Case Examples of Music Therapy for Children with Emotional or Behavioral Problems [1 ed.] 9781937440244

Citation preview

Case Examples of Music Therapy for Children and Adolescents With Emotional or Behavioral Problems Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy for Children and Adolescents with Emotional or Behavioral Problems Copyright © 2012 by Barcelona Publishers All rights reserved. No part of this e-book may be reproduced and/or distributed in any form whatsoever. E-ISBN: 978-1-937440-24-4 Distributed throughout the world by: Barcelona Publishers 4 White Brook Road Gilsum NH 03448 Tel: 603-357-0236 Fax: 603-357-2073 Website: www.barcelonapublishers.com SAN 298-6299 Cover illustration and design: © 2012 Frank McShane

Table of Contents CASE ONE Creative Fantasy, Music, and Lyric Improvisation with a Gifted Acting-Out Boy Kenneth Aigen CASE TWO Improvisation and Play in the Therapeutic Engagement of a Five-Year-Old Boy with Physical and Interpersonal Problems Pamela Bartram CASE THREE Punker, Bassgirl, and Dingo-Man: Perspectives on Adolescents’ Music Therapy Jaakko Erkkilä CASE FOUR Crossing the Divide: Exploring Identities within Communities Fragmented By Gang Violence Sunelle Fouche and Kerryn Torrance CASE FIVE The Boy that Nobody Wanted: Creative Experiences for a Boy with Severe Emotional Problems Fran Herman CASE SIX Group Music Therapy with a Classroom of 6-8 Year-Old Hyperactive-Learning Disabled Children Julie Hibben CASE SEVEN Growing Up Alone: Analytical Music Therapy with Children of Parents Treated Within a Drug and Substance Abuse Program Juliane Kowski CASE EIGHT All Her “Yesterdays:” An Adolescent’s Search for A Better Today through Music Claire Lefebvre CASE NINE The Knight Inside the Armor: Music Therapy with a Deprived Teenager Simona Katz Nirensztein

CASE TEN Exploring Issues of Control through Interactive, Improvised Music Making: Music Therapy Diagnostic Assessment and Short Term Treatment with a Mother and Daughter in a Psychiatric Unit Amelia Oldfield CASE ELEVEN Just Don’t Do It: A Group’s Micro Journey into Music and Life Mercédès Pavlicevic CASE TWELVE Being Beverley: Music Therapy with a Troubled Eight-Year-Old Girl Helen M. Tyler

Introduction Kenneth E. Bruscia Case examples provide very unique and valuable insights into how different forms of therapy are practiced, as well as how clients respond to those therapies. This e-book describes various ways that music therapy has been used to help children and adolescents with emotional or behavioral problems. It has been compiled not only to provide practical information to students and professionals in music therapy and related fields, but also to inform all those affected by children and adolescents with emotional or behavioral problems about the potential benefits of music therapy. This introduction is intended to help readers better understand and contextualize each case example presented in the book, not only within the field of music therapy, but also within the literature on emotional or behavioral problems. To do this, it provides basic information on children and adolescents with emotional or behavioral problems, music therapy, and case examples. About Children and Adolescents with Emotional or Behavioral Problems Children and adolescents with emotional and/or behavioral problems comprise a very large diagnostic group, varying in symptomatology and classification. The ICD-10 (World Health Organization, 1992) distinguishes between those children and adolescents with emotional, behavioral, and both types of problems. Those with “conduct disorders” are characterized by persistent patterns of defiant, aggressive, or antisocial behavior. These conduct disorders can also be accompanied by emotional disorders, such as depression and anxiety. Those with “emotional disorders” may include those who have separation, phobic or social anxiety, sibling rivalry disorder, elective mutism, attachment disorders, and tic disorders. These emotional disorders can be accompanied by behavior disorders such as enuresis, feeding problems pica, stereotypic movement disorders, stuttering, and cluttering. The DSM-IV TR (APA, 2000) organizes these symptoms differently into one large category called “disorders usually first diagnosed in infancy, childhood, or adolescence.” This category encompasses many types of disorders other than emotional and behavioral ones. Included are: mental retardation, learning disorders, communication disorders, pervasive developmental disorders, attention deficit and disruptive behavior disorders, feeding and eating disorders, tic disorders, elimination disorders, and other such as separation anxiety, mutism, attachment disorder, and stereotypy. The case examples in this book provide myriad perspectives not only of how the above problems are manifested differently by each individual, both within and outside of a musical context, but also how these problems can be addressed through carefully designed music experiences that capitalize on the individual’s strengths and resources.

About Music Therapy (Based on Bruscia, 1993) Definition and Applications In music therapy, the therapist and client use music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help the client improve or maintain his or her health. In some instances, the client’s needs are addressed directly through music and its intrinsic therapeutic properties; in others, they are addressed through the relationships that develop between the music, client, therapist, and other participants. Music therapy is used with individuals of all ages and with a variety of conditions, including psychiatric disorders, medical problems, physical handicaps, sensory impairments, developmental disabilities, substance abuse, communication disorders, interpersonal problems, and aging. It is also used for self-development purposes, such as improving learning, building self-esteem, reducing stress, supporting physical exercise, and facilitating a host of other health-related activities. Given its wide applications, music therapists may be found in general hospitals, psychiatric facilities, schools, prisons, community centers, training institutes, private practices, and universities. Basic Premises The thing that makes music therapy different from every other form of therapy is its reliance on music as the primary medium for promoting the client’s health. Every session involves the client in a music experience of some kind. The main ones are listening to, recreating, improvising, and composing music. These will be described in more detail in the next few paragraphs; however, it is important to explain immediately that clients do not have to be musicians to participate in or benefit from music therapy. In fact, because most clients have not had previous musical training, the music activities and experiences used in therapy sessions are always designed to take advantage of the innate tendencies of all human beings to make and appreciate music at their own developmental levels. Of course, in clinical situations, music therapists may encounter clients who have physical or mental impairments that interfere with one or more of these basic musical potentials. Therefore, care is always taken to adapt music therapy experiences to the unique musical capabilities and preferences of each client. Music therapists also screen clients who may have adverse psychological or psychophysiological reactions to participation in music. Four Basic Music Experiences Used in Therapy To understand how music therapy works, it is necessary to examine the unique nature of each of the four types of music experience—listening to, recreating, improvising, and composing. In those therapy sessions that involve listening, the client takes in and reacts to live or recorded music in the style preferred by the client. The client may respond through activities such as relaxation or meditation, structured or free movement, perceptual tasks, free-

association, story-telling, imaging, reminiscing, drawing, and so forth. Music listening experiences are used with clients who need to be activated, soothed, or further developed— either physically, emotionally, intellectually, and/or spiritually—as these are the kinds of responses that music listening elicits. In those therapy sessions that involve re-creating music, the client sings or plays precomposed music. This may include learning how to produce sounds, imitating musical phrases, learning how to sing, learning to read notation, participating in group sing-along’s, performing a song or piece, participating in a musical show or drama, and so forth. Re-creative experiences are most appropriate for clients who need to develop sensorimotor skills, learn adaptive behaviors, maintain reality orientation, master different role behaviors, identify with the feelings and ideas of others, work with others cooperatively, or merely share in the joy of making music—as these are the main aspects of singing or playing pre-composed music that have therapeutic implications. In those therapy sessions that involve improvising, the client makes up his or her own music extemporaneously, singing or playing whatever arises in the moment. The client may improvise freely and spontaneously or according to the musical or verbal guidance of the therapist. Sometimes the client is asked to improvise sound portraits of feelings, events, persons, or situations that are being explored in therapy. The client may improvise with the therapist, with other clients in a group, or alone, depending on the therapeutic objective. Improvising music is most appropriate for clients who need to develop spontaneity, creativity, freedom of expression, self-awareness, communication, and interpersonal skills—as these are the basic components of improvising. In those sessions that involve composing, the therapist helps the client to write songs, lyrics, or instrumental pieces, or to create any kind of musical product, such as music videos or audiotape programs. Usually the therapist simplifies the process by engaging the client in aspects of the task within their capability (e.g., generating a melody, or writing the lyrics of a song) and by taking responsibility for more technical aspects (e.g., harmonization, notation). Activities involving composing music are used with clients who need to learn how to make decisions and commitments, or find ways of working in an organized way toward a goal. Most often, clients create compositions (especially songs) around significant events, people, or relationships in their lives, or to express thoughts and feelings that they are exploring in therapy. In addition to strictly music experiences, music therapists often engage clients in verbal discussions. Clients may be encouraged to talk about the music, their reactions to it, or any thoughts, images, or feelings that were evoked during the experience. Clients may also be encouraged to express themselves through the other arts, such as drawing, painting, dance, drama, or poetry. Music therapy sessions for children often include various games or play activities which involve music. The case examples that follow highlight the goals of music therapy for children with emotional or behavioral disorders, and the different kinds of music experiences used to address these goals. Thus, a key to reading these cases is to pay close attention to how each type of music experience affords clients many different opportunities to not only confront their problems within the music, but also to explore healthier ways of dealing with or resolving them.

This leads to the next important topic—the ways that case examples can be read or studied for greatest insight. About Case Examples For purposes of the present discussion, case examples can be divided into two main types: clinical cases, and research cases. A clinical case is a professional report written by the therapist, client, or observer to describe what transpired during and upon completion of the music therapy process with an individual client or group. The report is usually based on recordings of the session or notes and logs kept by the therapist and/or client. Efforts are made to present an accurate and unbiased account of the therapy process to the extent possible, and theories are often used to substantiate or contextualize the therapeutic approach. Objective data may or may not be provided to verify or document the report. In contrast, a research case is a data-based report, provided by the therapist or researcher, to document or verify the specific therapeutic effects of a particular music therapy protocol on an individual client or group. As such, a research case operationally defines and measures how the independent variables (e.g., treatment methods used by the therapist) act upon the dependent variables (e.g., targeted treatment outcomes for the client), when all other relevant variables and conditions are controlled. Perhaps the best way to derive the most benefits from a clinical or research case is to read it from a particular perspective, and to interrogate the case or group of cases from that perspective. Essentially, the reader adopts a particular lens or viewpoint to study the case(s), and then asks questions that arise as a result. Three of the most helpful reading perspectives are: scientific, personal, and clinical perspectives, each of which poses very different questions for the reader to ponder. Reading from a Scientific Perspective Scientists usually look for answers to two basic questions when reading a case. First, is the case credible? That is, how accurate were the perceptions and interpretations of the writer, and how trustworthy are the findings and conclusions presented? Of course, this is not a question that only scientists pose. One’s natural propensity as a reader is to question the truth value of what is read. Certainly, if the reader is involved in some way with a child with emotional or behavioral problems, the truth value of the case is of vital interest. That leads to the second scientific question: Can the information learned in this case be applied to other cases? Or even more rigorously, can the findings of this case be generalized to similar or matched cases? Here too, readers who are directly affected by a child or adolescent with emotional or behavioral problems are as interested in this question as scientists and researchers. Their interest is in whether that child or adolescent in their own lives can derive the same benefits of music therapy as the client in this case did. Scientists or researchers can also glean other very important information from case studies. Because clinical cases provide rich descriptions of the therapy process, they usually provide myriad ideas for what needs to be studied scientifically. By describing what seemed to work and or not work for a particular client, a clinical case reveals to the researcher which

