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International Journal of Art Therapy

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On amodal perception and language in art therapy with autism

Jo Rostron

Online publication date: 26 May 2010

To cite this Article Rostron, Jo(2010) 'On amodal perception and language in art therapy with autism', International

Journal of Art Therapy, 15: 1, 36 49 To link to this Article: DOI: 10.1080/17454831003751024 URL: http://dx.doi.org/10.1080/17454831003751024

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International Journal of Art Therapy, June 2010; 15(1): 3649

ORIGINAL ARTICLE

On amodal perception and language in art therapy with autism

JO ROSTRON

Abstract This paper is based on the analysis of artwork produced by a 36-year-old male client with mild learning disability, who was withdrawn or encapsulated for self-protection into mild shell-type autism. He was offered weekly individual psychodynamic art therapy for a two-year period in all. The analysis was carried out a year later as an MA research project, using two frameworks appropriate to non-verbal aspects of art therapy, one theoretical and the other visual. The findings offer evidence in art therapy of a language consisting of sensations and perceptions registered and expressed by the body, and between bodies, as contours, inscriptions or signs of expression. This language is structural, giving shape and form to sensed perceptions according to an innate temporal and spatial ordering. Its dynamic process constructs and develops the sense of self and other and underpins the capacity for intersubjective relatedness and learning.

Keywords: Art therapy, visual research, the body, inscription, contiguous object, language, autism, learning difculties, amodal perception
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Introduction

Theoretical framework

The research methodology is first presented with a brief description of the theoretical framework and of the development of the visual research framework. The client is introduced, and an overview of therapy follows. The body of the article is an exploration of the communications and unconscious process taking place in art therapy. A tracing of the structure of the clients sense of core self begins with a focus on Session 3, and then continues in relation to the images and notes, portraying the clients relationship with his feelings, and to space and time, and revealing his experiential understanding of separateness (Stern, 1985). The image from Session 3 is revisited to throw new light on communication through non-verbal analogy, and his capacity for intersubjective relatedness (Stern, 1985). The clients use of non-verbal analogue, common to his artwork, behaviour and speech, is then outlined to demonstrate its supplementary relationship to his use of metaphor and symbolisation. This understanding is used to identify a process of organisation or learning, and the form of object relating on which it is based, as it took place between the client and me, and as it was recorded in the body of his artwork.

The qualitative phenomenological methodology chosen was considered appropriate to the observations of art and behaviour made during therapy with one client. Phenomena occurring were inscribed during each session: by the client in his artwork and recorded afterwards by the therapist in written notes. Similarly based on observation, and thus a phenomenological approach, is the research into early intersubjectivity from developmental psychology. Daniel Sterns (1985) interpretation of this data presents a new perspective on interpersonal development from birth onwards, and offers a vocabulary for the earliest communications that occur between (m)other and infant. His account provided an alternative framework to the active imagination of Jungian/post-Jungian theory, and to the Object Relations theory that was previously used unsuccessfully for assessing this clinical work. The following ideas were used to look at the clinical work in terms of the therapeutic relationship, art and behaviour. The author found them relevant for practice as an art therapist working with autistic or learning disabled clients when verbal communication is nonexistent, or very limited. In these clinical situations, the therapist is entering an interpersonal world that is

Correspondence: Jo Rostron, 20 Princess Road, London NW1 8JJ, UK. Email: jorostron@yahoo.co.uk 1745-4832 (print)/1745-4840 (online) # 2010 British Association of Art Therapists DOI: 10.1080/17454831003751024

Amodal perception and language in art therapy with autism

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dominated by amodal perception. This is a mysterious place where thinking and feeling are inseparable, and where sensory information is transferrable across the five senses and between therapist and client. Perceptual information is experienced as contours of intensity, shape, shifts, patterns of feeling and mood tone rather than understood or thought about as overt acts or things seen or touched. Each activation contour is inscribed into the body, possibly registered in the central nervous system according to variations in the density of neural firing (Stern, 1985, p. 59). Since the same activation contour is produced whether a particular object is seen, heard or touched, this information must exist beyond the senses, in a form that can be recognised in any of the sensory modes (Stern, 1985, p. 51). Activation contours may be infinite in number, and are organised into recognisable groupings or families (Stern, 1985, p. 54), structuring the psychic representation of the body and creating the stepping-stones towards verbal language (Stern, 1985, p. 141). Activation contours are the underlying features of vitality affects. These feeling qualities are shared points of reference during (m)other and infant communications, and are best described in dynamic kinetic terms, such as surging, fading away, fleeting, explosive, crescendo, bursting, drawn out, and so on (Stern, 1985, p. 54). Such qualities of aliveness are not only displayed by the infant but in all behaviours, throughout life. Perceptions of another persons behaviour are experienced as vitality affects in ourselves because amodally cognition cannot readily be separated from feelings. The translation from perceptions to sensations experienced virtually also takes place through the rendering of art forms, according to their exact performance or style. Levels and qualities of exuberance expressed through art or behaviour, in terms of timing, intensity and shape, become shared communications during acts of attunement. Interactions referenced by vitality affects enable the identification of self-invariants, which are integrated to memory creating a dynamic sense of self and other (Stern, 1985, pp. 7299). Self-invariants emerge as islands of consistency as the infant begins to order experience by identifying whether a sense of volition precedes sensory stimuli, bodily movements and motor acts, and whether the consequences of these are predictable. Interpersonal experience begins to operate at around threenine months as the infant gains what Stern (1985) describes as a sense of core self through a growing awareness of its own

sensations and feelings (self-affectivity), of the surface and edges of its body (self-coherence) and of existing in time (self-history). Between 915 months, with the sense of subjective self mental states such as intentions or affects begin to be shared intersubjectively. Successful functioning of the sense of core and subjective self gives rise to the sense of verbal self at around 15 months. The driving force for the development of language and intersubjectivity is the sense of emergent self, a dynamic process functioning at birth that remains and develops throughout life as the primary organiser of self/ other experience.
Visual research framework

