Nr 18.  2008 sid. 19–30

Session with Thomas
and discussion

Anne Alvarez


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Anne Alvarez, Ph.D., M.A.C.P.,trained as a Clinical Psychologist in Canada and the USA before training as a Child and Adolescent Psychotherapist in the UK. She is an honorary Consultant Child and Adolescent Psychotherapist (and retired Co-Convener of the Autism Service), Child and Family Dep't. Tavistock Clinic, London. She is author of Live Company: Psychotherapy with Autistic, Borderline, Deprived and Abused Children, and has edited with Susan Reid, Autism and Personality: Findings from the Tavistock Autism Workshop. A book in her honour, edited by Judith Edwards, entitled Being Alive: Building on the Work of Anne Alvarez was published in 2002. She was Visiting Professor at the San Francisco Psychoanalytic Society in November 2005. Anne Alvarez has for many years been an appreciated teacher and supervisor in Stockholm, Oslo, Copenhagen and Helsinki.

Well, it is clear how much this child has improved since his assessment! What is so delightful is the urgency with which his ideas and play-thoughts come tumbling out. I understand the therapist’s confusion, as it is something I have experienced myself with children emerging from autistic states. There is so little evidence of ego function at such periods, and I have experienced a real technical dilemma about how much to celebrate their newfound freedom to speak and to use their imagination, and how much to begin to hold out for a bit of order, a bit of sequencing, a bit of logic, a bit of ego development. But if we think developmentally, this 6 year old child is like an 11 month old on the floor with a lot of toys, picking up one, then another, and another, and taking huge pleasure in his power to throw first one, then another across the floor, examine its new position (chosen by him) then retrieve it, placing it in a new place. This is power! We don’t say to the little floor-baby, why are you moving it again to a new place, you seemed to want it over there! We let him change his mind, and exercise his new powers over and over and over again. This is the stuff of exploration, adventure and of competence.

Session 74
The therapy work is beautiful and sensitive, and I want only to do a bit of fine-tuning. At the start of the session, the therapist felt confused with first the King, then the swimming, then mother and the Spiderman. But I thought that what Thomas might have been struggling to convey was something about the bountifulness of the world, the feeling of lots of lovely/good stuff about to happen – or happening at this moment. It is all a bit compressed, condensed and confused, and he hasn’t yet got the hang of the concept of an ‘and’ or rather an ‘and then’, i.e. ‘first this nice thing will happen and then this other nice thing will happen’. But one could say something to him like, ‘Oh, gosh lots of lovely things happening, and you and I are together again! – or, ‘and you are glad to see me’! (Anne Alvarez uses the name of the therapist, ed. remark) (in a delighted/a bit excited voice).

With the large bulldozer, one could say something like, ‘Wow, a big one, how lovely!’ Here I am thinking of the importance of getting what Bion (1962) calls ‘alpha function’ around an experience. He said that thoughts precede thinking, and alpha function is the function of the mind that makes thoughts thinkable, and lends meaning to experience. I think alpha function is a much earlier process than ego function.

Thomas, a six and half year old boy, lives together with his single mother. The father left the family when Thomas was two years old and moved back to his home country. Since that day they have had no contact at all. Thomas was assessed at the clinic when he was five years old. At that time he suffered from both severe speech and language disorders. He had difficulties in playing with peers and his mother and the staff at his pre-school were quite worried about the delay in his development.

He is in an ordinary pre-school with a personal assistant and has been to individual psychotherapy twice weekly.

The following two therapy sessions take place after almost one and a half years of treatment. Thomas has had severe difficulties with aggression. He has hardly shown any anger at all, he freezes, becomes pale and looks very frightened when someone raises their voice or when other children in the pre-school are angry. Lately he has started to show a bit of his anger in the group and he has been able to stand up for himself in conflicts a little more.

Session 74
To this session Thomas had brought a little toy car. He shows it to me when he enters the room and says: “It’s the King”. Thomas often brings some toys and he has brought this one before.

He enters the room and puts the car away by the table. He moves towards a children’s calendar hanging on the wall and says into the air that he is going to swimming school tomorrow. He looks at the calendar and utters something about his mother, that she is coming to pick him up and that she will also pick up some Spiderman cars for him. I feel a bit confused, as I often do when he talks. Something in the way he says this makes me feel unsure of what he means. Is she coming to pick him up today at pre-school or tomorrow at swimming school? And what about the Spiderman cars? He is not directing himself towards me when he talks and it is a bit difficult to hear what he is actually saying. I say: “Your mother is coming to pick you up and also the Spiderman cars”. Thomas doesn’t seem to react to what I’m saying. He asks: “What day is it? Can I pull a date patch off the calendar?” There is a calendar with pictures of all the months of the year. Lately he has started looking at the pictures of the months that are preceding the actual date. He has also just begun to relate to earlier occasions, such as the death of his friend’s grandmother and the break for summer. We look at the calendar together, a shared focus and joint attention and Thomas is particularly looking at a picture of Santa Claus. I ask him what he sees and Thomas says: “it’s Santa Claus bringing gifts. I want a Bulldozer, a large one”.

Then Thomas turns from the calendar and says he wants to play “swimming school”. He wants the Doll and the Teddy bear to go to the swimming school (he has used these two figures many times before during previous sessions). He asks me to get them. They always lie in the doll’s bed and he often wants me to “wake them up” for a particular play, just like he does this time. Thomas says: “they are one and two years old”. He walks to the table and starts writing on a paper there. He writes “1” on one part of the paper and then cuts it out. Then he writes “2” at another part and cuts out that one too. He attaches them to the Doll and the Teddy bear with tape. Then he changes his mind and says: “they are 6 and 10 years old.” He changes the numbers to “6” and “10” and then takes out a small doll (a bride) from the Erica-material and declares that she’s to be the swimming teacher (she is very small compared to the doll and the teddy bear). He divides the sand-tray approximately in the middle using boats from the Erica-material and says that one part of the tray has monsters in it, and that the Doll and the Teddy bear are afraid of them. I comment on this by saying: “It’s a good thing that the monsters are locked in on the other side of the tray”. He has taken out some toy canons and some animals using them as monsters: a crocodile, a polar bear and an elephant. The Doll and the Teddy bear are put into the sand tray (they look exceedingly big compared to the other toys in the sand-tray).




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