clinical protocols and therapeutic outcomes warrant further research, while also suggesting specific hypotheses that might be tested. Moreover, because events unfold naturally in a clinical case as they do in real life, and because variables cannot be controlled as in laboratory research, the clinical case gives very important information on what specific variables must be considered when doing research, not only the most likely independent and dependent variables that are likely to be related, but also what extraneous variables need to be controlled. Of course, a research case can provide the same insights, to some degree, as a clinical case; they too offer valuable information on potential independent, dependent, and extraneous variables to consider. The greatest advantage of the research case is not only that it provides objective evidence of what works or doesn’t work in therapy, but also because it can reveal the “effect size” of the therapeutic change. That is, a single-case research study can show how big an effect the independent variable had on the dependent variable, or the extent to which the treatment protocol was effective in inducing therapeutic change in the client. Though this effect and its size cannot be generalized, careful replication of research cases and meta-analysis can begin to build a case for the establishment of clinical cause-effect relationships. Reading from a Personal Perspective By their very nature, case examples invite the reader to identify with one or more characters involved in the case, and then move from identifying with one character to identifying with another. The characters may include the client, the therapist, other clients, loved ones, and so forth. Identifying with people involved in the case not only helps the reader to understand first-hand what each character is experiencing, but also gives the reader an opportunity to compare how the character reacted with how the reader would react. Here are some examples: 1) Identifying with the client: What must the client be thinking or feeling about the therapist, music, other clients, or loved one? If I were the client, would I think or feel the same? What does this client need and want from those involved in the therapy process, and would I need or want the same? These same questions can be posed for every client involved in the case. 2) Identifying with the therapist: What must the therapist be thinking or feeling about the client, the music, the other clients, or the client’s loved one? Would I think or feel the same? What kind of person would I be if I were working with this client? What is the therapist trying to do, and would I try to do the same? 3) Identifying with loved ones: What must the loved one be thinking or feeling about the client, the therapist, the music, and other clients? If I were a loved one, would I think or feel the same? What does this person need or want, and would I need or want the same? Does this person believe that music therapy will help, and would I? How does the loved one feel about the therapist, and how he or she is relating to the client? Does the therapist know what he or she is doing? The fascinating thing about taking an empathic position is that once one successfully steps into one character’s shoes, and becomes sensitive to who he or she is, an endless number

of additional empathic positions arise, and one’s entire personal reaction to the case becomes enlivened. Reading from a Clinical Perspective A clinical perspective is concerned primarily with methodological questions that are most often posed by other clinicians. Clinicians want to know what does and does not work when working with a client in music therapy. Practically speaking then, they are most interested in the following kinds of questions: 1) Based on this case, what should I be looking for in clients? What client needs and resources do I have to address more in my own work? How can I assess these facets of the client in music therapy? 2) Based on this case, what kind of therapist-client relationship is best for this kind of client, and what is the best way of forming such a relationship? 3) What is the role of music in working with this clientele? What types of music experiences are most therapeutically relevant and effective? What styles of music are most appropriate? 4) Based on this case, what are the best ways of responding to the client when he or she is acting out, abreacting, resisting, or not progressing? 5) Based on this case, what clinical criteria should be used in evaluating the client’s therapeutic progress? Other Writings on Children and Adolescents with Emotional or Behavioral Problems The case examples in this e-book were taken exclusively from various books published by Barcelona Publishers. Thus, these cases, though typical, may not comprise a representative sample of all clinical practices in music therapy for children and adolescents with emotional or behavioral problems. Here is a list of other published case examples along with other writings on the topic. Bowman, J. (1979). The Development of Criteria for Identifying Music Preferred by Children with Behavioral Problems. Dissertation Abstracts International Section A: Humanities & Social Sciences, 39, 7044. Burkhardt-Mramor, K. M. (1996). Music Therapy and Attachment Disorder: A Case Study. Music Therapy Perspectives, 14(2), 77-82 Chong, H., & Kim, S. (2010). Education-Oriented Music Therapy as an After-School Program for Students with Emotional and Behavioral Problems. The Arts in Psychotherapy, 37(3), 190-196. Chonga, H.J. & Kim, S. J. (2010). Education-Oriented Music Therapy as an After-School Program for Students with Emotional and Behavioral Problems. The Arts in Psychotherapy, 37(3), 190-196.

Cobbett, S. (2007). Playing at the Boundaries: Combining Music Therapy with Other Creative Therapies in Individual Work with Children with Emotional and Behavioural Difficulties. British Journal of Music Therapy, 21(1), 3-11. Cobbett, S. (2007). Playing at the Boundaries: Combining Music Therapy with Other Creative Therapies in Individual Work with Children with Emotional and Behavioural Difficulties. British Journal of Music Therapy, 21(1), 3-11. Coons, E. E., & Montello, L. (1998). Effects of Active versus Passive Group Music Therapy on Preadolescents with Emotional, Learning, and Behavioral Disorders. Journal of Music Therapy, 35, 49-67. Coons, E. E., & Montello, L. (1998). Effects of Active versus Passive Group Music Therapy on Preadolescents with Emotional, Learning, and Behavioral Disorders. Journal of Music Therapy, 35, 49-67. Cripe, F. F. (1986). Rock Music as Therapy for Children with Attention Deficit Disorder: An Exploratory Study. Journal of Music Therapy, 23(1), 30-37 de l’Etoile, S. K. (2005). Teaching Music to Special Learners: Children with Disruptive Behavior Disorders. Music Educators Journal, 91(5), 37-43. de Mers, C. L., Tincani, M., Van Norman, R. K., & Higgins, K. (2009). Effects of Music Therapy on Young Children’s Challenging Behaviors: A Case Study. Music Therapy Perspectives, 27(2), 88-96. Dellatan, A.,K. (2003). The Use of Music with Chronic Food Refusal: A Case Study. Music Therapy Perspectives, 21(2), 105-109. Deutsch, H., Parks, A., & Aylesworth, J. (1976). The Use of Contingent Music to Increase On-Task Academic Behavior in Children with Emotional Problems. Behavioral Engineering, 3(3), 77-79. Eidson, C. E. (1989). The Effect of Behavioral Music Therapy on the Generalization of Interpersonal Skills from Sessions to the Classroom by Emotionally Handicapped Middle School Students. Journal of Music Therapy, 26(4), 206-221. Eidson, C. E. (1989). The Effect of Behavioral Music Therapy on the Generalization of Interpersonal Skills from Sessions to the Classroom by Emotionally Handicapped Middle School Students. Journal of Music Therapy, 26(4), 206-221. Evans, D. J. (2010). The Challenge of Treating Conduct Disorder in Low-Resourced Settings: Rap Music to the Rescue. Journal of Child and Adolescent Mental Health, 22(2), 145-152. Gold, C., Wigram, T., & Voracek, M. (2007). Effectiveness of Music Therapy for Children and Adolescents with Psychopathology: A Quasi-Experimental Study. Psychotherapy Research, 17(3), 292-300. Gooding, L. (2011). The Effect of a Music Therapy-Based Social Skills Training Program on Social Competence in Children and Adolescents with Social Skills Deficits. Dissertation Abstracts International Section A, 71(8-A), 2818. Goodman, K. D. (1989). Music Therapy Assessment of Emotionally Disturbed Children. The Arts in Psychotherapy, 16(3), 179-192 Goodman, K.D. (2007). Music Therapy Group Work for Special Needs Children. Springfield IL: Charles C. Thomas. Grossman, S. (1978). An Investigation of Crocker’s Music Projective Techniques for Emotionally Disturbed Children. Journal of Music Therapy, 15(4), 179-184.

Haines, J. H. (1989). The Effects of Music Therapy on the Self-Esteem of Emotionally- Disturbed Adolescents. Music Therapy, 8(1), 78-91. Hallam, S., & Price, J. (1998). Can the Use of Background Music Improve the Behaviour and Academic Performance of Children with Emotional and Behavioural Difficulties?. British Journal of Special Education, 25(2), 88-91. Hallam, S., & Price, J. (1998). Can the Use of Background Music Improve the Behaviour and Academic Performance of Children with Emotional and Behavioural Difficulties?. British Journal of Special Education, 25(2), 88-91. Hibben, J. K. (1991). Identifying Dimensions of Music Therapy Activities Appropriate for Children at Different Stages of Group Development. The Arts in Psychotherapy, 18(4), 301-310. Hong, M., Hussey, D., & Heng, M. (1998). Music Therapy with Children with Severe Emotional Disturbances in a Residential Treatment Setting. Music Therapy Perspectives, 16(2), 6166. Hong, M., Hussey, D., & Heng, M. (1998). Music Therapy with Children with Severe Emotional Disturbances in a Residential Treatment Setting. Music Therapy Perspectives, 16(2), 6166. Hooper, J. (2002). Using Music to Develop Peer Interaction: An Examination of the Response of Two Subjects with a Learning Disability. British Journal of Learning Disabilities, 30(4), 166. Howden, S. (2008). Music Therapy with Traumatised Children and Their Families in Mainstream Primary Schools: A Case Study with a Six-Year-Old Girl and Her Mother. In A. Oldfield, & C. Flower (Eds.), Music therapy with children and their families (pp. 103-120). London, UK: Jessica Kingsley Publishers. Humpal, M. E., & Colwell, C. (Eds.). (2006). Effective Clinical Practice in Music Therapy: Early Childhood and School Age Educational Settings. Silver Spring, MD: American Music Therapy Association. Humpal, M. E., & Colwell, C. (Eds.). (2006). Effective Clinical Practice in Music Therapy: Early Childhood and School Age Educational Settings. Silver Spring, MD: American Music Therapy Association. Hussey, D. L., and Laymann, D. (2003). Music Therapy with Emotionally Disturbed Children. Psychiatric Times, 20 (6), 37-40. Jackson, N. A. (2003). A Survey of Music Therapy Methods and Their Role in the Treatment of Early Elementary School Children with ADHD. Journal of Music Therapy, 40(4), 302-323 Keen, A. (2004). Using Music as a Therapy Tool to Motivate Troubled Adolescents. Social Work in Health Care, 39(3-4), 361-373. Krout, R. E., & Mason, M. (1988). Using Computer and Electronic Music Resources in Clinical Music Therapy with Behaviorally Disordered Students, 12 to 18 Years Old. Music Therapy Perspectives, 5, 114-118. Krüger, V. (2000). The Use of Information Technology in Music Therapy: Behavioural Problems in Contemporary Schools. Nordic Journal of Music Therapy, 9(2), 77-83. Lathom, W. (1964). Music Therapy as a Means of Changing the Adaptive Behavior Level of Retarded Children. Journal of Music Therapy, 1(4), 132-134. Layman, D. L., Hussey, D. L., & Laing, S. J. (2002). Music Therapy Assessment for Severely Emotionally Disturbed Children: A Pilot Study. Journal of Music Therapy, 39(3), 164-187.