This methodology was developed by the author, using as a starting point the Frame within a Frame approach to visual research (Huet, 1995). 1. Preparation. The framework outlined below is a way of systematically considering the dynamic intersubjective process functioning in therapy. The clients approach and the therapists responses were integral to the development of its structure. The artwork was subsequently ordered according to theme to allow the therapist to identify changes occurring in his format and to attempt to make sense of why these had occurred. The paintings and drawings produced by the client in sessions usually adhered to three themes: paintings of rectangles and squares, drawing of a house, or drawing of a path in the park. On some occasions he painted stripes, patterns or shapes. He produced four drawings of an interior and two of a crossroads and once made a copy of a painting on the wall. Similar images were arranged in chronological order to reveal stereotypical themes/formats used by this client. Images containing variations in theme/format or construction were selected. 2. A verbal transcription of these images was carried out. The visual expressions originally recorded by the client in each image selected were copied according to the therapists perception of them into a different medium, that of the written word. This was juxtaposed with a digital copy of the image and presented. 3. An intuitive understanding of the clients use of visual and spoken language had developed over the course of therapy and so the written records of the sessions were integral to the visual

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research framework. Written records of the art therapy session(s) in which each selected image was made were presented in chronological order. These consisted of observations of the clients behaviour, his approach to the art making, his use of speech, and the therapists countertransference feelings and responses to the client. 4. The verbal transcription of each image was juxtaposed with the written record of the art therapy session in which it was made. Similarities and differences between the visual, behavioural and verbal communications that were shared between client and therapist during each session were identified and presented. During Stages 3 and 4, the analysis of images included temporal and spatial co-ordinates as follows. Each image was considered in its:
(1) chronological visual and verbal context (clients speech, therapists written records, verbal transcription of the image); (2) chronological visual and verbal contexts according to theme/format; and (3) temporal and spatial context in terms of: (i) construction; (ii) therapeutic boundaries; (iii) duration of art therapy.

Figure 1.

In the attempt to share this work coherently with others, this framework was used as a tool that uncovered new information, in turn requiring new integration. 5. Research findings written up for effective communication with colleagues and trainees who may find this work of interest.

Introduction to client Background

I will refer to my client as Travers in order to safeguard his identity and ensure confidentiality. He is introduced through an image he made during an assessment carried out before I met him (Figure 1), through information gleaned from a referral letter, and then in a vignette of our first meeting.
Inherently two dimensional, a house suspends itself by the chimneys from the top of the paper. Inside is darkness and outside nothing. The ornamented door is barricaded, wrapped around with bars or ropes. In the attic, two tiny windows appear to bear witness to something tragic that has taken place behind them. Traces of chalky fingers stain the paper alongside the house.

The letter was from a learning disability psychologist who was offering Travers anger management sessions. As part of the referral process, information was shared about the difficulties that the client was experiencing. He had been keeping his neighbours awake all night stamping and shouting in his flat and, relatively recently, he had also been charged with public indecency. He wanted the psychologist to tell everyone to leave him alone and disliked being told he was angry because he did not acknowledge that he was. He disliked people talking to him or asking questions; his own communication style consisted of repetitions of lists of names, places and dates. Anger and sexuality had been key themes in the sessions, and there had been periodic attempts to change session times. Travers was apparently normal at birth, but concern was expressed about his development when he was 18 months old. After attending a school for children with special needs, he trained in catering and cleaning services. In a violent bid for independence at the age of 17, he attacked and briefly hospitalised both parents in a successful attempt to move away from home, against their will, into sheltered accommodation nearby. He was currently employed in a hotel in west London doing cleaning and laundry. His adherence to routine included visiting his family daily at certain times, listening to particular radio programmes, drawing, writing up his diary, attending various social clubs or travelling around London on his own, learning different public transport routes. He would talk to himself, repeating conversations he had heard between people familiar to him and imitating their voices, but appeared to experience other people as intrusive. No friends or family visited him and he was very cautious towards the friendly approaches of people unknown to him.

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Amodal perception and language in art therapy with autism First meeting

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I include below a brief extract from notes made after my first session:
My first glimpse of Travers was of a chubby and smiling face surrounded by sandy coloured curls, looking through me and beyond with curiously glazed and deep-set blue eyes. He turned to hang up his jacket, revealing a patterned jumper and trousers at least a size too small. I introduced myself briefly as we sat down, and then a silence fell. After a few minutes, he seemed slightly at a loss and so I commented that Id heard he liked painting. He responded eagerly and I invited him to help himself to paints. He began squeezing and shaking the plastic bottles so they made airy squirting noises as he sniffed the paint. Although he was a large man, he seemed to struggle for several minutes to obtain green paint from the bottle. I commented on his perseverance, indicating there was another bottle of green on the shelf. He ignored me. Finally, he stuck the handle of a paintbrush into the nozzle of the bottle to free it and began to paint. I moved away from him slightly but he threw me an anxious look, so I moved back again, asking if he wanted me to sit next to him. People are always asking me questions, but I dont know he replied. When he had completed his painting, he began talking at length. I could barely follow the sense of it, since meanings seemed to be disconnected and his speech was like that of a three-year-old child. He was rocking backwards and forwards in his chair. I managed to decipher that he doesnt have to be like the others, and that he stopped worrying 11 years ago: Worrying is like mixed up food. Some you like, some you dont like. I suggested he could paint that if he wanted and, to my astonishment he painted some rectangles. My assumption that his image might in some way relate to our conversation, or fit within my own frame of reference, was mistaken.

