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07/2014
May Nilsson
Saying Farewell.
Aspects of Termination With Autistic Children
EFPP Psychoanalytic
Psychotherapy Review
EFPP Psychoanalytic Psychotherapy Review 07/2014
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www.efpp.org/review/
Abstract
This paper looks at aspects of termination in child
psychotherapy when working with autistic children.
The parents’ participation is discussed as well as how
simultaneous work with parents may influence the ter-
mination. Attention is drawn to the therapist’s view and
the importance of understanding the feelings that are
awakened in both therapist and child.
Keywords child psychotherapy, termination, autism,
simultaneous treatment, parents.
Introduction
Is there anything special about terminating child
psychotherapy with an autistic child? Does it give rise to
particular feelings, thoughts and reactions in the child,
parents and therapist? The aim of this article is to illumi-
nate these issues. However, let us begin by examining
some general guidelines regarding termination in child
psychotherapy.
Fabricius and Green (1995) emphasize that the
therapist needs to identify criteria specific to each child.
Has a developmental process started? How does the
child function emotionally, socially and cognitively?
In Anna Freud’s view, termination criteria seem to
fall into three groups: issues related to the analytic aim
of restoring the child to the path of normal develop-
ment; issues related directly to the progress of the ana-
lytic work itself, including the resolution of the trans-
ference; and the child’s developmentally appropriate
adaptation in his life outside the treatment setting, such
as his functioning in school and at home as judged by
the child, his parents, and the school (Sandler, Kennedy
& Tyson, 1980, p. 241).
Novick, J. (1990) talks of dynamic criteria, such as
those that indicate change, flexibility and capacity. The
most important criterion is that the child has gained ac-
cess to his or her capacity to develop further. Sometimes
the therapist’s feeling that it is possible to terminate
may come suddenly. The child brings in something
from the outside, and the focus is no longer on what is
happening in the room: it has moved onto a movement
in the child’s inner sphere.
How can such criteria be employed in psycho-
therapy with autistic children? This therapy is often
terminated regardless of whether the child is able to
function at an appropriate level for his or her age. At
the same time, other functions may have appeared: for
example, the child has gained boundaries around his or
her own body and person. Progress may also have been
made in increasing the capacity to integrate outer and
inner experiences. Hopefully, maturation and consoli-
dation have occurred, with the child having been able
to internalize something of the therapeutic process. The
child has received help in finding meaning and context
in diverse experiences and even the ability to symbolise
has developed (Nilsson. W, 1997). However, it is impor-
tant to bear in mind that there may be a discrepancy
between theoretical notions about termination and the
actual process as it is expressed, something of extra sig-
nificance when working with autistic children (Fabricius
& Green, 1995).
Even the thought of termination changes the
atmosphere for the psychotherapy. The child and the
psychotherapist are now placed in time and space and
the eternal perspective of the therapy no longer exists.
At the same time, thoughts about the past, present
and future can arise and the ”sense of time” exerts an
influence, as both child and therapist become aware
of the termination approaching (Lezak, 1995). Earlier
experiences of loss or being abandoned or neglected
are recalled. They are an important part of termination
work in child psychotherapy and might be of extra
importance to consider when working with autistic
children (Alvarez, 1992). The ending of therapy might
lead to the development of different types of anxiety as
mentioned by Blake (2008):
Feelings of falling apart, inability to cope, being
disorientated (unintegration/disintegration) or jealousy
and rivalry, with the feeling that the therapy is ending
because the therapist has found someone more inter-
esting (Oedipal). (p. 304).
The setting
During the past fifteen years, working with children
with autism spectrum disorders and their families has
become part of my clinical work as a child psychother-
apist at a training institute. Some of the children I meet
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Houzel (1990) emphasizes the importance of in-
viting the parents to speculate on the meaning of their
child’s symptoms and to support them in their search for
meaning, especially when working with autistic chil-
dren. Beginning in this way also lays a foundation for
the parents to become acquainted with and understand
the forthcoming termination work.
Balamuth (2007) writes: “Once the parent begins
to recognise more and more complex intentional action
plans in his child, he begins to identify and refer to the
child’s state of thinking, wanting, feeling and so on“
(p. 173).