Loewy, J. (1995). A Hermeneutic Panel Study of Music Therapy Assessment with an Emotionally Disturbed Boy. Dissertation Abstracts International Section A, 55, 2631. Lowenstein, L. (1982). The Treatment of Extreme Shyness in Maladjusted Children by Implosive, Counselling and Conditioning Approaches. Acta Psychiatrica Scandinavica, 66(3), 173189. McCarty, B. C., McElfresh, C. T., Rice, S. V., & Wilson, S. J. (1978). The Effect of Contingent Background Music on Inappropriate Bus Behavior. Journal of Music Therapy, 15(3), 150156. Meeker, A. M. (1985). “Empty Lizzie”: Using the Expressive Arts as a Tool for Dealing with Anger. Pointer, 29(3), 31-34. Metzler, R. K. (1973). Music Therapy at the Behavioral Learning Center, St. Paul Public Schools. Journal of Music Therapy, 10(4), 177-183. Montello, L., & Coons, E. E. (1998). Effects of Active versus Passive Group Music Therapy on Preadolescents with Emotional, Learning, and Behavioral Disorders. Journal of Music Therapy, 35(1), 49-67. Oldfield, A. (2006). Interactive Music Therapy - A Positive Approach: Music Therapy at a Child Development Centre. London, UK: Jessica Kingsley Publishers. Pratt, R. R., Hans-Henning, A., & Skidmore, J. (1995). The Effects of Neurofeedback Training with Background Music on EEG Patterns of ADD and ADHD Children. International Journal of Arts Medicine, 4(1), 24-31. Presti, G. M. (1984). A Levels System Approach to Music Therapy with Severely Behaviorally Handicapped Children in the Public School System. Journal of Music Therapy, 21(3), 117125. Presti, G. M. (1984). A Levels System Approach to Music Therapy with Severely Behaviorally Handicapped Children in the Public School System. Journal of Music Therapy, 21(3), 117125. Rickson, D. J., & Watkins, W. G. (2003). Music Therapy to Promote Prosocial Behaviors in Aggressive Adolescent Boys-A Pilot Study. Journal of Music Therapy, 40(4), 283-301. Sausser, S., & Waller, R. J. (2006). A Model for Music Therapy with Students with Emotional and Behavioral Disorders. The Arts in Psychotherapy, 33(1), 1-10 Sausser, S., & Waller, R. J. (2006). A Model for Music Therapy with Students with Emotional and Behavioral Disorders. The Arts in Psychotherapy, 33(1), 1-10. Spitzer, S. (1989). Computers and Music Therapy: An Integrated Approach: Four Case Studies. Music Therapy Perspectives, 7, 51-54. Steele, A. L. (1984). Music Therapy: A Community Resource for Children with Special Needs. Child Welfare: Journal of Policy, Practice, and Program, 63(6), 563-568. Steele, A., Vaughan, M., & Dolan, C. (1976). The School Support Program: Music Therapy for Adjustment Problems in Elementary Schools. Journal of Music Therapy, 13(2), 87-100. Steele, P. H. (1984). Aspects of Resistance in Music Therapy: Theory and Technique. Music Therapy, 4(1), 64-72. Wells, N. F. (1988). An Individual Music Therapy Assessment Procedure for Emotionally Disturbed Young Adolescents. The Arts in Psychotherapy, 15(1), 47-54. Wilson, C. V. (1976). The Use of Rock Music as a Reward in Behavior Therapy with Children. Journal of Music Therapy, 13(1), 39-48.

References for Introduction American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, Text Revision. Washington DC: American Psychiatric Association. Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ. World Health Organization (WHO) (1992) International Statistical Classification of Diseases and Related Health Problems (Tenth Edition) (ICD-10). Geneva, Switzerland: Author.

Case Examples of Music Therapy for Children and Adolescents with Emotional or Behavioral Problems

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE ONE Creative Fantasy, Music, and Lyric Improvisation with a Gifted Acting-Out Boy Kenneth Aigen Abstract This case study details individual music therapy with Will, a musically and intellectually gifted, non-pathological, eight year-old boy who was brought to therapy for fighting in school. Though Will engaged in a variety of musical forms during the course of therapy, the focus here is on his use of creative fantasy and music. The entire year and one-half of therapy is discussed, and the lyric and musical content of one crucial session is examined in detail. A psychological/developmental rationale is offered for the use of fantasy in personal transformation, and the role of music in enhancing the dynamic process is briefly discussed. Introduction In reading case studies, it often appears that treatment progresses according to a form common to works of art. In the beginning phase of treatment the participants become acquainted with each other and in some ways, the future course of the therapy is foreshadowed. This is followed by a deepening of the relationship and work—in other words, “the plot thickens.” Then, a climactic/cathartic session or series of sessions occurs involving significant insight or transformation on the client’s part. Treatment then concludes with a recapitulation of important themes and the mutual assent of both parties through a termination process of varying lengths of time. This neat form, however, is not always achieved with clients who seek music therapy treatment for significant emotional difficulties. Often clients miss sessions, leave treatment prior to achieving their potential, evidence growth in a halting fashion, and in general, express their individuality in a way that defies a neat recounting of planned events unfolding to a desired end. In short, the therapeutic work with many of these clients does not make for “good” case studies, and their stories are rarely recounted in the published literature. The present case study illustrates a therapeutic process that progressed in this latter form: the most significant session occurred relatively early in the treatment; there was no music for long stretches of time; and, there was no termination process of which to speak. Nonetheless, the therapy was considered successful as great progress was made in the problem identified as the most crucial one for this client. The value of this study then is to demonstrate that in spite of the lack of a neat, organic process of therapeutic development, important gains can still be accomplished.

Background Information Will is an unusually intelligent, creative, and articulate eight-year-old with a sophisticated command of feelings and concepts. For example, in his initial music therapy session Will said that he felt “guilty” about knocking down another boy at school, and expressed surprise that we would be playing music because we were at a “clinic.” Because his father abandoned the family when Will was three, Will has been without a significant male figure for most of the previous five years, living with his mother and sister. The once-annual visit from his father has proved to be a very damaging event to Will as the father tends to ignore Will and shower his sister with gifts. A minority youth living in a quite dangerous, inner-city neighborhood, Will has been attending a predominantly white school for gifted children outside his neighborhood. His referral to music therapy indicated that Will was “antagonistic to other children in group situations, possessed poor self-awareness and listening skills, and demonstrated impulsive behaviors,” leading him to frequently get into fights with other children. Since this fighting was jeopardizing his academic placement, this was judged to be the most important of his difficulties. Within the music therapy sessions, Will demonstrates no signs of emotional difficulties or pathology, outside of a slight tendency to hyperactivity and a resistance to prolonged interpersonal contact. Though he often tests limits to determine what is acceptable in the session, Will normally responds favorably to these limits once they are firmly set. Music Therapy Assessment Although I did not employ a formal musical assessment procedure with Will, his significant abilities in this area played an important role in the course of his therapy and they warrant a separate discussion here. The wide variety of musical interests and skills that Will possessed was reflected in the activities he chose to engage in while in music therapy. These included creating long blues and rap songs with improvised lyrics and harmonica playing; singing structured, pre-composed songs, ranging from the current pop repertoire to Gilbert and Sullivan songs he prepared for a school show; playing purely instrumental improvisations on the drums, piano, resonator bells or electric guitar; and lastly, weaving long and complex fantasies with musical accompaniment. In all of these activities Will demonstrated (1) a highly developed rhythmic sense, seen in his ability to maintain a constant rhythm while improvising as well as employing a variety of rhythmic phrases in an expressive and communicative manner, (2) a sophisticated sense of melody and pitch, singing in tune and improvising melodies in a variety of musical styles, (3) a strong aesthetic sense, seen primarily in his creative and flexible use of dynamics, and (4) a strong sense of musical form, seen in the ease with which he related through—and shifted among—call and response forms, rondo forms, and standard pop forms in his improvisations. More important than any of these skills, however, was Will’s motivation toward creative self-

expression. Combining this motivation with his skills made him seem to be the ideal music therapy client. Method Will’s weekly, 45-minute sessions, took place at the Creative Arts Rehabilitation Center, Inc. (CARC), an out-patient clinic devoted solely to the Creative Arts Therapies. Though providing a home to clinicians from a variety of theoretical perspectives, one binding element of the clinical work at CARC is strong sense of client-centeredness, where the client’s individual needs, desires, perspective on their own difficulties, and pace of growth determine the course of therapy. This approach was particularly well-suited to Will’s clinical needs for two reasons: First, his intellectual and expressive capacity, combined with a strong, self-directed drive, left Will perfectly capable of deciding how to use his time in therapy. My willingness to allow him this flexibility demonstrated my respect for him, an essential component of any successful therapy. This strategy is not undertaken lightly, however, and, as will be seen in the following section, it led Will’s treatment far afield of relating solely through music. Second, with clients for whom impulse control is a problem (a problem indicated by Will’s constant fighting) it is generally counter-therapeutic for the therapist to attempt to control the course and content of the therapy session. To attempt to exercise such control over the client--and a directive strategy is a controlling one--is to recreate the destructive dynamic that is proving so problematic to the client outside the therapy setting. The therapist’s task is instead to musically contribute to the creation of an aesthetic context which will allow the problematic impulse to be transformed from pure, uncontrolled discharge into self-expression. Here, it is the aesthetic form--as opposed to social expectations of appropriate behavior or, in the therapy session, the therapist’s limits--that functions as the resistance to the client’s destructive impulse, and a client/therapist power struggle is thus avoided. Certainly, Will’s strong aesthetic sense contributed to the efficacy of this approach for him. Treatment Process Will’s treatment consisted of 48 sessions over a one and one-half year period, and he passed through three distinct phases during this time. For approximately the first six months, Will was very engaged in music and seemed to be a willing and motivated participant in his own therapy. This period was followed by three to four months where Will was, at times, totally disinterested in music and somewhat ambivalent about continuing in music therapy, and another three months where his interest fluctuated. In the last three months, Will seemed to reach a middle ground and was moderately engaged in music, though deeply involved in the sessions. Termination, though warranted given Will’s progress and change in motivation, was unsatisfactory as a variety of factors contributed to Will ending treatment without the benefit of a termination process. The Beginning: Music, Music, Music In his initial sessions, Will introduced two structures that would be important components of his ongoing process. The first of these was his organization of the session as a

musical show, with the two of us serving as the featured performers. This format is a common one that many younger children employ in music therapy. Additionally, Will created a brief story in his first session that was stimulated by the autoharp. Will commented that this instrument sounded like a “dream” and he told a story about a witch who was Dracula’s wife. The witch was laughing at Will because she had turned him into a monkey. This mechanism of using music to stimulate fantasy material, particularly involving themes of transformation, was a crucial component throughout Will’s therapy, and will be discussed later in greater detail. During this time, Will often needed to control and orchestrate my musical contribution, much as a conductor controls an orchestra: he employed musical and visual cues that determined the timing and dynamic quality of my music. I went along with this need for two reasons: Since Will was treating his session as a “show” where he was the featured performer and I was his “back-up” band, accepting this structure (and hence Will’s reality) meant that it was natural that the “leader” should have a primary, directive role. Second, though on one level Will was “controlling” me—and I do not mean to minimize the importance of providing a context for a child such as Will to exercise his need for control over others in a positive context—it is important to realize that he was simultaneously controlling himself. In flexibly employing various dynamic levels and planning my musical entrances and exits, Will employed his need for aesthetic expression to inhibit his destructive and aggressive impulses. In allowing Will to “control” me, I was allowing him the opportunity to channel these impulses and thus enhance his own impulse control. In these first five sessions, Will sang popular songs, invented call and response “raps,” and created a few stories with primarily aggressive and violent themes. Our level of contact varied from week to week, and Will was feeling out who I was and what was allowable in the session. Though Will was quite engaged in the music, in his sixth session I sensed that he was ambivalent about playing music. This was confirmed by Will, and he asked to end the session early to play video games. This ambivalence served as precursor of a feeling that would dominate the second phase of Will’s treatment. Yet, it also led to a discussion with Will’s mother that provided some important information for me. Each day of the week Will was brought to a different afterschool activity. It was apparent that he needed more time to just be a child without being forced to meet the demands of some sort of structured activity. In an effort to care for him, his mother was actually controlling Will to an unhealthy extent that left him frustrated and without the resources to control himself. Then, in session eight, Will requested the song “Twist and Shout.” Playing this song became a regular part of the following few sessions, and was something that Will returned to later in his therapy. At first, Will just sang the song straight, without much embellishment or spontaneity. He soon began to use the section of the song containing an extended dominant seventh chord to scream at the top of his lungs. Here was an unbridled release, an unrestrained expression of Will’s aggression occurring within, and elicited by, the safe musical context. My clinical musical interventions were directed toward using the song structure, without getting caught up in the accurate performance of this structure as an end in and of itself. My goal was to tap the expressive potential typically associated with improvised music within the song form. Eventually, Will began using this song to express and explore all the extremes of his emotional life. In one session, for example, he sang “Twist and Shout” by

