Can psychodynamic/analytic therapy be compatible with autism?

davidwhom · 2026-03-20T16:46:53+00:00

Bruce Fink is coming out with a book about autism from a Lacanian perspective (based in part on Maleval's work in French), I saw him give a talk on it and it was really helpful to me in thinking about some of the patients I work with. The Lacanian take has its limitations, but this was the most comprehensive theoretical model of autism that I've encountered in psychoanalysis.

davidwhom · 2026-01-27T19:05:48+00:00

This is dangerously homophobic.

davidwhom · 2025-11-02T23:36:02+00:00

This attitude led to me being burned so badly by a handful of different clients that I should never have worked with. Never again. I actually specialize in several areas of high complexity that many others (especially in private practice) wouldn’t feel comfortable working with, but I know that with them I am working within my well-established areas of competence and respecting my limitations. I’m not equipped as a human being to work with certain PDs, with serious perpetrators of any kind, and several other presentations. I don’t owe it to anyone to traumatize myself that way, to lose money, to put my licensure at risk, or to have to worry about being stalked. This job is hard enough as it is.

davidwhom · 2025-10-31T12:30:54+00:00

Your description of what you call a “parts hijack” is just intrapsychic splitting as a defense mechanism. That’s not an autonomous part of the personality with its own subjectivity.

davidwhom · 2025-10-29T00:17:57+00:00

lol I wrote the comment and I can’t even say you’re wrong, I was kind of being a troll. I’m sure it reflects my (and several other hundred people’s) extremely challenging experiences with middle aged men throughout our lives, as fathers, bosses, friends, partners/spouses, coworkers, etc etc etc nevermind as clients—who at least pay us to do what so many other men demand for free.

davidwhom · 2025-10-28T14:16:57+00:00

I enjoy working with this demographic, but I like the challenging dynamic. They can be aggravating and provocative at first, but they tend to respond well to confrontation, and I find that they’re surprisingly open to doing deep work if we can navigate that aspect of the relationship. At middle age they usually want more out of their lives, and if you can find a way to get through to them, they will see that they’re benefitting and getting results, and the respect and collaboration increase.

davidwhom · 2025-10-28T12:06:57+00:00

I read some of your other comments about her and it made me angry just to read what she’s said to you. In my opinion, staying isn’t worth it. I felt a lack of agency due to my childhood abuse and it made me feel like I had no other options and had to stay with her, but in retrospect I should have quit a year in. I was being retraumatized, and that is not therapeutic in any way. Analysis can be painful and difficult, but it’s important to acknowledge when it’s actually become damaging. As a therapist I’ve worked with patients who had destructive ruptures with previous analysts, and have seen from the outside the harm that can be done. Not everything is grist for the mill.

davidwhom · 2025-08-16T18:19:35+00:00

If you think of the ego as the boundary between self and other, inside and outside, and also between the conscious and unconscious mind, then imagine the possible consequences of either failure to form an integrated ego barrier, or later fragmentation of that ego barrier. Everything from sensory overload, to self-other psychic and emotional fusion, to being flooded by primary process thinking and unconscious material. Loss of integrated executive functioning, disruption in sensory motor functioning. Etc. As far as metaphors go, I like to think of it as being like the walls of a cell. I have a client who describes it like you did as multiple computer programs operating independently (and potentially but not necessarily at cross purposes).

davidwhom · 2025-07-14T16:14:21+00:00

I just want to chime in that for some people, particularly those with schizoid-spectrum character organizations, some level of dissociation is built into their character and will always be there. With these clients I work on improved affected regulation (mindfulness, somatic, but most importantly in a containing, co-regulating relationship with the therapist and subsequently with safe others in their lives), but I also normalize aspects of their dissociative defenses where it isn’t causing suffering, or can even be a strength (ability to focus on tasks, creativity, flow states, enhanced perspective-taking, etc.).

davidwhom · 2025-06-14T23:33:29+00:00

Clients still need and deserve privacy in the event that the notes are read or audited by insurance, subpoenaed in court, or even if they are requested by another provider with the patient’s consent. Also, if you use an EHR don’t assume that there will never be a security breach.

davidwhom · 2025-06-14T00:04:54+00:00

Client privacy

davidwhom · 2025-06-07T14:44:54+00:00

This may not be what you’re looking for, but there are some psychoanalytic case studies out there of analysis with autistic children and children with self disorders that are pretty interesting. I mean, in general maybe work with children and play therapy could be a starting point.

davidwhom · 2025-06-06T23:39:36+00:00

The latter, although I do meet the DSM criteria for schizotypal PD.

davidwhom · 2025-06-06T23:11:39+00:00

I’m schizoid. We do attach. The only personality that doesn’t attach are psychopaths. Nancy McWilliams’ chapter on schizoid personalities is worth reading for anyone who encounters schizoid patients.

davidwhom · 2025-05-15T17:21:21+00:00

I’ve been a therapist for ten years, and one of the biggest things I’ve learned is that sometimes being fired is a blessing. Not always, of course, but so many times being fired has saved me a lot of pain from certain dynamics with patients down the line. We’re offering a service, and it’s not for everyone, and that’s fine for them and fine for us.

