Psychodynamic Art Therapy Practice with People on the Autistic Spectrum

Matt Dolphin, Angela Byers, Alison Goldsmith, Ruth Jones, Matt Dolphin, Angela Byers, Alison Goldsmith, Ruth Jones

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134481200
• Edition: 1
• Topic: Psicología
• Subtopic: Asesoramiento psicoterapéutico

Psychodynamic Art Therapy Practice with People on the Autistic Spectrum offers a valuable counterbalance to the phenomenological, cognitive and behavioural theories that currently prevail in the wider field of practice and research. The result of a decade of work by a group of highly experienced art therapists, this book presents eight frank and compelling accounts of art therapy with either adults or children with autism, supported by a discussion of the relevant theory.

The book begins with an overview of the theoretical context and the subsequent chapters give varied accounts of practitioners' experiences structured in a loose developmental arc, reflecting issues that may arise in different settings and at various stages of therapy. Each is followed by an afterword which describes the author's reflections in the light of their subsequent knowledge and experience. The conclusion brings together some of the common threads arising from their encounters and considers how these might be relevant to current and continuing art therapy practice in the field of autism. Psychodynamic Art Therapy Practice with People on the Autistic Spectrum is a thoughtful consideration of where art therapy meets autism and the particular challenges that arise in the encounter between the autistic client and the therapist.

Presenting honest reflections arising from lived encounters and highlighting general principles and experiences, this book aims to orient other practitioners who work with people on the autistic spectrum, in particular art therapists and art therapy trainees.

Chapter 1

Introduction

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This book begins with an overview of the theoretical context at the end of the twentieth century and looks at how art therapists have approached their work with people on the autistic spectrum. The main section gives varied accounts of practitioners' experiences ‘on the ground’ and is structured in a loose developmental arc, reflecting issues that may arise in different settings and at different stages of therapy. The chapters in this section mostly concern work that was done before our two Somerset House ‘Images and the Emergence of Meaning’ conferences in 2000 and 2002, and each account is followed by an afterword written in 2012, which introduces the author's further reflections. The third and concluding section surveys developments in theory and practice since the turn of the millennium. It brings together some of the common threads arising from our case studies and considers how these might be relevant to current art therapy practice in the field of autism, including an acknowledgement of ‘neurodiversity’.

In this introductory chapter we present a brief description of the condition of autism, its clinical presentation and a consideration of the particular ways in which art therapists use imagination and a shared symbolic language, for instance in addressing the characteristic triad of impairments (Wing, 1981). We include a review of the psychoanalytic theories and concepts referred to by authors in the book, and a description of theories of symbol formation.

A summary of the literature about art therapy with people on the autistic spectrum that was published before 2000 will precede a brief description of the case studies and their most significant themes.

Autism — the background

While it is beyond the scope of this book to provide an in-depth clinical description of autism, it is helpful to provide an overview. An understanding of the characteristics that may be displayed by people on the autistic spectrum can help to orient the practitioner, particularly if the focus of the work is on communication, the use of the imagination, aesthetics or interpersonal relationships.

Defining a syndrome

The psychiatrist Leo Kanner is usually credited with the first clinical account of autism as we understand it today. He described eight boys and three girls, paying particular attention to their interpersonal relationships, their language development and their interaction with the environment (Kanner, 1943: 217–50). His case reports highlight the children's aloofness and indifference to others, traits that were present from the beginning of life. Kanner recognised that the children he described as autistic were not lacking in emotion but had a disturbance of affective contact. He makes a clear distinction between the affective disturbance of autism and that of schizophrenia, saying of autism that it is ‘a fundamental disorder in the children's inability to relate themselves in the ordinary way to people and situations from the beginning of life’. He distinguishes this from schizophrenic psychopathology by saying of autism that ‘it is not a “withdrawal” from a formerly existing participation. There is from the start an “extreme autistic aloneness”’ (Kanner, 1943: 242).