alternating volume levels: Between softer vocalizations of infantile babbling sounds and shouted sections of “Shake it for me baby!” accompanied by macho posturing—quite surprising in a child of Will’s age. It was this exploration of expressive extremes in an appropriate manner in therapy that I felt would decrease Will’s need to gain mastery through destructive social interactions. After Will’s tenth session, his mother requested a meeting with me. Apparently, Will’s fighting with other children was intensifying and she was finding him increasingly difficult to manage. Until this time, Will’s relationship with me, and his use of the session time, had existed in a social vacuum of sorts, uncontaminated by the reality existing outside the session room. Yet it now seemed like I needed to discuss this problem with Will directly, if only to gain information about his perspective on the fighting issue. From these talks I emerged with two contradictory senses of Will’s self-image. On a more overt level, Will felt he was being scapegoated by his teacher and classmates, and that none of the trouble in school resulted from his actions. On a deeper level, however, I felt that Will considered himself to be a “bad boy” and that he was stuck continually reenacting behaviors (such as fighting) that would confirm this negative self-perception. It was this fixed, negative self-image that I felt was at the root of Will’s difficulties, and any possibility of helping him would involve finding a way to transform how Will viewed himself. I determined that my clinical strategy should be to support Will’s transformative tendencies as they emerged, to facilitate his identification with “good” characters, while simultaneously allowing for the creative expression (and hopefully transformation) of his “bad” self. Will’s fourteenth session was the most significant one of his therapy, and I will discuss it in some detail. After briefly experimenting with the electric guitar and drums, Will settled on improvising a fantasy while I played the piano. He was completely involved in the lyric and verbal aspects of the fantasy and was not concerned with maintaining control over my musical input. The fantasy grew out of an improvised song called “Monster Shout” that consisted of a very simple I-IV funky rock and roll chord progression. This song represented a familiar place to Will, and throughout the fantasy he regularly returned to it, using this song to end the session as well. Will was dressed in a rather ghoulish Halloween costume, which certainly influenced the theme of the session and supported his deep investment in it. What follows is a relatively detailed account of this session. Its significance for Will is more fully articulated later in the “Discussion” section. A Voyage to Trick Land While singing the words, “Monster Shout” over the I-IV progression Will spontaneously says, “And now for the story of ‘Monster Shout’.” I understand this as an indication that Will is ready to let go of the song structure and engage in his fantasy. I, therefore, change the music to open-ended, suspended chords with a much lessened rhythmic impetus. Will begins his story, with my musical contribution helping to contain the narrative while deepening his investment in the fantasy:

Once upon a time in a far away land there was a friendly monster named “Trick or Treat.” And if you went to his house he always let you play with his toys. But there was a bad witch after him. And there was a good pumpkin named “Pumpkin-head” who lived in a little cottage in a far away land called “Trick Land.” And if you went there the monster would be there to greet you. But there was an old witch and an old wizard that ate little girls and little boys. So that’s why they called this song “Monster Shout.” And this story was far, far, far away in another world. The Monster Shout. Will returns to the song for a few refrains. I then ask him to tell me what happened when he came to Trick Land. He responds: And in the far away land called Trick Land, when you went there, there was a nasty witch who also tried to kill pumpkin and get kids for her dinner and supper. But you don’t want to be part of that, do you? I know you don’t. You know why I know the story ... because I was there.... She turned all the little boys and girls into toys and put them in the toy factory and she made masks out of their faces.... And she made other witches out of monsters. The locale of this story in a “far away land,” and the unusual, magical music serving as a motif for this place, help Will to feel a sense of safety as the material is distanced from his personal experience. The theme of transformation--that I had previously decided to support-emerges as children are turned into toys. Will’s conceptions about growth and change are also contained in his story. That witches can transform children by making masks out of their faces suggests that, for Will, change does not “bring” the self. That is, one loses one’s identity through change (and, hence, through growth as a form of change) and, as such, change is discontinuous with the present self. Later on in the story Will says that: The good fairy helped the children by when they were turned into toys, she made them into fairies and they could turn themselves back into little children. And they could turn themselves into whatever they wanted to be... and they could turn themselves back... into whatever thing they want to. Here, the possibility of a transformation which includes maintaining one’s identity is introduced. One can be transformed and return to one’s former self, thereby sustaining contact with the enduring self. Thus, the possibility of a fluid self-identity (another goal I wanted to support) has spontaneously arisen in Will’s story. Will appeared as a fountain of musical and lyrical creativity in this session. The session content was a spontaneously created opera, complete with arias, transitional musical passages, and an epic theme. At one point in the story, Will began to sing the following lyrics in haunting and lyrical delicate tones that I accompanied with gentle alternated major and minor chords: If you don’t want to go to Mars You don’t have to but you stay because. Anybody knows that you can be,

Anybody knows, anybody knows. People think there is a big old wizard, People think there isn’t a big old wizard. But I know there’s bad wizards, And I know there’s good wizards. And I know... Anybody knows I sensed new possibilities from Will in this music. It contained neither the aggressive and murderous violence typical of much of his previous fantasy, nor the precocious “macho” posturing typical of his blues and rap lyrics. Here was the tender child coming through, whose young age left many possibilities open for development. And here was the child confused by adult conceptions of “good” and “bad” and struggling to differentiate between them through exploring their extreme manifestations. Will’s story then builds to a dramatic climax: Do you want to kill people and turn them into toys or do you want to save people and turn them into happy little boys and girls? And the bad wizard said, “No longer am I a bad wizard. No longer will I turn little girls and boys into toys. I am a good wizard. Hocus-pocus.“ (The following is with a triumphant musical accompaniment.) Turn the bad wizard into dust, Turn the good wizard this you must. And let them live a happy life. ... Nobody should feel nice Everybody should feel nice. Nobody should have gripes And if you’re not a nice wizard I’ll turn you into dust. And all the good wizards, all be nice. All you have to do is be a nice wizard. And ... they are dust. She was a nasty witch, but all of a sudden she found herself turning into dust. And getting smaller and smaller. But then she said: Hocus-pocus I am a good witch, and then the witch turned good, and she stomped on her ... the dust stomped. And you know what happened? She became a good witch and lived a happy life. And they lived a happy life. Though it first seemed that the music and story were building to a dramatic triumphant climax, Will was not yet ready to end. The story and music take a sudden pensive and introspective turn. Descending chords that again alternate between major and minor provide a sense of recapitulating a shared odyssey. The power, beauty, and sadness contained in Will’s story--and by extension, his life--are contained in this short interlude that precedes the climactic transformation.

If I can live a happy life, and I’m a little kid. And nobody started dying. And I never died. There was a bad disease and nobody died. Because of me, when I was a little kid I promised myself, I was a wizard. When I got to a teenager I thought I could rule the world with my wizardness. And I started to rule the world until the wizard of goodness came. And he taught me to be good--but I never listened to him. Now I am listening to little boys and girls, to explain. Why should I have to live a good life and everybody else live a good/bad/good/bad life? Every girl and boy. Then, with increasing dramatic urgency and tension, Will repeats the following four times: Hocus-Pocus. Razzle-Dazzle. Turn our toys into human beings and little girls. Nobody should have to live a bad life. The music and Will’s story climax here, and then Will indicates that he wants to return to the initial song, the theme of this story: Monster Shout. We conclude after singing a few refrains of this song. What is notable in this last, extended excerpt is that Will introduces the possibility of transformation between bad and good. Bad wizards and witches can turn into good ones and toys can be turned back into children. This was a very important theme as I felt that it was Will’s inflexible sense of himself as “bad” that would inhibit his growth in therapy. In his fantasy, at least, he entertained other possibilities. The many little transformations in the story act as a “rehearsal” for the big transformation at the end. Certainly this mirrors the pattern of normal emotional development and explains why children often need to repeat stories, songs, and other activities in therapy, and why the therapist must not only endure but embrace this repetition: It is what provides the child with the security to move forward. The fact that the transformation is a magical one (hocus-pocus, razzle-dazzle) is important in reflecting the child’s view of the world. Will was not able to alter his fighting behavior, for example, from a deliberate effort on his part or by insight into the self-defeating aspects of these actions. Since to a child, change is magical and comes from without, engaging in this magical fantasy allowed Will to work on changing himself within the context of the magical thinking that defines his maturity level. Lastly, it was quite important for Will to return to the “Monster Shout” at the end of the session. It was his way of “returning home” and returning to himself after a long adventure that involved experimenting with a variety of novel roles and forms of expression. After all, it was this song that served as Will’s entry point to Trick Land, thus it was natural that he would need to return to it. This music allowed Will to close the circle of his journey and to re-establish contact with his enduring self after such a perilous voyage.

This was the beginning of the end of this period of Will’s therapy. Though he did play some music in three out of the following four sessions, it appeared that he did so from a need to gradually ease out of the intensity of his “voyage.” In the session following this one, Will discussed an incident at school that began with another boy teasing him, and Will responding by pushing the boy. The other boy then attempted to kick Will, who grabbed the other lad’s foot causing him to fall and injure his head requiring three stitches. As a result, Will was suspended from school. Obviously, the metamorphosis hinted at in Will’s fantasy existed only as a possibility. Yet Will expressed feelings of shame at the incident in a manner that indicated--unlike previous expressions of guilt or shame--that he truly regretted this incident. This new response on his part indicated that Will was aware of a discrepancy between how he wanted to act and how he was actually acting. This awareness suggested that the change in Will’s self-image that I was hoping to facilitate was, in fact, beginning. The Middle: Where Did the Music Go? For a period of three months (comprising sessions 19 to 27) Will had very little interest in making music. During this time, we played ball, board games, and engaged in fantasy stories without music. Themes of transformation involving intense violence and aggression dominated Will’s stories. In one story Will and I scaled an enormous mountain where we encountered demons who were once humans and who were searching for an antidote to return them to human form. In these stories, Will created scenarios that required that I “kill” him or that he “kill” me. In the story with the demons, I had to “kill” Will so that he could return to being a demon and carry out a task that only a demon could accomplish. In the following session, Will and I were allies and had to kill the demon king who had stolen Will’s gold treasure. In still another story, Will acted out violent fantasies toward me as he was a policeman who repeatedly shot me in a location that a Freudian analyst could only see as acting out a desire to castrate the father! This period was particularly challenging to me as a music therapist. On one hand, I knew that it would not be fruitful to engage in a power struggle with Will by attempting to coerce his participation in music. It was important for him to know that I would be with him regardless of what he chose to do, and that my supportive and caring presence was not conditioned upon how he chose to use his time in therapy. Alternately, I felt that Will was coming to music therapy for a reason, that my expertise was working in music, and that if Will had no need of my skills in this area, I questioned whether he should continue in therapy with me. What I gradually came to understand was that musical interaction represented a certain kind of intimate contact to Will and that he needed to feel control over the depth and quality of this contact. Abstaining from music was one way for Will to control his environment and the relationship with me. I decided that this manner of expressing his need for control was a positive one and that my commitment to help him transcended my desire to work in the music. After all, it was Will’s need that was primary and it would be counter-therapeutic to demand that Will express himself or relate to me through music if he was choosing an alternate form of expression.

