Monday, 20 September 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.


Socrates said...

I benefited from Betty's style of child psychology for more than 20 years - the 70's and the 80's.

I remember an endless procession of kindly but batty ladies powered by the best possible intentions and an earnest desire to do good.

It's made me the man I am today.


Neuroskeptic said...

Ah, but according to Bettelheim you needed total 24/7 immersion in exactly the right therapeutic environment. He didn't quite come and say it but he basically meant "you need to be at my Orthogenic School".

Socrates said...

I've just read through your links to Betty's Ecce Homo - he really was a rogue - a salesman pimping his product.

petrossa said...

It was his fault i was misdiagnosed in my youth as having Severe Affectional Neglect Syndrome. Waisted 30 years of my life with pointless therapies till i got the correct diagnosis of Aspergers.

The guy should have had a postnatal abortion.

passionlessDrone said...

Hi Nueroskeptic -

Indeed, the realization that the child with autism does things for reasons that make sense to him, no matter how senseless they appear to the outside observer, was a difficult one to come around to.

My son insists that orange be paired with green. Crayons. Bell Peppers. Shape sorter blocks. It is the primary ordering of items, regardless of intended function. I still have no idea why, but I have, at least, figured out that he's got some kind of reason up there for doing it.

There are, some instances of extremen 'refrigerationess' leading to behaviors that can be called classical autism, for example, in Romanian orphans. From a strictly scientific standpoint, it might be of interest to see how the biomarkers from such a population mesh with other children who fit the behavioral classification of autism.

Have you done much reading on Environmental Enrichment? I'd be very interested in your take on it. It seems to show a lot of promise in animal models, but is problematic, or impossible, to test in humans.

- pD

Anonymous said...

Betty was a salesman pitching his product. Imagine that! Thank God Psychiatry had rid itself of such salesmen in this age of biological/pharma determinism! Where is Charlie Nemeroff when you need him? Different paradigm, but same old salesmen!

Mike said...

In terms of non-biological explanations of autism, I find Simon Baron-Cohen's "Extreme Male Brain" theory particularly intriguing. It subscribes to a dimensional rather than categorical classification. Basically it states that autistic individuals are on the extreme end of the normal distribution in traits that are more common in men. These include "systemizing" - relating more with patterns, objects, and machines than with people and relationships, as opposed to "empathizing". This theory also accounts for why autism is more commonly in boys to girls at a ratio of about 4 to 1.

However, the theory is applicable for high-functioning autism/Asperger's. What the theory cannot explain is why autism is so highly co-morbid with mental retardation and other distinctly biological conditions such as epilepsy and Fragile X. Clearly there is an additional biological susceptibility in this population. I wouldn't be surprised if there were differing neurological etiologies between Asperger's and low-functioning autism. I also disagree with the exclusion of Asperger's from DSM-V for this reason.

Neuroskeptic said...

Anonymous: True for psychiatry in general but autism research seems to be relatively free of salesmen so far.

Simon Baron-Cohen, for example, probably the most famous autism guy, isn't selling any treatments afaik.

You could say he's selling his books & promoting his ideas, but so is everyone who has ever researched anything.

This may change when Big Pharma decide that autism is the next big growth market. I'd say this will happen in about 5 years and the big story will be "it's too much glutamate".

But we'll have to wait and see...

Catherina said...

But, isn't "too much glutamate signaling" actually involved in the non typical brain development in children with fragile X?

Neuroskeptic said...

Yes, there's some good evidence for that. But that doesn't mean it's the same in all autism, or that drugs targeting glutamate would be able to treat Fragile X, let alone all autism.

But "autism is too much glutamate, so take this glutamate (AMPA receptor most likely) antagonist" might make a good selling point, in the same way that "depression is not enough serotonin so take this SSRI" is a good selling point, even though the truth is much more complex.

Anonymous said...

Well the glutamate approach has recently failed with schizophrenia... just ask Eli Lily.

strawberry shortcake said...

I think what Bruno is saying is something govts should introduce in schools.

Maybe if you observe the trends in autism demographics it might show something.

I don't buy the extreme male brain nor vaccines as causes. There are many folks who are good at spatial tasks, recognising patterns who aren’t labelled as autistic. Vaccine theory is a JOKE. All of us are a mix of genetic exposures to chemicals, toxins, pollutants etc. What about the other millions vaccinated? How come they're not autistic? How much were they paid to prove that theory?

I took the effort to get over the fact I was different. Different in the sense I could focus more intensely than others and do some extreme things. My social disabilities were no different to those who had difficulty making friends too. Doesn't matter how tall or short, black or white, in a wheelchair or not, short tempered, weird, SSRI deficient, you need to learn how to make friends.

If an autistic person tells you they don't see the point of friends, they're in denial and need help. No person with or without autism is an island. A label shouldn't excuse those from learning how to respond to social cues appropriately. Experience tells me autistic people are beautiful people to get to know, they don’t seem to have those purposeful mean character traits.