Child psychotherapists are trained to observe and
reflect on details. Through infant observation, therapists
have learned to see how babies relate to their care-
givers. This experience is of great use when one sees
parents and child together initially.
Infant Observation should also increase the under-
standing of the child’s non-verbal behavior and his play,
as well as the behavior of the child who never speaks or
plays (Bick, 1964, p. 558).
As a therapist I have become a bridge between the
child’s actions and the parents’ experience. I function
as a translator in order to make the child’s inner world
comprehensible. I might also be seen as a part of the
family system, thereby gaining access to intrapsychic
material from the child and interpersonal data from the
family.
The parents
During the parental sessions I am able to convey
my thoughts and ideas about the child’s inner world,
which results in the parents becoming interested in their
child in a different way than was the case previously.
Curiosity is often awoken when the initial parental
work is characterized by the parents’ reactions to the
child’s difficulties. The sessions swing between guilt
and shame when the child’s behaviour is often felt to
be demanding and difficult to comprehend. The idea
that the child’s behaviour is affected by his or her
emotional state becomes, for some parents, something
new to reflect upon. Over time the parents and I are
attend a day nursery for children with special needs,
which is close by and linked to the clinic. I often start
the therapeutic work by seeing the parents without
the child and then continue by seeing the parents and
the child together. Anna Freud commented on differ-
ent ways of working: there is a wide range of possible
arrangements, from simultaneous analysis of child and
parent to having the mother within the treatment room
even if only for a short time, to regular contacts, to
occasional contacts only, and so on (Sandler, Kennedy
and Tyson, 1990, p. 214).
By offering to meet them together with the child,
the parents are then able to hear some of my comments
when I verbalize something the child has done or in some
other way try to understand the child. In this initial ses-
sion, I deliberately do not turn to the parents but focus
upon the child, with the aim of observing what happens
but also in order to give the parents an insight into what
therapeutic work can entail. This often works very well:
the parents’ possible need to share thoughts and opin-
ions does not take over the session. In my experience,
letting the parents attend together with their child at the
initial stage increases their interest in the psychothera-
peutic work, whilst at the same time the child’s function-
ing becomes more apparent. Seeing the child and parents
together also gives me an insight into the relationship
between parent and child. Chethik (2000) writes: “Un-
derstanding the parent-child relationship must be a cen-
tral part in the diagnostic process, and when necessary,
modifying the problems in the parent-child relationship
must be a part of child treatment process“ (p. 16).
When the individual therapy has started, the child
attends twice a week and the parents once every two
weeks. Parents may sometimes have an appointment
every week, mainly in the therapy’s initial phase. In
my work I often use two rooms: a child therapy room
where I meet the child and another where I meet the
parents. The rooms are furnished differently: for exam-
ple, the child therapy room does not have a computer
or desk. Having these two rooms is a help for both
parents and child, whilst at the same time I am afforded
greater ability to keep the processes apart. Meeting the
child together with the parents in the parents’ room,
initially and in the termination session, gives a signal to
both parents and child about the boundaries concerning
the child’s therapy.
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(1999, 2004) and Tustin (1981), amongst others, have
described. The work in itself is challenging and places
great demands on the holding capacity and sensitivity
with regard to both the children’s specific mode of
expression and the parents’ situation.
For children with autism, the concept of time and
the capacity to think are often limited, in the same
way that their ability to know what they feel or that
it is possible to experience a feeling at all is limited
(Alvarez, 1999). I have met several children who have
found themselves initially in the “present point of
time”, where the waiting was very difficult. The psy-
chotherapeutic work is to a certain extent a matter of
linking together material and time, where the therapy
sessions and their regularity constitute a containing
, as described in my work with Peter: “Most of the
time I was sitting in the middle of the room on a little
chair, whilst Peter was preoccupied with looking at a
clock on the wall or putting sand into a toy sand mill
in a very repetitive way. I used to comment on this
as the hands moved or when the sand was running
through the mill. Perhaps the sound of the hands of
the clock introduced him to a rhythmical quality,
which I echoed as I helped him by describing the
sound, counting out ´one, two, three´, etc.“ (Nilsson,
2009:134).