Midway through this stage, Will and I met with his mother and her therapist. Though Will was extremely resistant to this meeting, he used it to voice his feelings that he was being forced to engage in many after-school activities (gymnastics, guitar lessons, play therapy) that he was not interested in. At the end of the session the four of us engaged in a musical improvisation--Will’s price for attending the meeting. Will enjoyed this playing so much that he actually requested that we meet as a group again! Actually “playing” with his mother was something that Will rarely did, and he seemed to take nourishment from the opportunity to just be a child with his mother. Though Will engaged in some music during the second half of this stage of therapy, his interest level fluctuated and our contact was relatively superficial. In session 38 (approximately nine months after the “Trick Land” session) I prepared Will for a six-week separation due to each of our summer vacations running contiguously. We played some music in this session. Will played the electronic keyboard and I played the drum set. I felt a significantly deeper contact with Will than I had felt in quite a long time. I realized then that regardless of all the other activities that we engaged in, our strongest bond was still in music. It also occurred to me that Will was abandoned by his father and that it must be very difficult for him to trust any males or to let our relationship grow past a certain point. Will’s reluctance to engage in music became more intelligible to me seen in this light. The Ending: A New Beginning for Will In Will’s thirty-ninth session, which took place after a six-week gap in his sessions, he appeared different and more mature. He was very interested in music again, though his tastes had changed. He was no longer interested in purely acoustic improvisations and wanted to recreate the heavy metal music he had been exposed to during his summer vacation. Will also wanted more autonomy in the music, expressing the wish that I should not “play the same song as him.” In other words, my playing should be more complementary to his and not so nearly reflect the structural elements of his music. Though Will was interested in electric music, in contrast to the previous stage, he was now using these instruments in an expressive way, creating sound “portraits” that reflected his then current feelings. He alternated between rapid, almost frantic, dissonant improvisations, and slower and more melodic ones. Also, though Will’s testing behaviors emerged periodically throughout the first two stages of his therapy--primarily seen in his need to prolong the session or turn up the volume on the electric instruments to excruciatingly loud volumes--these behaviors had now dissipated. Will no longer needed to create interactions designed to put me in a position which would be experienced by him as rejecting. This last stage, comprising nine sessions over a three-month period, was a transitional one for Will as he evidenced signs of growth and recapitulated elements of his year and a half in music therapy. In addition to his desire for increased autonomy, Will began to ask me what I wanted to do. He seemed interested in forging a more reciprocal relationship where I was not just an object for his fantasies, but a person in my own right. These signs of growth were reflected outside Will’s therapy, primarily at school. Fighting was no longer a problem and Will was not in danger of being expelled. Interestingly, his violent fantasies dissipated somewhat, though they still occupied a significant amount of his time in

therapy. They primarily involved the killing of evil beings that became transformed through death. His need for this ritual, symbolic slaying as a precursor to personal transformation remained strong. Unbeknownst to both of us at the time, Will’s forty-eighth session was to be his last. He engaged in make-believe gun play using curtain rods and did not want any music. At the end of the session he had planned to sing “Twist and Shout,” yet he abruptly changed his mind. Our last activity together was playing the song “Lean on Me.” Will’s abrupt termination was due to a variety of factors. I needed to change his session time, and Will’s mother was finding it difficult to arrange another time to bring him to the center. Will’s mother was herself a client at the center and had ambivalent feelings about continuing her own therapy--Will’s continuation became tied to her own. Lastly, Will himself seemed ready to let go of our connection. Though he could have benefitted from more time, or at least a reasonable termination, Will had, in fact, outgrown and transcended some of the problematic behaviors that had plagued him. Not possessing any pathology but merely the victim of an unfortunate family situation, I could see that Will was ready to fruitfully engage life without the benefit of a therapist. Discussion The Importance of Creative Fantasy Having provided the reasons behind many of my specific clinical interventions in the previous section, I will briefly discuss my rationale for what were the most therapeutically salient elements of Will’s treatment: his use of creative fantasy and music. Bettelheim (1975) discusses the psychological significance of fantasy material (in the context of fairy tales) in a manner that demonstrates its relevance for normal development. Since the source of the characters and themes of fairy tales lies in the archetypal experience of childhood, we can see how the process of therapy can evoke the same themes discussed by Bettelheim, though their specific form will be determined by the individual child’s personal experience. Thus, without having to accept Bettelheim’s theories on the meaning of specific stories and symbols, we can still fruitfully make use of his rationale on the importance of fantasy for the young child. This involves not a thorough examination of Bettelheim’s ideas on fairy tales, but merely a cursory look at what the elements of these fantasy stories tell us about the child’s view of the world, which subsequently allows us to better understand the meaning and role of fantasy material in the music therapy milieu. The characters in fairy tales have no moral ambivalence; they are either good or evil with no middle ground. Though not reflecting adult reality, this polarization reflects how children see the world. Thus, the creation of fantasy allows children to express their existential reality unfettered by (inappropriate) adult constraints on the nature of this reality. The child’s subsequent moral development is dependent upon developing notions of morality through exploring their extreme manifestations. “Ambiguities must wait until a relatively firm personality has been established on the basis of positive identifications” (Bettelheim, 1975, p. 9).

The characters in all of Will’s stories were either good or evil with no middle ground: No character ever possessed relative amounts of these qualities. It was important that I allow Will to enact his stories without trying to teach him finer points of morality and human nature. It was necessary for Will to explore moral extremes, to see pure good and pure evil, in order to begin to differentiate between the two and develop his own notion of morality. Providing him moral “instruction” (for example: “You see Will, you are not good or bad but contain relative amounts of these qualities as all people do.”) would not be appropriate for Will. His developmental level did not allow for this type of processing. As a therapist, my role was not to teach morality, but to facilitate the normal process of moral differentiation. Bettelheim also believes that fairy tales represent the process of normal emotional development, and the solutions reached by the characters in the stories provide solutions to the child’s own inner conflicts. Fairy tales do not teach in the sense that fables do, but instead encourage children to find their own meaning and solutions--their essence is necessarily interpretive. This belief in the child’s inner resources and ability to find solutions, when provided a supportive, creative context, functions as a rationale for the client-centered use of fantasy material. I could diagnose what I believed was Will’s need--such as developing a less static selfidentity--but I do not believe that I could directly provide this to him. Only by creating stories, themes, and characters that reflected his unique experience and conflicts could Will begin to work through these conflicts and find the solutions that made sense to him. Just as “in a fairy tale, [where] internal processes are externalized and become comprehensible as represented by the figures of the story and its events,” (Bettelheim, p. 25) creative fantasy in music therapy gave Will the opportunity to express the nature of his inner reality through an external form. His fantasy not only provided a manifestation of intangible inner processes in order to work with them, but also served an important function in externalizing the source of his difficulties. This distancing is important to children as the fantasy material must be seen as “something external ... to gain any sort of mastery over it” (Bettelheim, p. 55). Transformations One consequent of the child’s polarized view of people is that when alternate, “undesirable” character traits are expressed (such as anger or aggression), the child experiences the individual as transformed in some way. To Bettelheim, fantasy characters such as the evil step-mother serve an important function: they allow the child to pour all the anger and fear towards the real mother into an alternate form, thus preserving the real-life mother as a benevolent and nurturing presence. In the child’s view, then, it is necessary to undergo a transformation in order to express that which would normally be repressed. Now Will had no problem expressing his anger and aggression. Certainly his fighting in school was a testament to this. What was important for Will to do was to find a way to express his benevolent or “heroic” aspects, and this is what I attempted to provide in his music therapy sessions. It was not that Will needed to become “good” and that I was facilitating this type of actual transformation. This is an overly simplistic and concrete view of Will’s process. Instead, I wanted to help Will to experience the potential of transformation between good and bad, so

that he would not feel perpetually stuck in one end of this polarity. The only way to do this for Will was to actually experience this transformation as an active participant in his own fantasy. It was the possibility of transformation that I hoped Will would discover. Because young children externalize inner dynamic forces by projecting them onto fantasy characters, their perspective on growth and change is that it results from the action of external forces, not by one’s own conscious intent. It is wizards, fairy godmothers, and witches who facilitate growth and development through invoking their magical powers. Given this perspective, I decided not to focus on developing insight into the unconscious determinants of Will’s conflictual behavior (fighting) because, in his world view, change would not come about through his own efforts--it was endowed from without. Instead, the fantasy material allowed Will to facilitate his own development through the metaphor of magical transformation as that which was developmentally appropriate. Importance of the Music Although it may not have always seemed obvious, this is a music therapy case study and the music had a few important functions in facilitating Will’s ability to experience transformation. Though the role of music in accessing transformative processes in therapy is a broad (and too long neglected) area, I can only briefly describe those qualities that were specifically important to understanding Will’s process. Through my musical contribution, I was able to bring out the underlying feeling tone of Will’s fantasies, increase his investment in them, and, in general, make them more real and thus enhance his participation. I wanted to help Will to actually experience his own transformative potential rather than remain a passive observer as one might when merely reading a story. By creating such individualized music, I was able to help Will to experience the story as his own; by providing Will’s various characters with their own musical manifestation, I was able to deepen his identification with them. Music also provided me with a field for interaction with Will that existed within his reality. In other words, I did not have to step outside of Will’s fantasy to interact with him. This was important in allowing me to support, develop and comment upon the themes, such as examinations of the relationship between good and bad and movement between the two, that I felt would facilitate Will’s therapy. Though not attempting to control the content of Will’s sessions, I did use the music to comment upon and enhance the quality with which the emerging content was experienced. This was done through things like creating magical, otherworldly music for Trick Land, introducing triumphant music for the transformations, and alternately creating pensive or outgoing music to reflect Will’s level of self-examination. Another important function of the music was to provide a symbol for the enduring self that maintains itself through the dynamic changes represented by the voyage to Trick Land and the subsequent magical transformations. In the session previously described in detail, the tune “Monster Shout” served this function. This deep-seated human need can be seen in the developmental realm--as when a young child playing independently needs to make periodic contact with the mother--and in the musical/aesthetic realm, in a rondo that alternates between melodic explorations and re-statements of the primary, enduring theme. Similarly, Will could go on a perilous, explorative journey as long as he could make this same periodic

contact with that which represented his enduring identity and source of security and familiarity--the music. This song also served as Will’s dual-faceted entry point: It provided him with a transition from the “normal” reality of the session to the “magical” reality of the fantasy, while simultaneously performing the symbolic function of transporting Will to the “far-away” place represented by Trick Land. When engaging in this type of fantasy many children will use an actual vehicle, such as a bus, airplane, or rocket ship. Will’s ability to live in, and be absorbed by, music is indicated by the manner in which music served this transportive function. Conclusion Emotional development and maturity has an attractive force because it holds the promise of a more rewarding life. Yet, to some extent, we all fear growth because it represents change and yielding to a process whose ultimate result we cannot foresee. The work with Will illustrates one of the most powerful functions of music in music therapy, however, and this function is related to the fear of change. Music, for Will, reduced his fear of the unknown through associating novel experiences with the feelings of safety and security characteristic of that which is familiar. Will’s familiar songs gave him the courage and empowerment to contact and engage the powerful, magical forces living in his fantasy, and by extension, his unconscious. To the extent that music represented that which was familiar, Will was able to use music to enter and explore this previously unknown and fearful realm. References Bettelheim, Bruno. (1975). The Uses of Enchantment. New York: Vintage.