Travers had an ambivalent attachment style. A similar approach could perhaps be useful for art therapists as an equivalent to the Adult Attachment Interview when the client has no or little capacity for verbal communication. Travers conversation had been one-sided as he talked at me incomprehensibly, or failed to respond. I noticed that the words I, you, he, they were for him interchangeable, so that there was a confusion about identity, that of others and his own. Understanding him was further complicated as he seemed unable to use words to tell me about his own experience. Travers, by contrast, appeared to have understood everything I said. Although my use of words had been simple and concrete, this impression possibly marks the point at which I began to slip into the realms of madness with Travers.
Overview of therapy

Having read the referral and assessment information about this client I was aware that before our meeting I had been dreading the idea of listening to lists and was also not confident about my ability to cope with his anger and sexualised behaviour if it was directed towards me. Following our meeting this uneasiness disappeared. Travers himself had seemed ambivalent about art therapy and although he presented as aloof and passive there was a sense of struggle between us as he attempted to control my speech, my actions, the seating arrangements and the continuation or not of the sessions. My experience of the quality of the relationship that was developing between us indicated that

From here we entered a two-year period of art therapy. The first phase was carried out while I was a trainee for nine months within an adult psychiatric day service for outpatients in a London hospital. Art therapy supervision was provided on placement and through my training institution. Talking about the work coherently was a struggle and supervision was essential for giving me a perspective on this and containing my anxiety. The sessions were presented as a case study (Rostron, 2000) using a framework of object relations theory extended by Thomas Ogden (1989) to include, through his concept of the autistic-contiguous position, the recent findings from developmental psychology. For me, this left many questions unanswered. Our work not only seemed to have taken place in a void but had ended, so I was surprised to receive a response six months later. The referrers, based in the Learning Disability Psychology department of a neighbouring hospital, were offering to provide funding for this work to continue on a sessional basis because his key workers felt Travers had benefitted from art therapy. The impact of recommencing this work was not anticipated. Travers appeared to experience me as if resurrected and his inability to fully comprehend the situation, together with my lack of experience, placed us both in a vulnerable situation. We were allocated a side room off a geriatric ward due to shortage of space in the hospital and because there was no running water or a sink, it was necessary to carry water from and to the kitchen in a large bucket. The building was dilapidated and there appeared to be low morale generally among staff. A learning disability psychologist who had not encountered art therapy

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before but was familiar with psychodynamic work offered me supervision through the department each fortnight. Ten months later our room was reclaimed and we were transferred elsewhere without notice. This was disorientating, especially because it had not been possible for me to prepare Travers or to consider our sudden move through any kind of discussion with him. After a month or two I noticed that Travers was no longer producing paintings, preferring to draw. His work was rich, but his use of felt tip pens exclusively seemed to express some kind of tension. At the corner of my mind, too, there was a sense of uneasiness. We now found ourselves in an area of the hospital that was deserted at the time of his session. Some anxiety about working so alone together was hovering, but never got to be thought about or articulated in words. Yet it was not only me who was unable to think clearly at that time. An attack on thinking appeared also to have taken place in the learning disability psychology department. The absence of a risk assessment, when it was known that anger and sexuality were key issues for the client, amounted to very poor practice. Art therapy continued without incident until we needed to end our work. Over the three-month period of ending, I encouraged Travers to think about this from time to time. He reacted to my words by grumbling, becoming increasingly withdrawn and irritable. He repeatedly turned up late and when he arrived one afternoon armed with a metal coke can I was finally rendered speechless. He slowly finished his drink, stared into space, then back and forth at me, crushing the can in his hand, harsh metallic sounds ricocheting off the bare walls. A brief but intense showdown erupted. His murderous hatred of me was terrifying and impossible to contain. It was evident that I was at risk and we transferred to a room in the learning disability psychology department to complete the work safely. A recent article (Bull, 2008) has shown how important it is to take great care with engagement and endings when working with adults with learning disabilities. Over the two phases of art therapy there were around seventy sessions in all, three of them cancelled by the client and one by the therapist. Breaks were taken for Christmas, Easter and over the summer.
Unconscious communication through artwork, speech and behaviour