Another aspect of the initial work is often to assess
the quality of the child’s attachment. Balbernie (2001)
writes: “The quality of the attachment between the
baby and his caregivers lays down the template of ex-
pectations and responses for all future intimate inter-
actions in implicit memory, the unconscious internal
working models of relationships“ (p. 237-255).
Here is a sequence from the initial session with
Oscar, 5 years old, in which his difficulties clearly
emerge.Oscar comes together with his mother. In the
therapy room he suddenly jumps up onto my back,
holding tight, without eye contact with me or his mo-
ther. His mother tells me that this is a behaviour that
he has: he jumps up towards, for him, strangers by
seeking contact with their backs. I perceive an ‘avoid-
ant-insecure attached’ boy (Ainsworth et al., 1978),
whose major aim is to avoid any awareness of bodily
separateness (Tustin 1981, 1986).
able to discuss details or small things that the child has
done. Parents often bring examples from home, where
they start to observe the child’s actions and behaviour.
Together we are able to think about what the child’s
actions could mean. Simply this on its own, using our
therapeutic ability to perceive very small details and
atmospheres, is an important part of psychotherapy
with children, where our knowledge about children’s
early development is of great importance in creating an
understanding of the child.
During the parental sessions I have sometimes
viewed the parents as co-therapists, and we have
together sought meaning in the child’s actions and
modes of expression. By focusing upon the child’s dif-
ficulties, I have also, at times, been able to come closer
to aspects of the parents’ personalities and in this way
been able to help them to see how their behaviour
affects the child, and how the child’s behaviour affects
them. An important task is to contribute to the devel-
opment of the parents’ empathic capacity and enable
them to perceive the child’s difficulties and emotional
life. The parents often undergo a transformational
experience through an increase in self-esteem and
self-knowledge. Through sessions with the parents,
I also have the opportunity to experience the child’s
environment outside the therapy room, something that
helps me to establish an understanding of the child’s
mode of expression and behaviour. During the sessions
I am able to create a picture of both the child’s and the
parents’ future possibilities.
Sometimes, the parents find the process too slow,
which is why I think it is important to bring up at an
initial stage the question about what will happen
when the therapy is terminated and the therapist is no
longer there. In the parents’ view, ending the therapy
might present difficulties. They might be aware that
from now on they will have the responsibility for their
child on their own and worry about the future. As one
father asked: “Will he get married? What will happen
when we are no longer there for him?”
The child
Therapeutic work with autistic children demands
specific knowledge and understanding, which Alvarez
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When the session was over and we were on our
way to the waiting room, we passed by my other
room (where I was seeing the parents). David looked
towards the door, appeared to recognize my name on
the door and said, “Is there a break?”
The sequence has several origins. In my first meet-
ing with David, two and a half years earlier, he hardly
noticed me. He had been diagnosed with autism and
impaired cognitive functioning. In the room, together
with his parents, he was completely occupied with
repetitively pouring sand into a sand mill, again and
again. In his world I did not yet exist; even less inter-
esting was the question of whether I might talk to his
parents. His father tried to interact with David in the
room but the boy shut him out by not responding to
his father’s attempts at contact. When the parents, like
my two rooms, turned up in David’s thoughts during
the termination phase, it could be regarded not only as
an indication that his conscious level had increased but
also that he had attained access to feelings of frustra-
tion and envy.
In my experience, at termination only a few chil-
dren have been able to talk about the future: for most,
any thoughts about the future have not been reflected
in the spoken word. References to the past have not
been observed, and it has been even more difficult
to connect to what the child initially did in her/his
therapy.
For the most part, termination and the termination
date are decided upon in consultation with the parents
and, sometimes, other staff working with the child.
Usually, when the children from the clinic’s day nurs-
ery are about to begin school (at the age of seven),
they can leave the nursery while continuing with their
therapy. It might be hard and confusing to end both
the placement in the day nursery and the individ-
ual psychotherapy at the same time. Sometimes it is
necessary to collaborate with the family and the child’s
network to enable the child to continue with the ther-
apy. To offer less intensive therapy might be a way to
resolve the problem, but in my experience, to reduce
the frequency often affects the termination process
negatively. The child might regard the less frequent
sessions as a punishment and there is always risk that
the termination itself will not be worked through.