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE TWO

Improvisation and Play in the Therapeutic Engagement of a Five-Year-Old Boy with Physical and Interpersonal Problems Pamela Bartram Abstract Tom is a five-year-old boy with a history of seizures, physical complaints, and interpersonal problems, both at home and at school. In the 37 music therapy sessions which have been summarized, he engaged with the music therapist through musical improvisation and play. Tom’s plight is considered in the light of the material arising out of these interactions. Prologue Tom: (Talking to a puppet of Humpty Dumpty lying down). Oh Humpty, you’re a very naughty boy....a very naughty boy. Pamela: Because he keeps lying down all the time when it’s in-time? Tom: (Silence) Pamela: He flops down dead. Tom: He keeps going...flimp. Oh, now he won’t...he’s doing tricks. (Tom is holding Humpty by his two long legs and spinning him round and round). Pamela: Oh no, poor Humpty, he’s feeling sick with his upside-down tricks. Tom: Oh whee, whee (spinning Humpty round). Pamela: He’s spinning around, spinning faster and faster. That’s going to make him feel very sick, all that spinning. Tom: Look....(laughing to Humpty). Look, you’re tangled. Pamela: Mmm...That’s what spinning does. It makes you all tangled. Tom: (Anxiously) How can this get back? In this dialogue, Tom and I (with the aid of Humpty) are exploring themes central to this study. There is the naughty boy, the boy who flops and flimps, or who spins around doing tricks. But the spinning tricks make him sick and tangled. How can he rediscover a better state of being? Here we will have the opportunity to consider more fully Tom’s state and the conditions which may have been instrumental in bringing it about. We will also consider issues raised by Tom’s own question about how it may be possible for him to be something other than in a ball and sick or spinning, tricky or tangled. For two reasons I will neither attempt to focus on changes through time in his behavior, nor to make a case for improvement in his condition having arisen due to music therapy. These are firstly, the way in which I structured my own contribution to the sessions changed as my

understanding of his difficulties deepened under the influence of supervision and personal therapy (thus, I myself was a variable in our “equation”); secondly, it was clear that Tom associated his concurrent experiences in psychotherapy with those in music therapy. It was likely that processes prompted by his psychotherapy would bear fruit in the area of his creativity, both in general and in his musical material. It would be impossible, therefore, to judge music therapy events, and even less so, strictly musical events, as sole agents in any change process that might be identified. My aim is, therefore, restricted to using session material to illustrate how it is possible to know through music or through the mixing of music (i.e., the therapist’s with the patient’s), to explore how such knowledge may be understood in relation to Tom’s presenting difficulties, and to explore the meaning for him of moving in and out of musical material. Background Tom, aged 5 1/2, was referred to me for music therapy by a clinical psychologist, both because he himself showed an interest in rhythm and musical instruments, and because she felt he needed to succeed in a noncompetitive environment. At home he would sometimes sing rather than talk about his school day. Having met Tom for the first time, I had the impression that music therapy might indeed be a medium in which he could channel and creatively use his imagination and his physical energy. However, I also wondered to what extent a child as verbal and as scattered as he appeared to be, would actually take up and use the medium of improvised music-making. Tom is the first child of financially comfortable upper middle-class parents. He has a younger sister who was born when Tom was three years old. Tom’s development had been described by his pediatrician as “unusual” but not grossly delayed. When he was three years old, his parents took him to a Child Development Unit where they were told that he was retarded, hyperactive, and that he would “never earn his own living.” On taking him for a second opinion, no doubt in a state of shock, they were told that Tom was well within the normal range of development. In the parents’ minds, therefore, there has been confusion as to Tom’s potential. He was referred to speech therapy at three years three months, where he was described as having poor concentration, immature articulation and poor expressive language. A few months later, Tom was sent to a school run along formal academic lines, perhaps as a preparation for going to boarding school at seven years. Around this time, he began to suffer from recurrent attacks of headache and vomiting. There is a history of migraine in the family. School described him as unable to concentrate, disobedient, and failing to achieve, and he was often punished by, for example, being kept in to do school work at break time. He had no friends. At four years eleven months he suffered a generalised convulsion in bed, and another almost a year later, also in bed. On the second occasion, he went into status epilepticus, requiring intravenous valium. When he regained consciousness in hospital some hours later, he did not ask where he was or what had happened. Some weeks later however, he referred to the hospital as the place where he’d had his headache.

CAT scans have shown no gross organic damage, although there is a hypothesis of fetal distress during his delivery by Caesarean section, and a possible lack of oxygen having led to “minimal damage.” After the second convulsion, an EEG showed abnormal activity which might indicate that, apart from the generalized convulsions he may experience brief absences or petit mal seizures, which go undetected. He has a history of eczema, allergies, and a “droopy left eye” which becomes more pronounced when the nausea, headaches, and vomiting prevail. He sometimes has a tic, a movement involving a head jerk back and slight roll of the eyes. When Tom’s mother first brought him to meet me, she referred to his difficulties primarily in terms of his vomiting, headaches, and his short concentration span, which was making him unsuccessful and unpopular at school. She said he ate well, although he always tended to regurgitate feeds as a baby. There was no disruption of sleep, in fact, she described how Tom loved to go to bed, fell asleep straight away, and slept soundly all night. He would often ask to be allowed to go to bed long before bedtime. I subsequently learned that he suffered from nightmares and bedwetting, which upset him considerably. I also learned that he had a difficult relationship with his father, he bullied his younger sister, he was “disobedient” and without friends at school, and that there were difficulties in his relationship with his mother. Tom also had a tendency to be inappropriately friendly with adult strangers. At the initial meeting with mother and son, I was struck by the contrast between them. She is a tall, elegant woman, softly spoken, and with a gentle, dreamy, sometimes absent manner. (It has sometimes been difficult for her to remember Tom’s appointments for music therapy). She described Tom (while he played outside) in bemused, slightly irritated, and mildly ironic tones, as if he were a naughty boy and as if the situation were tiresome. Any anguish she might have felt was not expressed. At that interview, Tom came into my office, a rather overweight little boy, with angry red blotches on his face. He looked disheveled, and his tic was noticeable. He spoke to me immediately, asking questions, and then moving around the room without waiting for an answer, but helping himself to objects in the office and asking more questions. He spoke very loudly in what seemed to be a falsely sociable, apparently self-assured tone. Beside mother, who seemed so quiet and stylish, Tom looked a mess--and after a few minutes the office began to look a mess too. When I took him to meet a colleague who had agreed to occupy him, he did so willingly, running ahead of me without a goodbye between him and his mother, and then talking incessantly with my colleague. Tom gave a superficial first impression of being a “bit of a character.” When I returned to the office, mother raised her eyebrows, smiled gently, and gave a shrug. Tom’s father is a successful businessman, who on a later occasion described how he arrives home tired in the evening with little patience for a naughty son. After Tom’s second seizure, he was remorseful at the idea that he had sometimes disciplined Tom for bad behaviour, which might have been related to his condition. At that time, both parents still tended to view Tom as a boy with medical problems, hitherto undetected, which had resulted in management problems. Thus, they assumed that once the medical problems were solved, the others would disappear.

In the case review a year after the initial referral, the pediatrician expressed the view that while Tom does have medical problems, possibly related to minimal damage at birth, his disposition and life events have interplayed with them to produce phenomena which cannot now be treated as medical problems, pure and simple. A few months after beginning music therapy, Tom began anti-epileptic medication. Shortly after that, he moved to a less academic local school where he was, at first, excessively aggressive to other children--especially in the playground. This aggression subsequently diminished, however, his difficulties in concentrating and in making relationships remained. At the same time, Tom began weekly psychotherapy. Before offering him sessions, the psychotherapist contacted me, and after some discussion, we agreed that it would, at least, not be harmful for Tom to attend both psychotherapy and music therapy, and indeed together they might be useful. Treatment Process From the first sessions, Tom brought a mixture of musical and nonmusical materials. The latter often taking the form of nonmusical use of instruments and competitive games. The overall trend was away from music-making, although each session contained at least some musical material. Although the organic development of session material cannot be sharply delineated as the following schema might suggest, the sessions can be conceived as falling into three sets. In the paragraphs that follow, an overview is given of what transpired in each set, and a more detailed transcript is given of the second session. Sessions One through Eight The first eight sessions were characterized by a pervading atmosphere of anxiety, disorder, and brief, inconclusive engagements. Tom found it difficult to stay in the therapy room for the duration of the session. I had to discourage him from dismantling instruments and from bringing items such as food or toys into the room. Beginning and endings of sessions were abrupt and disordered. Tom commanded and attempted to direct my musical and nonmusical activity. Musical material in which I had to imitate him was particularly significant. I tended to resist Tom’s commands and to insist that I make my own choices. He often spoke in false voices, including a witch voice. There was little sense of satisfaction, either individual or mutual. I felt resentful of his apparent communication that whatever I offered was not the right thing, and I also resented his attempts to help himself to something better. Notes on Session Two This session began with Tom racing me from the waiting room to the therapy room, and running into the therapy room, alone. A variety of instruments are arranged as for the beginning of the first session with the addition of a reed horn which he had requested. He goes straight to the horn, picks it up and plays it briefly, then moves to the drum, playing with a

bouncy body movement, and soon brings in the cymbal. I have closed the door and made my way to the piano where I sit, listening. Without stopping playing, Tom gesticulates for me to join in, but as this gesture is ambiguous, I have to talk over his playing to ask, does he mean for me to play. I begin to play, but after sharing only one full phrase length, he breaks off, saying that when he plays the drum, I must play the bells (which are small and tinkling). He tries to give them to me, but I am reluctant to change instruments at this point and especially from the piano to the bells, given the force of his drum and cymbal playing. I say that we can each decide what we are going to play and I choose the piano. He returns the drum, though still appearing to instruct me in a lisping babyish voice. When he announces with stage-authority, “Off you go...the big drum,” a duet begins with him on drum and cymbal and me on piano. This turns out to be an unusually sustained (six minutes or so) period of shared musical engagement. During this “episode of engagement” (Stern, 1977), Tom changes his instrument several times (drum and cymbal, horn, drum, glockenspiel, piano, cymbal, drum and cymbal). Yet there is an overall sense of continuity, largely due to the rhythmicity of his playing, the recurrence of a tempo of 120 beats per minute, and the continuity of my own playing. Tom himself gesticulates and instructs me verbally to carry on playing during his changeovers, and I have an image of him trying to keep me going (like a machine) by conducting with one hand, while playing with the other. He has a natural tendency to organise his percussive playing into a strong pulse which is regularly inflected and which contains rests that allow for the formation of repeated phrases. These features give a robust quality to his playing, and provide firm material for engagement. The volume and timbre give his playing a sturdy quality. At the same time, his prevailing choice of percussive instruments limits his exploration of melodic qualities which might suggest to him contrasting dynamics, timbres or rhythmic forms. I try to play music which reflects and contains the strength of his playing, and which accommodates the changes in his tempo, rhythm, pitch, and timbre. At one or two moments there is renegotiation of the elements after one player has introduced new material. We play an intense “trembling” duet on the piano, but Tom abruptly breaks off and begins to spell out the piano brand name. Then giving one cymbal crash, he asks “How many minutes are we going to go?” I remind him of the length of the session and ask, “Does it feel like a long time to be away from Mummy?” He replies with an unexpectedly powerful and very loud cymbal crash. This leads into a few slow and deadly drum/cymbal beats, and then speeds up into strong pulse playing (126 beats per minute) which breaks off mid-phrase. Here, my own playing becomes dissonant in response to the wilder character of his. Nevertheless, I am almost inaudible at times as I struggle to judge the register and volume required to withstand the ferocity of his playing. The final break, which ends this episode of musical engagement, occurs as did the previous two, mid-phrase, cutting across the musical phrase rather than arriving at a natural ending. Tom anxiously suggests, “Shall we go now...or something?” Even this short section of material reveals the extent and limits of Tom’s creativity in musical and interpersonal relationships. His music is powerful and often has a recognisable form and organization. It feels like a force to be reckoned with rather than, for example, a tentatively formed and executed music whose manifestations need to be awaited and delicately nurtured. Music such as Tom’s might have a lot to contribute to a relationship.

On the other hand, he also seems to be struggling to create the illusion that he alone is starting, maintaining, and ending our musical engagement, as well as largely determining its character. When I had refused his offer of the little bells, he acted as if he was the one determining the course of events, presuming to instruct me to do what, in fact, I was already doing. Rushing into the room and beginning to play without me, then conducting my playing while he changes instruments are perhaps other examples of this illusion-creating. I sense that he feels responsible for my part, for my liveliness, as well as his own, and the energy he expends playing so strongly seems to serve the function of also keeping my part alive. It was unusual, but in retrospect understandable, that when Tom ended the episode, I suggested that he sit down and have a rest from playing. It was as if this illusion requires such energy to maintain, that Tom is left exhausted after only a short time and there is a feeling of the impossibility of going on. In fact, there is no more sustained music until the last eight minutes of the session, when I remind Tom that it is near the end and ask whether he would like to play again. We improvise a horn/voice duet. It has a jittery quality reminiscent of the “trembling” duet on the piano. There is a tense sharing of phrase lengths in antiphonal exchanges. Antiphonal playing seems more tolerable to Tom than simultaneous playing, perhaps because it promotes a clearer demarcation of the separate parts. Tom further controlled even the antiphonal play by often insisting that I imitate him in this way, even more closely “keeping an eye” on my part. Later, in a drum duet, Tom divided the drums between us so that he had the bigger ones, and then proceeded to divide the musical material by insisting that I imitate him antiphonally, thus making my part dependent on his. As a leitmotif, he used the following rhythm in duple meter that he introduced in the first session:

This sort of controlled duet could easily feel more like a mechanical test for me than a shared musical expression, nevertheless, we manage to enjoy a playful moment when I imitate his accidental stick-click, and he adopts it as part of our shared repertoire. Although Tom is laughing, the sound of his laughter has a tense, choking quality. For some time, I have resisted Tom’s attempts to control my instrumentation and musical material, as this sort of domination feels entirely inappropriate within an art medium. The feelings evoked by being ordered, “Sing now!” or “Play like this!” painfully arrests the free inward ranging and suspension of disbelief so necessary to shared musical expression. Here, I was faced with a choice either to satisfy the requirements of creative improvisation or satisfy the requirements of the anxious boy in the room with me. It now seems to me that to be helpful to Tom, I needed to be able to tolerate the feelings of being interrupted and cut-off, of being un-free, of being like a puppet, of being at best, a musician in his orchestra, playing his score...the feelings which he put into me. It was these considerations which led me to abandon some of my earlier structuring tactics, such as insisting that I choose my own instrumentation.

