way you are all involved in the problem of social adaptation the way Adler, Horney, etc., were and the danger is that you may begin to forget the intrapsychic determination. The balance between understanding unconscious motivation and finding the social niche into which a person fits is not essentially a paradox, but people have chosen to do either one or the other instead of trying, as present psychoanalysis tries, to reach a synthesis. The problem of adaptation versus the problem of freedom from crippling defenses is a problem of ego psychology.
     I would now like to proceed to some points in ego psychology which have direct clinical relevance. I will first present a concept termed by Hartmann "preparedness for an average expectable environment" and labeled "mutuality" by Erikson. Its significance and clinical relevance is in shedding new light on the mother-child relationship. What is preparedness for an average expectable environment? Erikson and Hartmann attempt to collate evidence that the human infant is born so that it is prepared to be able to survive in an average expectable environment. That is, the mother has a receiving apparatus for the signals of the infant; the infant has a receiving apparatus for certain nonverbal signals of the mother; and from the beginning on there exists a mutual relationship by which the infant steers the mother and the mother steers the infant. Inherent in this concept is the idea that it speaks of an evolutionary product, of one which is guaranteed by evolution for this creature, man, who has the longest dependency period of all creatures. His helplessness has evolutionary advantages only because of certain mutual steering devices of mother and child by which this helplessness can be managed. This might seem to be a very abstract concept. What does it have to do with the clinic? You all, I am sure, have heard about the "schizophrenogenic mother," the mother who makes her child schizophrenic. Such concepts as those of Erikson and Hartmann demonstrate that this is an inadequate concept. This is important because if the concept of the schizophrenogenic mother is canceled out, then our outlook on the illness changes and therapeutic work becomes somewhat more hopeful. I would like to try to show you in what sense the concept of mutuality militates against the concept of the "schizophrenogenic mother." If the relationship is mutual, then the relationship between the mother and child is relative and neither party can be blamed. Once you start with this assumption, you hit on clinical evidence which was not noticed around Washington, where the concept of the schizophrenogenic mother was born. The infant who later becomes schizophrenic often displays very early a certain lack of response to signals. Clinically we see these children later as borderline schizophrenics who do not give you any indication of whether they like what you are doing or not. In that type of case, which is called the autistic or schizophrenic child, there is apparently from the very beginning some kind of lack of mutuality, lack of signal giving and receiving. This deficiency then comes into the hands of a mother who herself may have difficulties of some sort. She reacts to his deficit with rejection and guilt, and thereby perpetuates it. It is easy to forget that it is partly the child who made the mother like that and that it is hard to be a mother to such a child. This is an ego-psychological issue for three different reasons: (1) It deals with the apparatuses, namely, the threshold for signal giving and receiving. (2) It deals with the very first adaptation, and it deals with preadaptation on which all other adaptations are built. (3) As the therapist, you will deal with these patients not by approaching this type of problem in terms of motivation but in terms of the problem of re-establishing a human relationship in which the lack of ability to give signals is going to be re-encountered and re-evaluated, in which the desire to give adequate signals may arise for the first time in such a patient's life. No interpretations are going to bridge the original gap in equipment, yet this gap is not irremediable. It certainly is remediable with schizophrenics who before they became schizophrenic had some achievements, and it is remediable even in some autistic children who never developed the requisite thresholds and signals. All of us as children had, in some respects, weak signals. Our thresholds varied greatly, and our mothers, having met our deficiencies, helped us slowly to develop adequate thresholds and helped us to develop a mutual relationship, out of which later in life trust could develop instead of leaving us in a condition of lack of mutuality, the hotbed of mistrust as a fundamental ego tendency. Even before Hartmann and Erikson, Paul Schilder had pointed out that man does not "become socialized" from being first an "egotistic" little wild animal, as the period of enlightenment and even psychoanalysis thought. Schilder asserted that man is a social being from the word go. This is something important to keep in mind when working with a schizophrenic, because if you had to make him into a social being by your work with him, at some point you would give up, unless your megalomanic ideas about yourself are unlimited. Unless you know that he has it in him and you need only to discover and to liberate it, the courage which is necessary to stick it out with a schizophrenic cannot be had. Even this fundamental, primitive, and really remote ego-psychological concept thus has considerable clinical relevance.