progression and how the conclusions are reached. A focus now follows on the interactions during therapy through the shared capacity for amodal perception. A vignette of Session 3 describes a therapeutic act of attunement as well as a failure of attunement, and the lack of self-affectivity in the client.
There was a long cycle of bottle tipping, wheezingsquirting wet paint sounds, paint sniffing and bottle squeezing. He picked up a piece of wire to insert it into the nozzle of the bottle, and pushed it slowly back and forth, his eyes fixed into the middle distance. The wire thrusting became incorporated into an enlarged cycle of squeezing in and out, blowing and sucking, pushing back and forth, tipping up and down. I finally became so uncomfortable I suggested, The bottle may be empty. He seemed not to have heard me . . . there is another green on the shelf. Then he said quietly, I like this green. The surreal quality continued as I wondered to him if it was the same green as last time. Yes, its the same green as last time, it is. I like this one he replied, still squeezing. Do you like the feeling of it? Yes, I like the feeling of it he echoed. This acknowledgement seemed to enable him finally to get a small glob of into the palette. He began to carefully paint a series of ellipses in bright warm colours. He put his finger into the centre of some of them as they were completed, as I thought, to hook them out. Then he put his finger and thumb between the loops as if measuring the distances in between. I like the shapes he said. Then he put down his brush, and remained silent for some time, absorbed in more measuring, whispering and giggling to himself. I made the mistake of enquiring whether he had finished his picture. The peace of the session was shattered as he rounded on me to loudly deliver a list of names, places and dates, which erupted so rapidly that I had the impression he was reciting them off by heart. The form of the communication was expressed rather than the meaning. As the end of his string of words linked directly into its beginning, I visualised a string of worry beads, in a loop similar to those in his painting. Witnessing these articulatory loops was like seeing words being sicked up, swallowed and regurgitated, providing no space in which meaning could be expressed or digested. I finally picked out one name asking Who is that person? He shouted menacingly, Dont! I dont like words like whatandhowandwhoandwhichandwhenandwhy. The art therapy is going to stop people asking me questions. Feeling assaulted and almost concussed, I understood my question had broken some kind of protective spell. I apologised and he

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This article continues with a gradual and graded process of analysis so that the reader can see the

Amodal perception and language in art therapy with autism transformed himself from bully to child again, telling me with a sweet smile and a babyish voice that he talks gibberish, that he is a mental creep, that he is stupid and mad, and people treat him like a child. I observed to him that he was smiling as he was telling me sad things, and his face dropped immediately, his mouth looping open and slowly shifting into different positions. He was watching my face closely, perhaps expecting it to tell him when hed got it right. Towards the end of the session, when I anticipated that it would again be difficult to get him to leave, I suggested that each session had a time shape of 50 minutes that always remained the same. I visualised this as a loop.

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In the earlier part of this session, becoming aware that I was sharing Travers sexual/erotic feelings as he interacted with the paint bottles, I suggested, The bottle may be empty. Naming these feelings for myself pulled us out of a cycle of behaviour that had begun the previous session when he was distracted by the lids of the paint bottles, tracing his fingers round and round the nozzles. I was confused that the sexual erotic impulses on my part had alternated with maternal ones. He lost interest in the paint bottles after this session, but situating myself in relation to him remained difficult. I often felt drowsy and comfortable when he was painting, my eyelids heavy with a sensation previously experienced during pregnancy or breast feeding, while Travers was ecstatic about the wonderful floating colours. Once, in this kind of atmosphere he spotted some workmen outside whom he appeared to view as rivals. I could suddenly become aware that he had the body and sexuality of an adult male as he presented himself like an infant or a child. There was an occasion when he turned towards me., squinting and grinning and masturbating furiously, as if expecting me, I thought, to join in the fun. In a split second I responded flatly, You are telling me something about your willy. My intervention startled us both but was so effective that he subsided into giggles instead. The erotic transference appeared to be the motivational force of therapy, perhaps reinforced through our male/female gender configuration. It was often easy to forget that any change in my movements or tone of voice could in an instant frighten and enrage him. Travers was highly sensitive to the vitality affects displayed in my behaviour, but he seemed unable to track them in sequence, neither as overt behaviours nor as familiar, known emotions, creating a lack of self-affectivity that usually caused him to respond simply in terms of pleasure/unpleasure and approaching/avoidance.

It has recently been discovered by neuroscientists that dyadic co-ordination is enabled by adaptive oscillators, acting like clocks within the body, bringing their firing into synchrony with the incoming stimulation or signal (Stern, 2004, p. 80). Our clocks were often out of sync, and difficulty distinguishing between perceptual information belonging to him or to myself was often my own experience in therapy. My lack of attunement during his measuring activity, and his inability to self-regulate his feelings, resulted in me being split off as something he wanted to avoid, or perhaps annihilate. By the end of the session, I understood that the loop shape conveyed a feeling of boundedness for Travers. Shape became the basis of the attunement between us as I sensed a similarity between the forms in his image (Figure 2), in the form of his mouth later, and in the form of his speech while he echoed my phrases and articulated his lists. This understanding in my mind was linked to my thoughts about the ending of the session and to positive affect, to the sense of sight and touch and finally through the words time-shape, to the sense of hearing and to cognition. Travers then accepted the time-limited session without anxiety. This mingling of feeling and perception, transferred across the senses and between therapist and client, was not consciously thought about, just as art making is experienced rather than thought about as the senses of sight and touch are yoked. The idea that a translation occurs amodally from perceptions of others behaviour and artwork to create the illusion of sensations and feelings in oneself is now supported by evidence of a resonance system (Stern, 2004, pp. 7882). Neuroscientists have identified mirror neurons that create a pattern of firing, as we watch another person act, identical to the pattern created by the

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Figure 2.