Also characteristic were a lack of spontaneity in play, an absence or unusual use of language and a desire for the ‘maintenance of sameness’ (Kanner, 1943: 245). Kanner applied the word ‘autism’ to the emerging syndrome, a term that had been coined (from the Greek ‘autos’, meaning ‘self’) by Swiss psychiatrist Eugen Bleuler in relation to schizophrenic self-absorption and withdrawal (Bleuler, 1908).

While Kanner conducted his research in the USA, his contemporary Hans Asperger was investigating a different group of children in his Viennese clinic. These youngsters — to whom Asperger (1944) applied the term ‘autistic psychopathy’ — were similarly socially isolated and averse to change. However, they were distinguished from Kanner's subjects by their cognitive and linguistic development, which was at or beyond what could normally be expected. But their use of language was odd, with (for example) an over-formal or disembodied quality. Asperger noted that these idiosyncrasies could find expression in the form of originality in thought and perception.

Like Kanner, the children Asperger wrote about were not lacking in affect; they could, for example, display extreme grief and homesickness. However, there seemed to be a disjunction between affect and intellect, which disrupted their relationships with others and their understanding of the emotional norms that regulate social conduct.

Kanner's descriptions, written in English, were initially more influential in forming the diagnostic criteria for autism, as his work was enlarged and elaborated upon into the 1970s. In 1978 Michael Rutter created a new definition of ‘childhood autism’ (Rutter, 1978), which drew attention to the fact that many autistic children were also affected by global developmental delay impacting upon all areas of cognitive functioning. The diagnostic manual Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association, 1980) placed autism in a new category of ‘pervasive developmental disorders’.

Autism as a spectrum

In 1980 Asperger's papers were published in English and began to influence practitioners in the autism field. Among them were Lorna Wing and Judy Gould, who had been studying children attending special schools or classes in South London. They observed a pattern of presenting difficulties that allowed them to formulate a continuum of autistic features. They saw traits displaying a recognisable commonality but varying in expression and severity according to the personality, skills and cognitive ability of each individual. This has become known as the autistic (or autism) spectrum.

Wing and Gould gave shape to these commonalities by delineating a three-way pattern or triad of impairments, which has been influential in informing both the diagnostic criteria for autism (American Psychiatric Association, 1994; World Health Organization, 1992) and subsequent clinical interventions:

•absence or impairment of genuine two-way social interaction;

•problems with comprehension and the use of language, particularly in the realm of ‘iconic’ communication (non-verbal language and pragmatics, the idiomatic application of speech);

•an unusual quality of imaginative activity, and a narrow range of repetitive interests or pursuits, often taking the place of flexible, co-operative play.

The first of these criteria is subdivided into a ‘mini-triad’, based upon the individual's approach to interaction: aloof — passive — active but odd (Wing and Attwood, 1987).

Importantly — and somewhat controversially — the concept of a spectrum allows for the inclusion of ‘high-functioning’ autism and Asperger's Syndrome, in which difficulties associated with Wing's triad are present but there is no discernible cognitive delay (indeed, some abilities may be enhanced and highly developed). A debate continues over whether there is a need for these two separate terms. Tony Attwood, for example, concludes that there is no clear reason to make a distinction and that the education and support available to both groups would be similar (Attwood, 2003). Psychiatrist Fred Volkmar notes that diagnosis is more problematic when assessment criteria are applied to people with very high or very low cognitive abilities (Volkmar, 1998). There is a related question of the overlap — or not — between autism and cognitive learning disabilities (see, for example, Chapter 7 of this book).

Central Coherence Theory

Alongside the derivation of the term ‘autism’, accounts of work with autistic people in this book and elsewhere suggest an absence or fragility of self as a central ordering principle. In her Central Coherence Theory, psychologist Uta Frith (1989) contends that this is the chief deficit in autism, with all other manifestations of the condition stemming from it. Perception and cognition are atomistic rather than global, so that the concepts or ‘gestalts’ that would normally give meaning to experience are lost in a welter of detail. Frith's conception may be supported by the way that some autistic people experience unbearably heightened sensory responses. This impartial or undifferentiated kind of seeing can also lead to exceptional abilities and originality in some autists. Temple Grandin's life and pioneering work as a designer of systems for the humane handling and slaughter of livestock was the subject of a recent biopic (director Mick Jackson, 2010). Grandin, a prodigiously gifted visual thinker who also experiences sensory hypersensitivity, has said that most people seem to test existing theories against reality whereas she uses (concrete) reality to move slowly towards the formation of concepts (Sacks, 1995: 270).