Tustin (1981) has also described autistic children as
being aware of the fronts and backs of objects, but not
of insides as distinguished from outsides, something
that was apparent in the initial work with Oscar.
One can of course reflect upon how the individual
child psychotherapy is affected by my initially meeting
the child together with the parent, and also by the fact
that the child might understand that I will also meet
the parents from now on. In the case of a child with
autism spectrum disorder I have never received a direct
question from the child as to whether or not I am
seeing the parents; it has rather felt as if the parents’
approval of me has affected the initial work in a posi-
tive way. Towards the end of the treatment, however,
the question has arisen:
David, 7 years, looks at me. He has been in ther-
apy for two and a half years and we are seeing each
other again after the summer break. There is an agree-
ment to terminate the treatment during the term.
David: There has been a break, there are breaks,
and are people afraid of breaks?
Me: When there is a break, you might be afraid,
that we won’t meet again.
David [looks at me]: Are you afraid of breaks?
Me: I think you are wondering what I was doing
during the summer break, but I knew that we were
going to meet again. [He looks happy.] We are going
to meet on Mondays and Thursdays as we used to do.
Wednesday, Friday, Tuesday are breaks.
David [looks at me]: There was no break this
Wednesday.
Me: No break this Wednesday?
David: In your other room, there was no break.
Me: I think you are envious of me seeing your
parents and are worried that I might see them more
than I am seeing you.
My interpretation, i.e. saying that he is worried
about me seeing his parents more than seeing him,
was much too difficult for him, too concrete and I
perceived that David took my words as a truth. He
became anxious and I had to assure him that we would
meet twice a week just as before. I was probably
affected by being moved to reflect on the fact that he
had brought the issue of his parents into the session by
referring to the previous Wednesday when I had met
them.
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to depression) has become aware of separateness from
the mother in an insecure mental ‘containment’. This
can, occur, for example, with a depressed mother who,
for various reasons, has felt unsupported by the father
and by her own infantile and childhood experience“ (p.
15).
The abandonment, being isolated from his mother,
had had implications for Peter’s development. In many
children I have worked with, infancy has been charac-
terized by abandonment or traumatizing experiences
of other kinds. Perhaps, in the light of this knowledge,
it may be that a certain feeling of abandonment arises
when one begins a termination. Both the child’s and the
therapist’s experiences of parting and separation are
reactivated and both transference and counter transfer-
ence become important to reflect upon and understand.
Let us return to Oscar, who initially hung onto my
back and who, in the termination phase, had reached
the age of 7. “I want to be here all the time”. Oscar
looks at me. We have met twice a week for two years,
parallel with my sessions with his parents. We now
have ten remaining sessions before we terminate our
contact. Oscar pulls me by the hand and drags me into
my walk-in closet and puts chairs and a table in front of
the door. I stick out a small rod through the door, out
of concern that I would get locked in. “You are going
nowhere”, says Oscar. From inside the closet I say, “It
is sad to end”. Now Oscar becomes anxious, his voice
sounds tense. He lifts a telephone receiver and says, “I
have shut May in. She is to stay here all the time”. I
say, “I hear that you want me to stay here the whole
time, but I need to come out in order to see you”. “You
can come out for a little while”, says Oscar and pulls
the chairs away.
During our last session, when I am talking about the
termination, Oscar says, “I will make trouble at school. I
will box ”. I perceive his statement as his way to tell me
that if he is troublesome then perhaps he can come back.
The sentence is important in itself. “I will make trouble
at school.” When therapy started Oscar was very afraid
of loud noises and often asked me if I was angry.
I perceived his statements as a reaction to post-trau-
matic stress when he perceived the world as life threaten-
ing and without any chance of rescue. Oscar lacked the
capacity to regulate and understand his expressions of
feelings and he swung between tantrums and being iso-
To work with children with autism spectrum disor-
ders puts great demands on sensitivity and flexibility,
and it is not always possible to incorporate the child’s
views. Posing direct questions does not always neces-
sarily elicit the response one had hoped for. Sometimes
it is not possible to obtain any response at all, but the
child expresses in his or her own way what he or she is
thinking and feeling.