     Now I would like to pick up another concept, Freud's definition of the ego in The Ego and the Id (1923). The first definition that Freud gave of the ego, and the most general one, was that the ego is "a cohesive, organization of mental processes" (1923, p. 15). This definition distinguishes the ego from the id, which is not a cohesive organization; drives coexist in it side by side. The superego is not a cohesive organization either. It collaborates with the id in what it is intending and punishes the ego for its intentions. Maybe you know the story about the little boy going toward the candy jar. Before he got there, there was a great clap of thunder and the boy looked up and said, "Good God, isn't one even permitted to think of it?" I suggest that the superego does that in an even more extreme way. The boy would not even have to be sure he was going after the candy; just some slight yearnings and punishment would already be there. On the other hand, there is a fluid transition between the ego and the superego in what we call the ego ideal. So the superego is not cohesive either. This definition thus counterdistinguishes the ego from the other structures in the psychic apparatus. Is this all it is supposed to do for us? No, this definition implies quite a bit more. If it is a cohesive organization, then it should be capable of keeping various of its aspects coordinated. It indeed does so, through what we call the synthetic function of the ego. What is this synthetic function and what is its clinical relevance? I will try to give an example. Suppose that among the few ideas I have introduced so far, one is relatively new to some of you here. Let us assume that I tried to present that relatively new idea so that it should not come out of the clear blue sky. But even then the connections in which I presented it were only in my mind and did not yet have a place in your own thought organization. After a while, however, if you are struck by one such idea, it will lodge safely and securely among other ideas you have in your mind. It is not my job to put it in place in your mind. If you had to place it by an effort, listening would be a most difficult job. Actually, neither my nor your special effort places a new idea in its place in your thought organization. It is done quasi-automatically by the synthetic function. The new idea is put together with old ideas rather automatically. True, we can do a deliberate and effortful job of thinking at times, but most of us, most of the time, rely on the synthetic function of the ego in general, and in particular on that aspect of this function which works in thought organization to put things together for us. We say it "fell into place" and we understood. This may not happen while we listen, but maybe not until later; the beginnings, however, are there. The speaker tries to bring the material in and move it into position for that function to grab it and put it into place. What is the clinical relevance of this? First of all, it is relevant in relation to the long-standing discussion of the dynamics of the effect of our most important therapeutic tool, namely interpretation. How does it help? An interpretation brings into a new relationship the existing conflicts and defenses and then leaves it to the synthetic function of the ego to do its job on it. If the interpretation did not take, you work it through, over and over again, applying it with the patient to ever new areas. It is like a big stone which is lodged heavily in a stream. You are trying to get the dirt from around it and start rolling it. leaving it to the stream to lodge it in a place where it will not be an obstacle but an advantage. With schizophrenics we know that unless we bring about a situation where synthetic forces can work again, the job cannot be done, because it cannot be done by the therapist alone. To achieve this is often not a job of interpretation but a job of a different sort, that of creating a relationship that can free sufficient energies with which synthetic forces can begin to work. A knowledge that you can rely on the synthetic forces to come into play sooner or later is actually what can keep you working at psychotherapy with the schizophrenic or even with the neurotic.
     I would like to turn now to a third problem, that of autonomy. What is autonomy? First of all, it means that the sensory apparatuses, the motor apparatuses, the memory apparatuses, and the threshold apparatuses are not born out of conflict. These are ego apparatuses, the most important use of which is in searching for the drive object in reality. If one assumes that ego apparatuses are, from the beginning, part of the psychic organization, then the old psychoanalytic conception that ego is born out of id does not hold up. It becomes necessary to assume, as Hartmann indeed does, that the ego and the id both emerge by differentiation from a common undifferentiated matrix. These primary ego apparatuses pre-exist conflict and enter the conflict as independent factors. Although they may be drawn into conflict, they are autonomous from the beginning. But there is also another type of autonomy: if, in the course of an instinctual conflict, new structures, for example defenses, are created, these defenses may persist after the conflict that gave rise to them has long since subsided. They become independent from the original conflict and become secondarily autonomous apparatuses. They become ready-made tools to cope with all kinds of tasks of executive, conflictual, or adaptive nature. Language is a good example. There may be a question about any autonomous apparatus or ready-made tool of behavior, about whether it is a primary, ready-made tool pre-existing the differentiation of ego and id, or is only acquired in the course of the battle of life
and then becomes detached from its instinctual, conflictual source of origin.
     There is one specific issue of autonomy on which I would like to dwell further. Suppose a person developed a certain defense; for example he cannot show, or even experience, his aggressions. He leans over backward and is oversweet, with a great inclination to be very helpful to all comers. "No, I am not aggressive at all, I am most accommodating." He aims to please. Suppose you analyze that person. Does it mean this person then must quit being a helpful and serviceable human being and become an aggressive bastard? Is this an inescapable implication of therapy? Luckily, human nature is not that way. An autonomy once achieved survives. That is why Koestler is wrong when, in his Arrival and Departure, he has his hero arrive on an island as an honest radical and depart from it after being analyzed as a smug Philistine. Man does not happen to be made that way. What is the clinical relevance of this? It is that in a schizophrenic the structures that have been built up in the course of the development of his personality have not been obliterated by his illness. They go into disuse, they become unreachable-just as your sense of humor may be lost for a time when you are in a disagreeable position but returns to you later-but they are not destroyed. Sometimes when we are with a bore, we find ourselves to be just as big a bore as our counterpart. You know the situation, don't you? Does it mean that we have lost all the structure we have achieved, all the knowledge, all the interest? We do not lose them, they have just become unusable. The same for the schizophrenic patient: his structures just become unavailable to him and your job as the therapist is to help rediscover them. This is what we help them to get at and not something strange that belongs
to somebody else. Dynamically as well as therapeutically, this autonomy is of the greatest significance. It is easy to see what is wrong in our patients but a lot more difficult to see what is right, what is preserved. To learn to look for what is preserved is of great importance and is the point driven home to us by the conception of autonomy: whatever was once achieved is never lost. Any achievement noted anywhere in the case history, any valid perception, any single bit of knowledge, any differentiated feeling, any success, indicate to us that somewhere there was once something that can serve again as a nucleus of a new departure, providing we can reach it, free the synthetic forces, and progress from there to further self-discoveries of the best in the patient's essential social nature. This is the point no patient fully expects and that many of us do not fully appreciate in ourselves: there are persevering secondary autonomous structures and there is a basic sociability, and there are primary autonomous ego apparatuses even in our sickest patients.