Relationships and theory of mind

Simon Baron-Cohen, Alan Leslie and Uta Frith (1985) have suggested that people with autism do not employ a theory of mind, and so have difficulty attributing desires, beliefs and intentions to others when they interact with them. This capacity is termed a ‘theory’ because the mind of the other is not empirically testable through observation; rather it is a construct based on analogy with one's own mind and deductions about the motives underlying others' behaviour. As such it is fallible and also, by extension, cannot be proved. The usual vehicle for developing this capacity is social interaction, and the autistic person is likely to have fewer opportunities than others for experiencing and learning in this interactive way.

This links to Frith's concept of ‘central coherence’ in that one of the main precursors to the development of a theory of mind is the development of joint attention, in which (for example) infant and caregiver look together at an object of interest. This kind of seeing is necessarily focused rather than scattered. The attainment of a theory of mind — and the same can hold for empathy — depends on an understanding of the mind as the metaphoric ‘engine-room’ of representation, including the production of beliefs and categories of feeling.

People on the autistic spectrum seem to share the experience of feeling unprotected by relationships. Compensatory — or over-compensatory — rituals and structures take the place of relational bonds in creating a feeling of safety in the world. Again, it would be a misconception to assume that people with autism are cold and unemotional. They can have and express strong experiences of anger, sadness and grief; it may even be said that the autist's affective world is characterised by surfeit rather than scarcity of emotion. There might be difficulties in understanding more subtle shades of feeling or those based on belief (surprise or jealousy, for instance), where an imaginative leap into the mind of the other is needed. People on the autistic spectrum may also struggle with the appropriate or conventional expression of emotion in a social context (like at a funeral).

Art therapy and autism: psychodynamic approaches

During the 1990s psychotherapists in London were working together at the Tavistock Autism Workshop to develop post-Kleinian psychoanalytic theory and practice in response to the disorder of autism, the accompanying developmental delay and personality defences of the children they were treating. Their approach was both psychoanalytic and developmental, anchored in the analytic triad of the reliability and consistency of the setting, the transference and the countertransference. They took lack of emotional relatedness to be the core symptom (not cause) of autism, and saw the therapeutic task to be one of drawing the child into relatedness, with the therapist in the first instance as a precursor to more generalised relating to others. Usually the child was seen three times a week, with work also being offered to the parents by another therapist in the team. A significant collection of their findings was published (Alvarez and Reid, 1999) using narrative descriptions of the work in order to convey the unique problem and individual personality of each autistic child.

Art therapy works on a different basis, taking the triad of client–therapist–art-making as its core structuring principle. The art therapy approach focuses on development of creative and aesthetic as well as relational capacities, particularly as there are questions about the availability of transference phenomena in the autistic person where developmental delay pertains. The prevailing model in the 1990s for art therapists was informed by psychoanalytic theories, applied in a (usually) once weekly, non-directive process held in the predictable frame of regular session times and consistent conditions. As there is a broad-ranging pluralism of bodies of psychoanalytic theory that attempt to articulate the workings of the unconscious mind, the psychodynamic orientation has myriad applications in practice. Consequently, the papers collected in this book are deeply individual, although we do draw upon some common therapeutic structuring principles. Most notably, we made use of our own countertransference experiences within the non-directive process.

The non-directive process means that we make ourselves, the art materials and the time and space of the sessions available to the client, and, within reason, we create the conditions for them to take the lead and initiate activities, interactions and communications. Our task is openly to facilitate this process and then to try to make sense of what happens and respond in a useful and enabling way, which will be different for each person. With some the focus will be on enhancing communication, with others it may be on supporting expressive and communicative capacities, or enabling the development of creativity and relational confidence. It is often a combination of some or all of these.

Rather than being concerned with structural categories of difficulties (the triad of impairm...