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adjacent motor neurons when we make the same action ourselves. The subjective quality of feeling organises experience across a number of contexts and with different people and plays an important role in emotional self-regulation. It has been shown that adults with learning difficulties can reveal their emotional state and their individuality and through their responses to the art materials, through their artwork and in the strategies they adopt (Tipple, 1992, 1994). Sterns concept of affect attunement has been used to develop an approach to art therapy in children with autistic spectrum disorder whereby the raw material of sensation, feeling and emotion is shaped by the art therapist using her body proactively to enhance verbal communication and create shared meaning (Evans & Rutten-Saris, 1998; Evans & Dubowski, 2001). The concept of attunement in relation to the rendering of art forms described by Stern (1985, pp. 157161) was used in an attempt to enhance Travers self-affectivity and to connect his sense of touch and sight to words, but it remains unclear whether this approach was effective. His drawings and paintings were used as a shared point of reference to reflect his emotional state to him through interpretations made by the therapist. For instance, blacked out windows to his house drawings produced before breaks in therapy were connected to not wanting to see in or out, not wanting to know, smeary handling and colour linked to sad and tears, or feeling red hot and angry, split construction and coffin-shaped windows to ideas of darkness, loss and fear. The failure of his self-affectivity appeared to give predominance to two further self-invariants described in Sterns model. These were the sense of self-coherence that defines the surface and edges of the body, and the sense of self-history, an awareness of existing in time. Their functioning was manifested continuously through his artwork, speech and behaviour, and demonstrated during Stages 3 and 4 of the research. For example, Travers could create a sense of self-coherence in relation to pictorial space. The forms in his series of painted squares and rectangles were usually contiguous with each other, and there was always one touching the edge of the paper. He habitually took great care to prevent paint spilling over the paper edge onto the table. Through his drawing activity, he seemed to gain some kind of grip as he explored the tactile sensations of the resistance of the felt-tip pen on the paper laid on the table surface. He would begin each drawing with a horizontal line to which the image would be attached, as if tuning in to the hard surface of the

table beneath it, and at the same time separating off a quarter of the picture surface, which lay empty. In his series of house images, one chimneypot would always be clinging to the top paper edge, and after a holiday break, he once produced an image of a house that was completely justified to the left hand side of the paper. Similar approaches have been reported in the art therapy literature. Rees (1995), researching the use of spatial strategies by people with learning disabilities, described the behaviour of a woman making circuits around the room exploring the physical edges of her environment, and whose painting activity consisted of repeatedly overlaying the edges of the paper, and the edges of the table, with paint (Rees, 1998, p. 25). McGregor (1990) suggested that children with autism display no concept of volume or internal or external space in their drawings, which are constructed from a fixed viewpoint and in terms of surface, line, edge and contour. Travers images were always two-dimensional, and his behaviour reflected his similar perception of his body. He was clumsy, often bumping into the furniture, and I occasionally observed that he seemed to have no awareness of himself as a substantial three-dimensional form. Once, as he sat next to me drawing, with the window behind him, I commented that I couldnt see him against the sunlight. He turned his face towards me, smiling, holding this pose for me, still against the light, waiting for me to acknowledge that I could see him. I understood that he was aware of himself only as a face, a face that might reflect from a shaving mirror or a photograph, existing only in two dimensions. He seemed to have little sense that he was a person in the world, but rather that he could slip in and out of visibility, or even his own existence. His use of peripheral vision to scan the environment gave the impression that there was no centrally organised perspective from which he could see. Occasionally he could feel to me almost physically absent when he failed to respond. For him, my words appeared to carry no meaning and I seemed not to exist. Midway during the first phase of therapy, I noticed Travers was also attempting to bind himself in time as well as in space. Sometimes if there was a disruption to the regularity of the sessions he would produce contiguous stripe paintings, visually represented temporal patterns simultaneously connected to the sense of selfcoherence, as the stripes abutted each other, and involving a calming regular stroking action of the paintbrush. An image of long strips, expressing properties of duration, interval and number, inscribed feelings of resentment about our

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Figure 3.

Figure 4.

separation as he told me They are long shapes for a long holiday (Figure 3). The drawing activity itself seemed to function as a temporal pattern as Travers coloured-in with even patches of shading that created a hypnotic scrubbing sound, anchoring him through the sense of touch and encircling him with sound in a manner that reflected his use of speech. For example he sometimes made whispery sounds while fetching water from the tap or bucket, exploring the qualities of water, articulating these and creating onomatopoeic words of his own. As he engaged in an amiable loop of words at the end of a session, I would tease him about putting on his warm coat of words before he went outside, or thank him for reciting another poem, which, after his initial puzzlement, came to amuse him. He experienced my own speech as something real, and would echo phrases of mine that he was taken with, apparently because of their alliteration or their rhythm. My phrase bung the palettes in the bucket once seemed to delight him as he repeated it several times over. It was possible to make Travers aware of the similarity between his drawing activity and his speech as he worked methodically on the individual roof tiles in his house drawings. As a result, he began to slow down his speech, taking deep breaths so that he became more coherent verbally. He used to wear colourful patterned jumpers, and these, too, offered a correspondence with his spoken lists of names, dates and places. If he was anxious, rocking back and forth in his chair, it was possible to ease his anxiety by making links between the patterns on his jumper and the pattern of the sessions. Annotations of the dates on which he had been working on a particular drawing would become a significant part of the design, appearing as a visual rather than spoken list (Figure 4). In his artistic responses to breaks in therapy, he used

temporal tactics to gain a sense of continuity alongside to his use of pictorial space to gain a sense of contiguity. He would start an image before and complete it on his return, or work on a particular drawing (or series of drawings) on alternate sessions in a very symmetrical manner as he did towards our first ending of therapy. His response to the final ending was to withdraw for three months into the repetitive drawing of houses, deliberately leaving his final image incomplete. Similar behaviour has been observed by Stack (in Rees, 1998) who describes the holding mechanism provided by art therapy for a client with many autistic features who could move in and out of his encapsulating shell by interacting with the therapist for the first part of each session and then retreating into the production of repetitive Humpty Dumpty images. With little conscious awareness of himself or others existing in time and in three dimensions, it was as if he had not yet been born (Tustin, 1992, pp. 98110). For me, working consistently at an intuitive level, it was difficult to think during the sessions. Trying to make sense of what was passing between us through an embodied language of being was arduous and slow. I usually emerged from the sessions feeling stunned and thankful that there was only one autistic client on my caseload. Difficulties in understanding the communications of learning disabled clients, and powerful countertransference feelings of being deskilled, or made stupid have been reported by other art therapists (Kuczaj, 1998; Lomas & Hallas, 1998; Stack, 1998). My struggle to give meaning to this experience and my often merged state of identification with the client could at times trigger off extreme anxiety about not knowing who or what I was. Art therapy supervision provided a frame to think about this, and to begin to recognise the vulnerabilities, and a desire to know, that were my own.