Peter had just had his sixth birthday. We had
met regularly over four terms and during the previ-
ous months I had spoken with him about our contact
terminating. On the wall calendar I had made a large
red cross indicating our final session. “I know.” Peter
throws a bit of paper at me and does not turn around
when he leaves, as he usually does. There are three
sessions left of our contact and it is the first time that he
directs anger towards me so clearly.
When he comes to the next session he looks in my
closet and I have a feeling that he wants everything
to be as usual with me and between us. “I know”, he
says when I start by saying that we have two sessions
left. Peter looks me up and down, almost as if he wants
to register who I am. When I talk to him about the ter-
mination and how it can feel he says “don’t talk”, and
I perceive sorrow in the room. Then we play a board
game, in his special way, as we have done many times
before. He is meticulous about me putting the game in
the closet when I tell him that the session is about to
end. “I’ll find my own way”, he says and I think that he
wants to show me that he is able to cope on his own.
The statement and the sentence “I know” may
have meant “I am aware but do not want to feel”.
But from my knowledge of Peter, I interpreted it as “I
can feel it, but I do not want to talk about it”. I also
believe that Peter’s desire for me to put the board game
in its usual place was connected to his desire for me to
respect his feelings in light of the approaching termina-
tion.
Peter’s start in life was in an incubator, isolated
from his mother who was deeply depressed and hospi-
talized. The father wrestled with his own despair about
both his wife and his son’s situation. Peter’s earlier
experiences (Nilsson, 2009) emerged throughout the
whole therapy in a similar way described by Tustin
(1994): “This fear reaction seems to be due to the fact
that a vulnerable infant (possibly with a predisposition
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child-therapist herself who sees the parents, but an-
other colleague.
Simultaneous treatment
By working with both the parents and the child
(Burlingham, Goldberger & Lussier; 1955, Chazan; 2003,
Houzel; 1990, Nilsson; 2006), it is often possible to settle
the termination date by mutual agreement. I gain confi-
dence in the parents based on my own experience of the
sessions with them. My feeling is that the parents also
then have confidence in me, when initiating the termina-
tion. At the same time as we discuss the termination date
they have the opportunity to raise possible concerns and
worries during our regular sessions.
When the parents meet another therapist while I
have been seeing the child, I have often experienced
that the parents want more contact with the thera-
pist who is treating the child. When the question of
termination then arises I have felt more like an ’external
therapist’ who is conveying her views.
In the cases where I have met the parents and a
colleague has treated the child, the termination has
often taken other forms: my experience is that the par-
ents have wanted to continue their sessions despite the
termination of the child’s therapy. Perhaps the parental
work takes longer when one, as a therapist, does not
have the child ’under one’s skin’ and does not know
what it may imply to be the child’s parents.
When working as a sole therapist, one aspect
requiring particular attention concerns transference and
counter-transference, in the sessions in which infor-
mation may affect, and have to be contained by, the
therapist on several different levels. The nature of this
way of working entails greater vulnerability and the
possibility of having a colleague to discuss these issues
with is often crucial.
Ending
How can one then prepare the child for the termi-
nation? In my experience one ought to be extra clear
and sensitive to the child’s specific needs and wishes
and one may need to repeat and clarify the ending in
lated. He seldom sought eye contact with me, with looks
being fleeting or absent. During the first term Oscar
had a certain predilection for toy swords, but he walked
around with them without using them in any particular
direction. He often said, “A guard”, but the words and
the connection with what should then happen with the
sword were not there. When he was now able to say “I
will make trouble at school, or even box”, there was a
link between action, thought and consequence.
The therapist
How do we as therapists manage the termination
when we work with children with autism spectrum
disorders? The feeling that the child perhaps does not
understand that we are going to terminate might result
in a tendency to delay raising the termination issue.
A feeling of guilt can arise: guilt about the qualities
and capacities that we ourselves possess but that the
child does not. I believe that it is extremely important
that we, as therapists, think about our own feelings
and motives. Perhaps we can be tempted to delay
the termination date, as we know what a difficult and
emotionally loaded task it is to work with a child with
special needs.