     The last point I would like to dwell on is the issue of identity. I have indicated already that the social adaptation that man makes is outside of our ken while we are hunting only for motivations. The explanation of social adaptation has not been part of our psychoanalytic teachings for a long while. While Adler, Kardiner, Fromm, Horney, and Sullivan were very interested in this adaptation problem, they forgot to deal with the problem of unconscious motivation. The problem arises: What kind of concept can one develop by which both adaptation and unconscious motivation can be dealt with simultaneously? In order to be able to talk about concepts I will dwell on Erikson's concept of identity. Let us assume that to begin with there is a loose ego organization holding together the various thresholds and the apparatuses of motility, perception, memory, etc. As instinctual development progresses, we reach the point where this ego organization has to cope with thoughts, approvals, disapprovals, etc. All of these will impinge on this ego organization and alter it. There will remain a continuity between the original, loose ego organization and the later, more differentiated ones. For this continuity we do not have an agreed term. Sullivan talked about "self." But he used this term for the ego also, while it does not replace the "ego." In the eight stages of man, Erikson attempts to represent both the alterations in ego organization coming about in the course of libido development and the constant features of ego organization and their developmental phases. Hartmann and Loewenstein too speak of autonomous ego development, but Erikson's eight phases are the only consistent attempt to characterize the autonomous course of ego development. To come closer to the clarification of this point, let us turn to another definition Freud gives of the ego in The Ego and the Id (1923). According to this definition, the ego is the precipitate of identifications with abandoned objects (p. 36). The point is that in order to sever a relationship to a drive object, we reinstate it in our internal world by identification. Indeed, you know people tell you, "You are just like papa"; you put your coat on the way he does, you spit the way he does, etc. But what of the continuity of ego development? Do a person's identifications simply remain a congeries of all these identifications? According to Erikson, in the course of development the synthetic functions of the ego jell all these identifications into one unity. They do not remain disparate parts within us, such as father, grandfather, Uncle Sam, etc.; they are turned into one unity. It is similar to what happens in the course of studies; when you have studied books by various authors your knowledge of psychology is that of the authors, but you are not going to keep each of their thoughts and
principles separate very long. Sooner or later they will yield to a unity: your own view of psychology will jell out of them. Similarly the identity jells together all identifications. Erikson was able to demonstrate that in puberty and adolescence there is not only a recrudescence of the various impulses of earlier libido-developmental phases, but also of identifications which were made in the periods in which they were prevalent. They are revived and pass review. Indeed, these and many new identifications which are made are then jelled into one unity: the identity. But these identifications, their socialrole, vocational-role, etc., components, acquired skills and expectations, are so jelled into an identity as to guarantee the person a niche in society compatible with his expectations and self-respect. In other words, you find here in Erikson's concept a flowing together of three different conceptual strains. (1) From id psychology the dynamics of identification. (2) From ego psychology the dynamics of synthesis. (3) From social psychology the dynamics of fitting into a social niche, social role. You can see that here we are dealing with concepts integrating these three strains. This I believe is the core and the most lasting merit of Erikson's contribution.
The clinical significance of this is great. In our society, young adulthood is prolonged and reaches well into the 30s, which is later than-to my knowledge-has ever been the case before in history. Because of this, finding an identity and a definite choice of occupation becomes necessary and is made possible by a social moratorium, that is, by society's acceptance of experimentation. This does not explain the dynamics and I am not endeavoring to go into that now. We do know, however, that what the adolescent and young adult are struggling for is to unify identifications and a lot of roles so as to find the niche that fits them, and thus to gain recognition which will guarantee self-respect. Our first rule in therapy is to interpret what is readily available. This struggle for identity and role definition is usually the most obvious and readily available material in young adulthood.

REFERENCE
Freud, S. (1923). The Ego and the Id, tr. J. Riviere. London: Hogarth Press, 1927.