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However, it was not until Stage 2 of the research project, during the verbal transcription of the images, that my understanding of the client and his language moved to a different level. As I revisited the Loops image, I became aware how Travers had been inscribing there the transference to the therapist, as signs that corresponded to it. It has previously been observed how the transference can be channelled symbolically into the images (Damarell, 1998). Looking again at Figure 2 alongside its verbal transcription revealed a vivid correspondence to an exchange between two people, expressing, as contours, the qualities and attributes of the therapeutic relationship:
There is a series of loops of differing sizes, or circuits of colour, captured dancing around each other and sometimes touching, fluidly paired in red, blue, yellow and green. Vertically down the sheet of paper, and to the right, a large yellow ellipse triangulates slightly to make contact with a larger loop that is centrally placed. This is red and although it is the largest loop in the composition, it merges into the red background, glowing. Potentially circular, its lower half contracts upwards, recoiling from, or perhaps attracting into it, a vivid blue loop below. It nudges a smaller blue loop against the paper edge, mid-left. Beneath these two blue ellipses, a second red loop fills the space evenly in relation to the paper edges. Its complementary twin, in green, appears parallel to it on the other side. A smaller green loop, almost circular, is attached to the paper edge diagonally opposite, rather like a pea to its pod. A second yellow ellipse shines horizontally against the red paper and abuts the upper edge of the larger red loop.

Figure 5.

As the vitality affects contained in the image reached my consciousness while I was writing, I saw that his measuring of the distances between the loops with thumb and forefinger, described earlier, was an attempt to order his lived experience of the therapist, and the space between us. As the extent of his capacity for intersubjectivity, and his experiential awareness of separateness became visible, I appreciated why my interruption had provoked his rage. It was now possible to reassess his series of images as they had been transcribed verbally in Stage 2, by juxtaposing them in Stage 3 with my written records that included the clients use of spoken language. For example, I had been surprised when he handed me his drawing to look at for the first time during Session 14, saying it was a path in the park (Figure 5). The theme in his spoken language, expressed with affection, had been his only girlfriend whom he had got to know at the age

of 19 at a social club; she had Downs syndrome. A closer look at the image again demonstrated that a correspondence, contour or sign for two figures was inscribed, this time intertwined and interpenetrating. This writing clearly held a meaning for Travers in the context of our relationship. Travers continued to invite me to look at his drawings, as if he was interested to know and be known by me. The Path in the Park series proved to be a liberating way for Travers to take a line for a walk and to make sense of our interactions. This theme progressed from a plain T shape initially into many variations and back again, recording the quality of his lived experience during the erotic intensity, or otherwise, of our engagement. Stage 4, which included a focus on temporal co-ordinates during therapy, revealed that Travers also had the capacity for intentional communication, which is acquired with the sense of subjective self. Prompted by the news, given six weeks in advance, of a months break in therapy, he began to work towards it, producing a new format for his drawing. Over two sessions he drew an interior of a room containing four chairs and a table with four empty bowls on it (Figure 6). The gist of his spoken language, several times while drawing, was that at home he would never eat when there were four people at the table; only when there were three. I could make no sense of what he was trying to show or tell me, partly because of the new symbolic elements in his image. In the penultimate session before the break, Travers augmented his communication with three paintings (Figure 7). The first was divided into four rectangular flood areas, spreading over the table, and dripping onto the floor. Remembering the image with four empty bowls, I asked him Whats four in your life? He replied quite clearly My mum, my dad, sister and me. I asked if he was trying to say something about them in his image, but he told me Its four pictures. I wondered if they were pictures he

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Figure 6.

Figure 7.

couldnt do over the break, and he confirmed this saying There are four weeks in April. He immediately produced a second image, divided into three flood areas, and then a third image, divided into two, in a ritual countdown. I acknowledged he wanted me to take only three weeks off, rather than four. Analysis during Stage 4 of these two approaches to the same theme demonstrated a transition from metaphor to analogue as the break in therapy approached, as well as the supplementary relationship between both to achieve his communicative goal. In Figure 6 Travers was using metaphor to represent the four sessions in which he would not be attending therapy, as four empty bowls on a table. His thinking about this idea was also reflected through a plan view perspective he had not used before. His use of metaphor confused me and delayed effective communication between us. He was now developing an imaginary register, no longer giving form on paper to his immediate lived experience through the language of nonverbal analogy, or correspondence, that I was accustomed to, and that he readopted in the countdown images (Figure 7). Metaphor as a linking process governing perception and associations between experiences is currently the subject of inquiry by cognitive linguists (Stern, 2004, p. 200). The use of nonverbal analogy, based on activation contours and expressions, rather than metaphor, symbolisation and words, is now given further clarification. It is used intuitively during the process of attunement between mother and infant, as the behaviour by which the infant expresses its internal state is recast into a corresponding behaviour by the mother. This simultaneously registers the infants communication and signifies a corresponding yet autonomous response through analogy. To give an example: the face of a nine-month-old boy opens up to display interest and amusement to his mother as his eyebrows rise, eyes widen, and he grins before his expression fades again. She responds with Yeeeaaah! in a pitch that rises and falls smoothly, matching the contour of his facial movements with a corresponding contour in her vocalisation. Stern (1985, pp. 140141) offers further examples of nonverbal analogy occurring during motherinfant interactions to show how it creates stepping-stones towards metaphor, the use of symbols and so to verbal language. A closer look at this relationship between analogue, metaphor and symbolisation, as it was analysed during Stage 4 of the research, now follows. Figure 8, for example, communicated, by way of analogy, unpainted pictures preceding a