This can lead to us continuing with a child that has
progressed instead of taking on a new child with similar
problems. We also need to make sure that we do not
continue unnecessarily with therapeutic work if the child
is not progressing, being spurred on by our own wishes
and needs to feel that we are successful as therapists. To
be able to see that, as a therapist, one has been able to
help the child, and also to be able to mourn the fact that
there are things which it has not been possible to change,
despite initial hopes to the contrary, are important com-
ponents in the therapist’s termination with the child.
Perhaps the questions become even more delicate
when one works only with the child. There can be a
risk that one does not believe the parents are capable
of continuing to help their child develop and that one
over-identifies with the child. One might, for example,
seek to try to “vitalize” the child if you find the parents
depressed. It can also be extremely hard to inform the
parents that the child has been unable to benefit from
the therapy, contrary to the initial assessment. I think
that this can be particularly difficult when it is not the
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mother was the one who met him when he drew a train
driving towards the Central Station.
How can this be understood? In my attempts
to put words to those feelings that I perceived, Da-
vid responded by staging those games that for him
represented the termination. David seldom expressed
emotion in the form of words. But he cried when we
sang a song together about a pig that was going to go
out for a walk. At the beginning the pig had ten friends;
towards the end he was alone. Through the song and
those games that David initiated he was able to give ex-
pression to sorrow over the termination. He sang, in his
way, and I filled in the missing words. Together we sang
the song again and again, session after session and each
time I wrote the text on a piece of paper in the way Da-
vid wanted. David was clearly sad, but not depressed,
and it was possible to work through the grieving.
During the termination process, one can also use the
parents’ thoughts and experiences. As with the work on
termination with the child, the sessions with the parents
are important in order to: be able to instil hope for the
family’s future; highlight the parents’ ability to support
their child in the future; and, when needed, seek further
help. For the child it can be very important to feel that
the parents are there to support her/him as the therapy
comes to a close. In my experience it is also preferable to
have a final family session together rather than send-
ing an assistant or teacher to fetch the child. That the
parents themselves take their child out from the final
session takes on a symbolic meaning.
Only when the parents have worked through the
process and been able to accept the child for what he or
she is, can one, in my experience, start to think about
the termination. The parents have an important task to
fulfil by showing the child that the termination of the
therapy will not be a problem – “we will help you” – at
the same time as they need to provide reassurance as
the child might feel sad to see the therapy end.
Coming back
The question of being able to come back is inter-
esting in itself. What is it that one is to come back to?
Is it the room, the therapist, the toys, the feeling, the
words or the special atmosphere that arises between the
various ways. When working with children with autism
spectrum disorders, one often needs to initiate the
termination in a pedagogical and concrete way whilst
talking about the ending.
To draw a cross on a calendar, to remove tabs that
show how many sessions are left, to cut off centime-
tres from a tape measure, or to play with a ball may be
ways of clarifying the number of remaining sessions in a
treatment. At the same time one needs to show respect
for the child, by not initiating this too quickly or initi-
ating something that perhaps does not help the child.
The child can sometimes show the way and in doing so
indicate how the termination can take place.
Let us return to David, who earlier had discovered
that I was also meeting his parents and who was in the
middle of the termination process.
David stages a funeral. He takes a little doll repre-
senting a witch. The witch has been used many times
and he has referred to the witch as a troll. In the ther-
apy I have been given the voice of the troll and through
the troll have been able to talk with David. David places
the witch in the sandbox and pours sand over her and
puts a flower from our material on top. We have ten
sessions left. He repeats, “A little troll has died, a little
troll has died. We shall bury the troll”. He now wants
me to draw a cross that we together put into the sand.
Afterwards, I am given the task of writing a list which
says what is to be buried: a finger, a toe, a mouth, etc.
