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Monday, September 20, 2010

The Refrigerator Mother

Autism is biological: that's the one thing everyone agrees about it. Scientific orthodoxy is that it's a neurodevelopmental condition caused by genetics, in most cases, and by environmental insult, such fetal exposure to anticonvulsants, in rare cases. Jenny McCarthy orthodoxy is that "toxins" - usually in vaccines - are to blame, not genes, and that the underlying damage might be in the gut not the brain: but they agree that it's biological.

However, it hasn't always been this way. From the 1950s to about the 1980s, there was a widespread view that autism was a purely psychological condition. Bruno Bettelheim is the name most often linked to this view. Bettelheim spent most of his career at the University of Chicago's Orthogenic School, an institution for "disturbed" children, including autistics as well as "schizophrenic" and others.

His magnum opus was his book The Empty Fortress: Infantile Autism and the Birth of the Self, in which he outlined his theory of autism illustrated by three long case histories. His ideas are now referred to as the "refrigerator mother" theory.

For Bettelheim, autism was a reaction to severe neglect. Not of physical needs, which would be fatal, but of emotional relations. In his view, the most common underlying cause of this neglect was when the mother (and to a lesser extent, the father) did not want the child to exist. They cared for him, but they did so in a mechanical fashion, treating the baby as a mouth to feed and a nappy to change, rather than as a human being.

Hence the "refrigerator" - it provides food, but it's cold.

The result was that the child never learned to interact with the mother on anything other than a mechanical level; and for Bettelheim, as for most psychoanalysts, our relationships with our parents were the model on which all our other relationships were based.

The mechanical mother thus left the autistic child unable to relate to anyone, indeed, unable to conceive of the existence of other human beings, and thus lacking a sense of "self" as opposed to "others".

The repetitive behaviours and obsessive interests characteristic of autism were seen as an active, even heroic, coping strategy. They were the child's way of asserting what little self they had, by doing something for themselves, albeit something "pointless". But they also had symbolic meanings: "Joey's" interest in fans, propellers and other rotating objects was interpreted as a representation of the "vicious circle" of his life. And so on.


Bettelheim's ideas are now generally derided as dangerously wrong; his reputation suffered a hit when, after his suicide in 1990, stories emerged from former colleagues and patients painting him in a nasty light. But psychiatry's wider turn away from Freud and towards biology probably made his downfall inevitable.

Today the "refrigerator mother theory" is routinely cited as a cautionary tale of how deeply one can misunderstand autism. Ironically, Bettelheim's only reference to that term in The Empty Fortress is a quotation, from none other than Leo Kanner, the man who coined the term 'childhood autism' in 1944. Kanner referred to the "emotional refrigeration" he observed in the families of autistic children, although it's not clear that he thought of it as causing the autism.

There is no doubt that Bettelheim's approach was unscientific. He repeatedly claimed that the fact that many children improved after three or four years at the Orthogenic School proved that their autism was psychological, because if it were biological it would be permanent.

Yet there is no reason to assume that children with a neurodevelopmental disorder would never change as they grew up. There was no control group, let alone a placebo group, to show that the children wouldn't have "grown out of" some symptoms anyway. (Edit: In fact, Kanner himself had written about improvement with age way back in 1943, in the first ever paper about autistic children! So there was simply no excuse for Bettelheim's flawed argument.)

Bettelheim's attributing the cause of autism to family dynamics was post hoc: for each autistic child, he looked back into their family history (i.e. what the parents reported) and found that they "consciously or unconsciously" didn't want the child to exist.

Yet all this proves is that it is possible to interpret a parent's behaviour in that way, in retrospect, if you want to. The "or unconsciously" caveat creates endless scope for over-interpretation.

But even if we now see autism as a neurodevelopmental disorder, there is something attractive about Bettelheim's book: it seems to be a serious attempt to understand the autistic experience "from the inside", and to appreciate the autistic child as a person rather than a disease. This is something that we rarely see nowadays.

Bettelheim's problem was that he tried to understand autistic behaviour from the assumption that the autistic child was, deep down, entirely "normal". Hence his interpretation of, say, Joey's fascination with rotating objects as symbolic of his life situation (and also as reflecting the fact that his father was often flying away in propeller-driven aircraft, which he was).

Yet couldn't it be that Joey was just fascinated by spinning fans per se? There's nothing interesting about rotating objects. They must have a hidden meaning. Otherwise it makes no sense - to someone who isn't autistic. But all that means is that trying to understand the autistic child is rather difficult if you don't bear in mind that they are autistic.

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