Even today faces terrify me, I hate leaving the house but I’ve learnt to be courageous about it and just go for it. Piss my pants have a heart attack whatever, go talk to them mingle. I tell myself the LORD is with me, He won’t let me die of shock, and if He does that’s just life get over yourself you’re not in sub-saharan Africa wallowing in poverty. Count your blessings you boohoo.

But I do think there is an inherent biological mechanism in autism because my mother was not a fridge. The fridge mother could’ve lacked copying skills in reacting to an autistic child. But educational intervention to identify autistic traits and implementing programs to nurture their strengths should be the way.

My main problem was with the education system. Teachers and professors didn’t understand the way I thought and the way I wrote. It was always something wrong with me when it took a few individuals especially my mother to say hey, you’re brilliant, it isn’t something they’ll understand, but there are others like you, you will meet them. Just keep going, do your thing, but be kind to humanity.

Roger Bigod said...

Around 1970, it was common knowledge around a certain East Coast medical school that the Chairman of the Medicine Dept had an autistic child. It was a sophisticated, avant gardish place, so everyone knew the term "Refrigerator Mother".

I'm surely not the only person who compared him with the specification and found something amiss. If anything, he was unusually open to other people, approachable and almost playful in his willingness to explore unusual suggestions if they showed some original thought. People often have a side they show only to family, but it would have been a huge disconnection in his case.

In retrospect, he and his wife were among the many people who suffered unnecessarily because of Bettelheim's guilt trip. He had enough responsibilities without the distraction of worrying about being a Refigerator or co-Refrigerator.

I've tried to think of an example of a "diagnostic" term more denigrating than "Refrigerator Mother", and I can't come up with one.

Neuroskeptic said...

Maybe "Nazi mother" or "Death camp mother"? Bettelheim refers to his experiences in a Nazi concentration camp (1938-1939) several times in The Empty Fortress, likening the autistic child's experience to that of the inmates...

Jon Brock said...

Thanks for another fascinating post. One thing I've often wondered is whether Bettelheim et al were actually picking up on autistic-like traits in some parents and misinterpreting it as the cause of the child's autism (rather than being a milder expression of a common genetic predisposition). Another possibility is that the child being autistic alters the behaviour of the parent. Either way, Bettelheim was making a massive (and incorrect) assumption about the direction of causality.

Incidentally, if you haven't already read it, I'd highly recommend Rimland's 1964 book "Infantile Autism". It's a brilliant riposte to the psychodynamic account of autism. And in tearing Bettelheim's argument to shreds, Rimland essentially came up with what we now think of as 'weak central coherence' as an alternative account. He also proposed an early version of brain 'underconnectivity'. And he had some really interesting things to say about the distinction/overlap between autism and schizophrenia.

Anonymous said...

Well, the term "refrigerator mother" was tried with regard to schizophrenia also.

Recently I saw an entire hour-long program -- title, "When Medicine Got It Wrong" (as if that were the ONLY thing 'medicine' got wrong).

It was a pallid sort of program, but the basic point was that 'they' tried sticking the label on the mothers, and the mothers eventually won. Label off.

veri said...

I think what Bruno is saying is something govts should introduce in schools.

Maybe if you observe the trends in autism demographics it might show something.

I don't buy the extreme male brain or vaccines as causes. I'm assuming there are many folks who are good at spatial tasks, patterns etc. that aren't labelled autistic. Vaccine-autism theory seems novel. All of us are a mix of genetic exposures to chemicals, toxins, pollutants etc. What about the other millions vaccinated without autistic kids? Maybe reactions to vaccines should be a case by case basis and not a generalised theory because I'd rather not die of polio.

If an autistic person tells you they don't see the point of making friends, I say they're in denial and need help. No person with or without autism is an island. A label shouldn't excuse those from learning how to respond to social cues appropriately. Experience tells me autistic people are beautiful people to get to know, they don't seem to have those purposeful mean character traits.

But I think there is an inherent biological mechanism in autism. To suggest any mother is a fridge is not cool. When was a mother's bond to child characterised by works? The mother could’ve lacked copying skills in reacting to an autistic child, or maybe they're autistic themselves and express things differently. I say educational interventions to identify autistic traits and implementing programs to nurture their strengths should be the way.

Anonymous said...

Do you know of any research that has attempted to look at the effect of this book and theory on the parents of autistic children during the time the theory was accepted as correct?

Neuroskeptic said...

Interesting point... no I don't know of any. I think it's fair to say that they weren't very pleased.

Liz Ditz said...


Refrigerator Mothers.

If you go to you tube, and search for "kartemquin" + "refrigerator mothers" you'll see several segments (if not all) of the film.

Walks-in-Shadows said...

Would it be accurate to describe Bruno Bettelheim and those like him as 'refrigerator psychologists'?

Neuroskeptic said...

Well the man himself was not very nice by many accounts.