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Figure 8.

weeks break, and during the same session he painted a sequence of separate rectangles that were paired in terms of colour (Figure 9). Amongst these, two rectangles were fused together, and we considered ideas of being together with, or separated from, the therapist. Just before his reappearance 10 days later, with a huge bloody scab on his forehead, I learned his employers were concerned that he had begun lying at work, and that he had engaged in a bout of head-banging so severe that he had damaged a wall. The two fused rectangular shapes re-emerged several weeks later (three months into therapy) in his house drawing format, metamorphosed as double entrance doors (Figure 10, detail). This was shortly followed by a house image now lit up inside (Figure 4). Subsequently there was an expansion of his imagination with a corresponding ability to tell me stories about himself, documented elsewhere (Rostron, 2000, 2002). A complementary movement midway through the second period of art therapy demonstrated a development of this theme, in terms of separateness rather than fusion. He appeared disturbed when, for the first time, I had left the

Figure 10.

room to fetch a new bucket of water. On my return, he engaged in mass production of rectangles and squares paintings, until I finally wondered to him if he was enjoying his game of sending the teacher out of the room to fetch water. He dissolved into giggles. A couple of sessions later he again churned out painting after painting, this time because he was annoyed. He exited the room himself, angrily (with a jam jar) time and again to fetch water, sometimes shutting the door, sometimes leaving it open. Our lived experience of the outside coming in, being shut out or being shut in, was worked with as the room filled up with paintings of contiguous rectangles and squares. Amongst these were two large rectangles, one yellow and one red, on separate sheets of paper (Figure 11). This was soon followed by his third drawing of an interior (Figure 12) with an open door leading from one room into another, depicting perhaps a new permeability to our relationship. These supplementary shifts in this language were observed only from the perspective of Stage 6, as the research framework was used consciously as a tool. We had been engaged in a

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Figure 9.

Figure 11.

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Figure 12.

Figure 13.

dynamic learning process during therapy, but I could not fully appreciate this until I had reviewed the series of images and session notes. This unconscious process continued as our different experiences were integrated to give form and structure to the visual research framework, the MA essay, and as my thoughts were organised during the writing of this paper. It is what Stern terms the sense of emergent self, that he describes as a process of organisation as different experiences of self and other are integrated, as well as a product of these integrations. It is applied throughout life to whatever sensations and perceptions are available. The sense of emergent self is the counterpart of the self-reflective, verbalisable self from which perceived forms, thoughts, and indentifiable acts and emotions later arise. Its language was shown during Stage 5 to reflect lived experience through a form of object-relating that was continually present, based on spatial and temporal co-ordinates and directed towards the monitoring of the absence and presence of sensations of being enclosed by the maternal body, and yoked to the senses of touch and sight. This form of object-relating was recorded most clearly in a painting that Travers produced when he was extremely anxious, anticipating separation from the therapist (Figure 13):
He was exploring perceptions of absence and presence through properties of time: duration (horizontal line) beat (regular dotted line) and rhythm (purple and yellow blocks, and black crescents) in relation to the spatial co-ordinates of the paper. Feeling qualities were expressed through the layers of marks, the top one containing four yellow tooth-like shapes, the next made up of small black crescent-shaped lines, rather like fingernail indentations, two concave and two convex. The middle layer repeats the forms of the top layer, this time in mauve, and with

an extra narrow peg squeezed into a potentially large gap. This is underscored by a flesh-coloured strip stretching from one side of the paper to the other. The lowest layer has the appearance of a thick red thread that weaves itself in and out of the paper intermittently to create five short stitches.

This intuitive appreciation of the clients visual language was gained through my background as an artist/painter; his image also demonstrated his affinity with creative individuals from all walks of life. To give examples from the art world, poets, plastic artists, composers and dancers immerse themselves in the sensations and perceptions of their chosen medium inscribing new contours, correspondences, representations and languages for their audiences to share. Each particular language seems to function as a contiguous object through the exploration of perceptions of absence and presence and in relation to time and space. This language, a product of the babys interaction with the maternal body, structuring and developing the sense of self, emerges at a point where thinking and feeling and the five senses both converge and separate, where the dynamic mapping of sensations and perceptions of the body may reach consciousness. The flow of perceptual stimulation in relation to time parameters is currently being explored in cognitive linguistics and in recent developmental and neuroscientific work (Stern, 2004, p. 4154). Arts therapists are fluent in this language of what Lacanians call the Real, i.e. of raw experience beyond verbal language, patterned by sensation rather than verbal grammar, by analogue rather than metaphor. This language remains in adult life, structuring the unconscious. It diverges away during the separation of cognitive and affective processes as verbal language and consciousness begin to develop. It appears to be the experience of this psychological separation that Travers found almost impossible to negotiate, and that was