Tom’s use of the chimes in this session and in later ones, illustrated his tendency to make primarily nonmusical use of instruments. A small table would be laboriously covered with a selection of musical instruments, usually fetched from the cupboard with my help. Tom and I would sit opposite each other, and he would repeatedly engage me in unnerving “tests” less related to the sound of the chimes than to their appearance. For example, he would play a phrase for me to copy which consisted of two small black bars and one large white one with a green dot. I was supposed to respond by playing two small black ones and one large white one with a yellow dot because I did not have a green dot. I would, of course often get this wrong, as I would be listening to the pitches rather than thinking about the color and size of the bars. Subsequently, Tom would change his criteria for correctness so that I seemed ever doomed to get it wrong and earn an irate reprobation. Thus, Tom effectively gave me a clear experience of what it is like to be on the wrong end of a learning difficulty. Another chime game that developed was “Hey Pamela, Hey Tom.” We would begin playing antiphonally or together, and then Tom would venture onto one of my chimes, at which time I would give a cry “Hey Tom!” Often I would be instructed as to when to play on one of his chimes so that he could then be indignant and cry “Hey Pamela!” At other times our music games would require my imitation of his leitmotif. Sometimes these games began to move towards being truly musical, and short improvisations would “break out.” Occasionally, waves of ringingly dissonant simultaneous chime playing would emerge briefly, which had more an abandoned quality than the robust and square playing of much of Tom’s material. In these episodes it seemed that the small sounds of the chimes made our shared engagement feel more manageable than did the larger instruments, although, most often, we soon had to return to more formally demarcated structures in order to be co-active. In one instance, Tom even halted the musical interaction with “Oh, I’ve got one point,” as if we had been only scoring against each other rather than exposing ourselves in self-expression. Sessions Nine through 18 Much of our work in sessions nine through 18 was still characterised by disordered and interrupted exchanges, however, Tom did begin to initiate and sustain some episodes of more prolonged and satisfying musical co-activity. I began to allow him limited access to the cupboards. Particularly important in this period was that Tom began to find good objects (including the therapist) within the sessions, and began to communicate this. For example, he sings of one session, improvising “And it was good....and it worked...” I continued to feel anxious, resentful, and resistant to the unsatisfactory aspects of our relationship. Sessions 19 through 37 From the 19th to the 37th session, some ordered, slower and calmer episodes occurred, along with some welcome silences. Our musical activity decreased, while nonmusical play and conversation increased. When musical activity did occur, brief moments of freer improvisation

emerged within extended periods of playing together. Tom developed an increasingly important relationship with the gong. He was becoming more able to think about endings (e.g., of sessions and holiday breaks). I allowed him free access to the instrument cupboards, and allowed him to bring toys and other things into the room. Tom spoke more in his own voice, and I became, at times, the wicked witch to whom he had earlier given voice. He was also better able to take in what I said to him and to express his confusion verbally, thus allowing me to address it. Eventually, Tom began to acknowledge me as a possible container, commenting for example at the end of Session 30, “I’ll leave the mess in here.” I began to feel more able to accept his plundering and to tolerate my feelings of inadequacy. Discussion Earlier, it was mentioned that Tom would attempt to break away from an engagement by wanting to leave the room. While this continued to be a feature in almost all sessions, it later developed in the form of his wish not to enter the therapy room at all but to dash into nearby rooms which might contain instruments, a television, or people who Tom would try to engage in conversation. Sometimes he expressed a wish to stay in the waiting room playing with toys rather than come to music. Often, during our half-hour sessions, he would run to the window banging and shouting to passers-by in witchy, authoritarian voice. Tom’s avoidance of the therapy situation turned out to be an important clue to understanding the feelings underneath all of his naughty, controlling, and tricky maneuvers. It is therefore a fitting place to begin a more in-depth discussion of what Tom may have been revealing to me throughout these sessions. Session 19 was of particular significance. When our appointment time arrived, I found Tom sitting on the steps outside the building, sobbing, and refusing to come in the main door. The sense of his fear and misery seemed more evident than they had previously been. The manner in which Tom had characteristically moved around in the therapy room, or expressed his wishes and dissatisfactions had always been similar to that described at our first meeting, by his teachers, etc. He appeared confident, fussy, and bossy, and his attempts to control me were irritating rather than expressive of fear and deep distress. On this occasion, when I asked Tom what he was afraid of, he was able to tell me through his tears: It was the gong in the therapy room--he was afraid of going into the room if it was there. Tom’s reluctance to enter the room, his frequent requests to leave it, his wish to control my instrumentation, his preference for antiphonal over simultaneous playing, and his tendency to break away from musical improvisation seemed to be interrelated. As in his fear of the gong, they may be viewed as aspects of a phenomenon in which Tom is terrified and distressed by something which is very big, whose resonances multiply set off by a single stroke, and which grow with an overwhelming effect of vibration and sonority, impacting on mind and body. Perhaps the freedom of improvisation itself sets up these kinds of feelings within him. In fact, Tom developed an activity in which, standing together with him at the gong, I must be ready to dampen it on his instruction, so that he could hit it very hard without its full resonance returning. Perhaps it is when that fearfulness, here elicited by the gong, is not fully conscious, that Tom has to adopt a range of maneuvers in relation to other people in order to keep it at

bay. Maneuvers such as engaging in, but prematurely breaking off, interaction manifest as irritating, naughty, and “tricky” behaviour and appear to be the result of poor concentration or sequencing problems, but in actuality may be defenses. It is easy to see that his relationships with family and peers would suffer as the result of such defensive maneuvers, as would his ability to take in and keep down learning. Interaction with Tom often does feel tangled. It is difficult to sustain one activity with him without constantly expecting it to be broken off. In any setting where an adult had predetermined activity goals, I imagine that Tom would certainly be described as disobedient. It is as if Tom himself “gongs” around, as he did that first day in my office, a constant flow of physical and verbal activity, overturning and upsetting things, making sure that his “vibrations” disturb whatever is around him. Then, when he strikes the actual gong, it all comes back at him. Suddenly, all the unmanageability assaults him as if from outside--but magnified, amplified. What elements of his disposition and early experiences might have contributed to his inner world being characterized by a fearfulness which seems to vibrate like the sound of the gong through his whole body? This image itself conjures up the frightening image of finding oneself taken over by a convulsion, which shakes one from the inside. We do know of at least two occasions on which Tom suffered from extreme forms of generalised convulsion. Conceivably, there may have been others, possibly nocturnal, which went undetected but were, nevertheless, experienced by Tom alone. His bed-wetting could have been seizure-related at times, and headache and nausea may have accompanied the seizures themselves, and be more easily alluded to by Tom than the seizure itself. A family history of migraine might dispose him to experience these particular manifestations of illness. While this vision should be borne in mind, I am also reminded of the contrast between Tom and his mother which suggested itself at our first meeting. Perhaps he has had a repeated experience of himself as somehow too big for her, too much to be “borne” by her. It may be that his frequent request to leave the sessions comes from a fear of being too much for me, of damaging me as he fears he has damaged his mother. For the child who experiences his mother as absent in some way, or not there for him, must attribute the cause of her absence to himself. Tom may also leave the therapy room in order to check that his actual mother is still accessible (although she, in fact, chose to leave the building during his therapy sessions). He may need to be physically close to her because psychically the safe inner mother seems absent, or not big enough to hold him safely. These speculations seem to be confirmed by two themes in Tom’s music therapy sessions: Firstly, his preoccupation with broken objects, and an anxiety that he had broken or would break instruments; secondly, his preoccupation with big and little things, where he frequently tried to ensure that I have smaller instruments or beaters than his. The tragedy of this situation, or rather the tragedy of its internal meaning, is that while he feels frightened that he is too big for the therapist, he is equally frightened that she is bigger than him: for what could be more frightening than to feel completely vulnerable with a big person who may not respond to your needs? In the moments when he breaks off our contact, he may be frightened that he is going to damage me with his bigness, or equally frightened that in being out of his control, I am going to damage him with mine. In his rummaging in the cupboards, he seems to show that he needs to help himself to what he needs, rather than hope that together he and I can negotiate to fulfill his needs. If the

caregiver is experienced as unable to contain the child’s feelings, then the world feels intolerably unsafe, and the child feels unheld. The spinning trickiness seems to result. Tom moves quickly from one thing to another, not managing to settle into a satisfying engagement. As in feeding, food that is offered and taken in cannot be held down (vomiting), or feels as if it must come back up again (nausea). Tom feels ill; he rolls into a ball and asks to go to bed where at least the external spinning world recedes. But by lying down in a ball, he deprives himself opportunities to take in, to learn, and to make real relationships rather than attach himself, inappropriately, to strangers. Why might Tom experience himself as unheld and uncontained? Several factors may have contributed. Firstly, the dispositions of Tom and of his actual mother may have been in some way mismatched, so that if a slow and gently-moving mother has a fast-moving and extroverted baby, adjustments have to be made until they find possible ways of relating. Stern (1977) refers to such difficulties as the result of “missteps in the dance” of the mother-infant relationship. The fact that Tom tended to regurgitate feeds as a baby might indicate that it was difficult for him to ingest the good things that were offered. The pace of feeding may have been a source of difficulty between them, and an optimal “balance of power” was perhaps not successfully achieved. Furthermore, if Tom did suffer minimal damage at birth, which is now related to his having both generalised and petit mal seizures, he may have had recurrent experiences of, as it were, the world dropping away from him. That is, constitutionally he may have been disposed to experience absences. In petit mal seizures, this would happen quite privately within Tom’s world, unmitigated, therefore by observation and concerned explanation. When he awoke in hospital after his generalised convulsion, he may have had an experience not only of having dropped out of reality, but of reality itself having dropped away. This would easily integrate into an experience of a caregiver who seemed less than fully there, not quite “as large as life” as the child himself. What has been described so far may well have been compounded by his experience of losing his mother to a sibling in his third year, and shortly afterwards being sent to a formal, academic school, thus losing his own time to be a playful child at home. While a hearing loss and an articulation problem may, of course, have an organic component, they may also externalise the child’s experience of himself as not being able to take in and not able to make himself understood. If Tom feels that he has to stop the world from disappearing from his frenetic activity, he must be in a state of pain and fear. Unfortunately, his “naughtiness” and “disobedience” make it harder to get and stay close enough to him to understand more about his real state. The “tricky” Tom is a draining child, and a drained caregiver has even less energy with which to try to understand him. A father, himself stretched by professional responsibilities, may avoid spending more time at home when his son is so frequently naughty and troublesome. This study has in some ways focused on the tricky, tangled Tom, rather than on the sick and “in a ball” Tom who did not generally find a place in our sessions. One exception to this was the session following his hospitalisation, in which he made himself a bed on the floor and lay sadly hugging a small drum which he said was “the thunder in his bed.” Until now, I have perhaps not said enough about the well Tom, the hopeful Tom who engages with the therapist, bringing her not only his difficulties but also his resources. His