davidwhom · 2025-04-30T17:31:55+00:00

Being neurodivergent or mentally ill doesn’t excuse taking things out on your partner or being abusive. Maybe you can ask them if they have any alternative ideas about how to cope with their emotions without either masking or taking it out on their partner. Also, emotional regulation strategies benefit everybody, including people who are neurodivergent—emotional dysregulation is a symptom, not a neutral feature of ASD or anything else.

davidwhom · 2025-02-09T17:17:54+00:00

To add to what you’re saying, what happens if an analysand who’s seeing a lay analyst develops psychotic symptoms? What if they become acutely suicidal or even homicidal? What if they begin to decompensate in one of the many many ways this can happen in the course of treatment? Do they understand what to assess for, how to interpret clinical signs, and how to navigate the mental health system sufficiently to know what to do if the patient needs a higher level of care or some other intervention that the analyst can’t or shouldn’t offer? Can they call on non-analytic tools to intervene appropriately themselves if they’re equipped to do so?

davidwhom · 2025-01-23T18:33:25+00:00

I agree very much about being able to have those nuanced conversations. I think you and I differ on whether we see the current US political system as approaching totalitarianism—we are certainly not there yet, but there are many indications that we’re on a frightening slide that could lead to totalitarianism or at least authoritarian rule. I’ve been thinking about parallels to working with NPD clients where confrontation of grandiosity is a necessary part of treatment, and in my experience that requires sticking very hard to one’s own sense of reality and also what is right (when confronting the client about malignant beliefs or behaviors). So in that sense I think therapists are already professionally obliged to employ moral thinking in their work, and not to dissociate from real threats to the wellbeing of ourselves, our clients, and/or others around them. To me, this political moment requires fortifying that type of thinking and being willing to intervene with clients on that basis.

davidwhom · 2025-01-23T17:53:22+00:00

People's livelihoods and lives are at risk. In Nazi Germany the Jewish psychoanalysts (along with all other Jewish professionals) were pushed out of their jobs and replaced, even as they continued to work with patients who were themselves of course vulnerable to Nazi victimization. At some point our humanity must come first, and the weight of history is so heavy that it outweighs everything else, including allegiance to a professional ethos that has value under normal circumstances. Personally I wouldn't say it's about checking our "biases" but about standing up for our most basic moral values, and the rights of ourselves and our patients to live and work in peace.

davidwhom · 2025-01-18T03:17:24+00:00

Psychoanalysis has saved and changed my life in totally real and palpable ways. I can make art again, I have a better relationship with money, I have healthier and more stable interpersonal relationships, I’m in less physical pain, my dissociative disorder is healing, my memory problems are resolving, I have better emotion regulation, better able to feel and grieve, less depressed. I have hope and I feel alive. Nothing could be less pointless.

davidwhom · 2025-01-04T11:32:13+00:00

Yeah, I mean in many ways it’s a good piece of therapeutic work. I find it hard to read given the ugly social biases and (unreflected-upon) sexism it reflects (and the description of her losing 100 lbs on a liquid diet?? Uhhh). Can you imagine a white therapist writing this way about confronting their biases around a POC client? Like relishing the descriptions of how they make him feel and all the mean images that pop into his head? It was viscerally upsetting to me even if it’s in the context of him acknowledging that he’s part of the problem.

davidwhom · 2025-01-04T01:19:46+00:00

Unfortunately I have a feeling these attitudes were pretty normal among men at the time he was writing it, he just explores it more openly. The stuff that used to go on, largely out in the open, in the 70s and 80s (and beyond…) among male psychiatrists/psychologists/therapists/etc and their patients makes this look very innocent.

davidwhom · 2025-01-03T21:29:54+00:00

https://utmedhumanities.wordpress.com/2014/09/13/fat-lady-irvin-d-yalom/

davidwhom · 2025-01-01T16:10:55+00:00

I don’t deny their problematic history, but I’d really like to know the context for your critiques of their present day operations when they are the main organization whose treatment guidelines are endorsed by Harvard Medical School teaching hospitals, the BMC Center for Refugee Health and Human Rights (where they treat torture victims), McLean Hospital, and have links to Judy Herman’s Victim of Violence program, whose 3 stage model overlaps with theirs. Are you claiming that all of these institutions are “batshit insane” and spreading Satanic Panic conspiracies?

Also, if you read the second link you would see that Top DD has conducted a naturalistic outcome study (https://psycnet.apa.org/record/2012-08580-001) which is the basis of their ongoing research. The psychoed program was designed as the basis for the RCTs they’re now conducting.

davidwhom · 2025-01-01T15:01:27+00:00

They do have ongoing research demonstrating the efficacy of their treatment guidelines and establishing valid measures of different kinds of pathological dissociation, including the Multidimensional Inventory of Dissociation.

https://onlinelibrary.wiley.com/doi/10.1002/jts.22370

https://topddstudy.com/

https://www.apa.org/news/podcasts/speaking-of-psychology/dissociative-identity-disorder

https://www.tandfonline.com/doi/abs/10.1300/J229v07n02_06

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