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difficult for the therapist. Although attunements occurred, they were often out of the therapists awareness, and many communications were missed altogether. At times the client seemed to experience the therapists speech as an inscription of sound that could hold meaning. At other times it was received as meaningless, or had an embodied significance for him that was unknowable to the therapist. It was often not possible therefore to be sure in what register communications were being given or received. This made the use of interpretation problematic. The therapist could perhaps adopt a position that motivates the client to engage in a play with these differing uses of language to organise self/other experience, that also prevents the therapist from inadvertently imposing meaning from the outside in the form of assumptions. My encounter with Travers took place as he began to emerge out of what I assumed I knew about his thoughts and feelings, entirely unpredictably, perhaps spurred on by my mistakes and misattunements. He used the therapeutic space for his own unique purpose, that was always beyond conscious grasp, producing his richest work when least anxious. His drawings of interiors appeared during the mid-points of both periods of therapy, and seemed to represent both the idea of home and the art therapy room. Clues about the quality of interactions taking place inside this interior can be seen in the symbolic elements contained in the images. The erotic transference is transformed as bedroom, double-doors or breast-shaped light switches, as places where food/nourishment may be offered or withdrawn. They depict a place like home where a trace of a human being could feel comfortable in bed, and where traces of four people, perhaps the members of his family, could each be comfortable in a chair. Light is cast through the windows, or from the lamp stand. As he drew, I heard about his first home, his memories of banging his head against the bars of his cot at the age of one, and the childminder. This woman, who used to hit him when he called her Mrs Willy, seemed to represent a phallic mother for Travers. He told me how his mum took him away from there when she saw a red mark on his arm, and how, at the age of five, he started drawing houses every day and upside down. During the second phase of therapy, his narratives included his plans for the near future. Together we held on to the hope that he may one day escape from what he called his obsessions, and this was poignantly expressed as he enquired, at the ending of the first phase of therapy, where and how he could get a new

passport. His desire to get to the other side was visible in an image of a boat crossing the Channel, and, during the second phase of therapy, in two images of crossroads. The final image in this series was dark, executed in despair as he tried to come to terms with the idea that our work was ending. There were more complaints from his employers, who were disappointed that he had been gazing out of the window for ten minutes at a time, his hoovering and cleaning routine abandoned. I wondered if he was experiencing a similar space inside him for imagining a new kind of life. Had his art work functioned for him as a threading together of the registers of the real and the symbolic? Several medical tests and examinations were carried out to ascertain if he was physically ill. Later, on learning he had decided to quit his job, I wondered if our difficult work had amounted for him to anything at all. Of what use was Travers now to the people on the other side? And as for myself? I had become surplus to requirements.
Conclusion

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The research supports the idea that the unconscious is structured by a primary and supplementary language of contours and inscriptions mapped out through spatial and temporal co-ordinates. The client appeared to have been unable to separate himself from this language of lived experience, due to his inability to negotiate the divergence between feeling and thinking that occurs as cognition and verbal language develop. A consequent lack of self-affectivity may have contributed towards the dynamic structure of his sense of core self, which could seal him off defensively into shell-type autism. The therapist offered interpretations linked to the expressions she perceived in the clients speech, art making and in the artwork. Unpredictable responses by the client, and the extent of the communication that was missed by the therapist during the sessions, revealed the limitations to knowing what the client was feeling or thinking. A feature of therapy was the clients understanding of separateness, inscribed early on in the art work and later read by the therapist. His work elaborated on this as therapy continued, progressing from analogue to metaphor to create an imaginary world that he became able to talk about with the therapist. Both client and therapist are shown to have been engaged in a dynamic unconscious process of intersubjective organisation.

Amodal perception and language in art therapy with autism Acknowledgements Darian Leader, Lacanian Psychoanalyst, Centre for Freudian Analysis and Research and Visiting Professor, Royal College of Art, for the term contiguous object. My thanks also to Vincent Dachy, Astrid Gessert, Gerry Sullivan and Joan Woddis. References
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A. Gilroy & C. Lee (Eds.), Art and music therapy and research (pp. 117137). London and New York: Routledge. Rees, M. (1998). Drawing on difference. London: Routledge. Rostron, J. (2000). Working with autism in art therapy. Unpublished nal clinical report, Goldsmiths College, University of London. Rostron, J. (2002). An exploration into the use of visual and verbal language in art psychotherapy with an adult male with mild learning disability and an autistic spectrum disorder. Unpublished MA art psychotherapy research essay. Goldsmiths College, University of London. Stack, M. (1998). Humpty Dumptys shell. In M. Rees (Ed.), Drawing on difference (pp. 92110). London: Routledge. Stern, D. (1985). The interpersonal world of the infant. London: Karnac Books. Stern, D. (2004). The present moment in psychotherapy and everyday life. New York and London: W.W. Norton & Co. Tipple, R. (1992). Art therapy with people who have severe learning difculties. In D. Waller & A. Gilroy (Eds.), Art therapy: A handbook (pp. 105124). Buckingham: Open University Press. Tipple, R. (1994). Communication and interpretation with people who have a learning disability. Inscape, 2, 3135. Tustin, F. (1992). Psychological birth and psychological catastrophe. In Autistic states in children (pp. 98110) (rev. edn.). London: Routledge. Waller, D., & Gilroy, A. Art therapy: A handbook. Open University Press. Waller, D., & Gilroy, A. (1994). Communication and interpretation with people who have a learning disability. Inscape, 2, 3135.

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Biographical details

Jo Rostron is an art psychotherapist based in London and employed by Children and Families Services. She is a research associate of the Centre for Freudian Analysis and Research.