The sequence is interesting in itself. At the time,
I was unclear as to which of us was to be buried. Or
were we both to be buried? What actually happens at
a termination? Perhaps David perceived it as if we were
going to die and that we would perhaps be changed
into ghosts? Or was it that the ghosts would be able
to change the threatening termination? In the therapy,
there had also been a recurrent theme whereby he
would travel to different places. From the beginning
there was no direction. Different stations and names
of communities were said out loud, and he seemed ex-
tremely anxious. Sometimes he tried to make drawings
but there was seldom an addressee . As time went on,
I became the one who met him, I was in his drawings
and I was also the person who drove the bus when he
wanted us to play buses in the sessions. As we moved
towards termination, his mother was in his drawing : his
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a special focus upon children with autism spectrum
disorders. Above all, I have wanted to emphasize the
importance of trying, in a sensitive, playful and em-
pathic way, to understand those feelings that are awak-
ened in the child. As a therapist, one has learned to
understand the child’s own, sometimes very special and
specific, use of language and modes of expression and
one can make great use of this in the termination phase
when the child can regress or show his or her anxiety in
other ways. In the clinical examples above, the children
showed a capacity for play in the interaction with the
therapist, and the termination process was of major
importance in helping the child to work through grief
and separation.
Another intention has been to reflect upon the role
of the parents in the child’s treatment, with a special
focus upon the therapeutic gains that can be attained
when one works as a sole therapist with both parents
and child.
References
1. Alvarez, A. (2004). Finding the wavelength. Tools in com-
munication with children with autism. Infant Observation:
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cations, 7(2), 91-106.
2. Alvarez, A. (1992). Live company. Psychoanalytic Psycho-
therapy with Autistic, Borderline, Deprived and Abused
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3. Ainsworth, M.D.S., Blehar, M.C., Waters, E. & Wall, S.
(1978). Patterns of Attachment: A Psychological Study of
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5. Balbernie, R. (2001). Circuits and circumstances: the
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child and the therapist? Is it possible to re-experience it
or is it only in the teenage years or as an adult that it is
possible to look back and meet the therapist with whom
one played as a child? What does one remember of
one’s child psychotherapy?
“I remember a shoe shop”, says Anna, who is now
20 years old, and who began child psychotherapy with
me when she was four (Nilsson, 2000). “Mum and I used
to go there”. A shoe shop. All the 170 hours that we saw
each other, when she kicked and fought, when we slowly
established contact and she and I, at last, were able to
focus on play, with meaning, during a whole session. “I
recognize you”, Anna said after a year of therapy and
she uses the same words when we meet later in life.
I never terminated Anna’s therapy as her school
placement demanded continued child psychiatric con-
tact and her problems were such that a change of ther-
apist would have made her situation even more difficult.
I have been in the wings for several years. As a child she
was thought to be “psychotic”, and in her teens was
diagnosed with Asperger’s syndrome.
Perhaps just the knowledge that one can meet the
child again after therapy has terminated can make it
easier for the therapist to terminate. Perhaps this is of
extra importance when one works with children with
autism spectrum disorders and when one may worry
about how things will turn out for the child in the
future. In my experience it seems that many families
like the idea of knowing that ‘it is possible’ to come
and say hello, or to send a greeting, a card or similar.
In reality, however, few have come back to me to tell
me how things are. I have, however, been contacted by
telephone, email and letter. I also at times send cards to
children where I know they miss continuity in life, often
children who are in foster-care. I think it is important to
say farewell, not goodbye, to children who have been
abandoned or neglected early in life. As a therapist you
are an essential part of their life story and your shared
moments might be the longest period of time they have
had with someone.
Concluding comments
My intention with this article has been to illuminate
aspects of termination in child psychotherapy, with
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16. Nilsson, M. (2009). Table hockey: attack or linking? Psy-
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tens perspektiv. Rapport nr 9, Stockholm: Ericastiftelsen,
Fallmarks tryckeri AB.
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EFPP Psychoanalytic Psychotherapy Review
Editor in Chief Gila Ofer, PhD
Editor Peter-Christian Miest, lic. phil.
Editorial Board Pierre Benghozi, MD · Athena Chatjoulis, PhD · Simona Nissim, MD
Associate Editors Mário David · Åke Granberg, PhD · Tomislav Gajic, MD PhD · Christine Leroy, MA · Manuela Porto, MD ·
Jan van de Sande, MD · Ulrich Schultz-Venrath, Prof. Dr. med. · Michael Stasch, Dipl.-Psych. · Cathy Troupp, MA
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The Author
May Nilsson
child psychotherapist, lecturer and supervisor at the Erica Foundation, Stockholm, Sweden.
may.nilsson@ericastiftelsen.se