playing, as we have seen, could be remarkably strong, sturdy, outwardly directed, selforganised, forward-moving, trembling, and even randomly free. His break-off points were not due to a lack of sensitivity to my playing. On the contrary, it was his sensitive awareness of our being together in phrase, volume, etc., which seemed to drive him to break off. In his rummaging in the cupboards he often remarked as if to himself “Something might work...” His pun on the piano’s brand name, substituting his own name for its second half, seemed both proprietal and celebratory, and became a repeated and much enjoyed point of shared understanding. His present of a flower to me, with the remark that queens have flowers, and brides do too...all these aspects of Tom seem to show that he has had good experiences, albeit incomplete or unfinished, and that he is hopeful of finding more or of “getting back.” In one of our last sessions, Tom acknowledged that “Humpty needs a doctor...a lady doctor...the one he’s pointing at” (Me). The material in his sessions became less musical as time went on. In the last sessions before summer holiday, he very much wanted to play a game in which he repeatedly called me towards him, and then sent me away again just as I drew near. When I related this to the holiday and the breaks between sessions, he was able to say solemnly and without “gonging” how much he would miss music. It should be understood that when faced with the choice of committing myself to the medium of “pure” music versus trying to help Tom, I chose the latter. This did entail working beyond the medium in which I was originally trained, and was a responsibility which was not taken lightly. Though this did cause some anxiety, I came to accept less truly musical meaning in the sessions. Tom did surprise me in Session 35 by playing a free solo improvisation on the piano strings, an instrument he had previously anxiously avoided, fearing that it was broken. When he asked me if I liked what he played, I replied that I did and then asked him rather prosaically, “What did it say?” To this Tom replied, looking at me as if I should know better, “It didn’t say anything, it was music.” Perhaps my acceptance of all his material actually freed him to make musical explorations, which previously felt impossible because of his experience of my own resistance. In the nursery rhyme, no one was able to put Humpty together again. This may have been at the back of Tom’s mind when he asked anxiously, “How can this get back?” The answer is that he couldn’t really get back, in the sense of putting back the clock and growing differently. However, my hope was that through the holding he experienced in therapy, he might find the ability to feel the pain and fear of his early losses fully, rather than being driven through current experiences under their power. The role of improvised music-making in this process remains unclear. It may offer holding experiences; it may also reflect changes which have originated in nonmusical play. It may facilitate the surfacing of fear, although it cannot refer directly to its causes. It seems certain however, that therapeutic theory and technique must always adapt to the needs of the patient, rather than vice versa. Glossary

CAT Scan: Computerized Axial Tomography. A technique using computer technology to produce cross-sectional X-ray pictures of the body. EEG: Electroencephalography. A recording of the electrical activity of the brain as measured with the aid of electrodes attached to the scalp (Scott, 1969). Episode of Engagement: A sequence of social behaviours of variable length bounded by clear pausing time on either side (Stern, 1977). Generalized Convulsion: A violent series of involuntary contractions of muscles usually associated with complete loss of consciousness (Scott, 1969). Petit Mal Seizures: A brief epileptic fit...not associated with convulsive movements but with a brief loss of consciousness (Scott, 1969). Status Epilepticus: A serious condition in which one major fit follows another without consciousness being regained (Scott, 1969). References Scott, D. (1969). About Epilepsy. London: Duckworth. Stern, D. (1977). The First Relationships: Infant and Mother. London: Open Books.

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers.

CASE THREE Punker, Bassgirl, and Dingo-Man: Perspectives on Adolescents’ Music Therapy Jaakko Erkkilä Introduction During my years as a music therapist I have often thought about core guiding principles when working with adolescents. Although I use different clinical methods to meet the needs of this very diverse group, was there something that guided my thinking, attitude, or stance to working with adolescents? After all, the concept of adolescence only refers to a certain phase of life, with its developmental characteristics, and not a specific illness or problem. In this chapter I will focus on the results of the above-mentioned thinking, illustrating core phenomena of my work with clinical examples. In music therapy with adolescents, various models and clinical techniques are utilized (Gold, Voracek, & Wigram, 2004). For example, I often found myself looking at the clinical situation from a different perspective depending on the goal of therapy in a given moment. Sometimes learning is the focus; sometimes change in behavior, sometimes a need to be accepted and to gain compensatory experiences. In other words, I find myself moving across behavioral, cognitive, and psychodynamic theories (Erkkilä, 1997). Similarly, depending on the phase of the therapy and the needs of the client, it is sometimes important to be flexible with clinical techniques as well. With many young clients, I prefer a kind of soft start by employing receptive techniques at the beginning of therapy and active techniques in later stages for engaging them gradually in the therapeutic process. Interestingly, a meta-analysis of the effectiveness of music therapy with children and adolescents (Gold et al., 2004) confirmed, amongst other things, that treatments with eclectic approaches proved the most effective. However, none of these theoretical constructs or methods alone results in successful therapy if there is no real contact, motivation, trust, and mutual acceptance within the working alliance. It is this living relationship with the therapist that is primary to the effectiveness of psychotherapy and which, in turn, significantly influences method and technique (Wampold, 2001). Foundational Concepts In my work with adolescents, I soon learned that talking about the client’s problems is seldom possible or beneficial, particularly in the earlier stages of therapy. In fact, you first have to make contact with the client (see Figure 1). At this point, it is good to avoid “difficult” topics.

By difficult topics I mean a problem-orientated approach where the therapist immediately focuses directly on the client’s problems as well as on therapeutic goals. For example, it is important to consider if the client seems to be noncommittal, or if there are any signs of resistance from his/her side. It is helpful to bear in mind that the adolescent has already met various health professionals (e.g., psychologists, doctors, and psychiatrists) and may be tired of talking about his/her problems. It is often a good idea to start by discussing hobbies and preferred music, and to ask the client to bring some of his/her favourite CD’s to listen to and discuss in the session. That is, not to start with the client’s problems (such as their emotional or behavioural issues), but to start with something that is part of his/her everyday life. This is both safe and accessible for the adolescent, as I’ve not yet met a client without a preference for a particular type of music! At this stage of the process, the therapist’s role is typically more active (see Figure 1). The aim is to create contact and trust, as well as to get to know as much as possible about what is important for the client. The therapist’s hidden agenda at this stage is to investigate what might be the most appropriate way to engage the client in creative work. But why is it so important to find, or arouse one’s creativity? It is because creativity is connected to symbolic process1 and, when it is active, there is always a direct connection to one’s emotional world. Practically all mental health problems are more or less emotionally related and thus, in order to deal with the emotions, it is important to enter the “world” of emotions, metaphors, symbols, and associations – the preconscious.2 Bruscia (1998) has defined the preconscious as kind of a mediating level between the unconscious and the conscious. Thus, whatever the content and form of the preconscious process, we can think of it as somehow linked to one’s mental landscape – as well as to one’s psychopathology – and therefore it is worthy of investigation.

Music can be a powerful tool for entering the preconscious level and conveying various emotional and symbolic meanings (Bruscia, 1998; Erkkilä, 1997, 2004). However, when working with children and adolescents, the principle of symbolic distance is often important (AhonenEerikainen, 1998). The therapist has to understand that the young client may not be ready to make connections between his/her own reality and the symbolic (music related), emotionally loaded expression linked to it. The connections may be very clear to the therapist, but the client may need some distance as if acting as a symbolic shelter against too painful or unbearable experiences. The therapist often feels a pressure to deal with the client’s problems more concretely by discussing them. In my experience, adolescents can manage an amazing amount of psychic work on the symbolic level without ever really verbalizing their problems. What then is the role of conscious processing in adolescents’ therapy? In Figure 2, the term conscious processing refers to rational thinking including skills, knowledge, and techniques. I have found that, with adults, this often means gaining insights about the meaning(s) of their emotionally loaded symbolic experiences. Adults may reflect on how these experiences are linked to their problems, for instance, but unlike adults, adolescents are not so eager, or competent, at making these kinds of direct connections. For adolescents, the zigzag movement between conscious and unconscious processes may be based more on the interaction between practical elements (skills, knowledge, and techniques) of the session, and the creative musical act, with its emotionally loaded symbolic experiences. In particular, when creating contact and exploring the young client’s creativity (first two phases in Figure 2), the therapist may find him/herself in the role of a teacher. It may be necessary to offer some basic advice on instrumental technique or to help the client to find an appropriate form for their creative product (e.g., to structure a song writing experience). If the therapist understands the meaning of this process, s/he should not be worried about moving away from the role of a therapist and into the role of teacher. When the relationship and therapeutic process deepens, this relationship will naturally shift and the therapeutic nature of the sessions will solidify. The working phase (see Figure 1) starts when the client has found his/her personal way of expressing him/herself through musical activities. Attaining the working phase may take months, and sometimes even a year or more. The Finnish music therapist Kimmo Lehtonen (1999) demonstrated this in his work with “Jaska,” whose music therapy began when he was 12 years old, and ended some five years later. In Jaska’s case, it took almost two years until the working phase really began. This was because Jaska had experienced a very traumatic childhood. His mistrust of adults, in particular men, was very deep, and he also suffered from severe psychotic disorders. The therapist had to work for a considerable amount of time to help strengthen Jaska’s ego, to develop a trusting working alliance, and to explore the signs of normal functioning, free of paranoid or neurotic thinking and behavior. In the working phase it is typical that the client is responsible for most of the content of the therapy. The therapist takes a few steps back, taking a more empathic role, and sometimes even acting as “a technical assistant” who enables the client’s creative work. When the working phase has ended and the closing phase approaches, the role of the therapist becomes more active again. In this final phase, the client is often more interested in verbal discussion--partly because of the long, shared time together and increased sense of trust, but also because he/she is more mature and capable of verbal expression and interaction.

In my experience, adolescents are action oriented. Although it may be a good idea to begin therapy by utilizing receptive techniques, and to sit and discuss things with the client, it often happens that after this initial stage of the process, the client really wants to create something instead of just talking and listening to music. Most of my young clients have been able to find an interesting and motivating way to execute their creativity through music-related activity, and when doing so, I have observed that there is always part of the client’s inner world attached to the creative product. Song writing (Baker & Wigram, 2005) has been by far the most often employed method with my young clients. This has been the case even though the relevant musical skills may not initially be present. If the client has or can attain the motivation to actively engage in music making, the drums (for example) are relatively easy to begin with. If the client has even minor musical skills when entering therapy, these can be used as a starting point. I have also had clients who are not so eager to play a musical instrument, but may want to write songs and then later sing them. In these cases, the client may have an inner vision of a song and then asks the therapist to create a musical framework based on that vision. Many young clients have written songs this way, which serve as a glimpse of their inner world. The Clients I have worked with adolescents in many contexts: In a psychiatric hospital, in a special school and in a psychiatric clinic. To illustrate my work in these contexts I have chosen three cases to refer to here. I will call them “Punker,” “Bassgirl,” and “Dingo-man.” These clients

provide contrasting examples of my clinical work because they had notably different reasons for entering therapy. Punker was 16 years old when he started therapy. He did not show severe behavioral or emotional problems. However, because his family background was very challenging, and he had experienced many losses and traumatic events (such as the divorce and alcoholism of the parents, and an early move to a children’s home), he was given as much additional support as possible to prevent minor symptoms, such as isolation and withdrawal, from getting worse. Punker was rather withdrawn when I met him for the first time, which was not a good sign. But he loved punk music, which rather contradicted this inward presentation. The aim of therapy was to enrich his self-expression and communication skills as well as to support him in dealing with, and regulating, his emotions. Bassgirl was 15 years old when she started therapy. She was very anxious, with suicidal behavior, and used to slit her wrists when her anxiety became overwhelming. She had been living with her grandmother because her parents could not take care of her, but was now at an adolescent ward of a psychiatric hospital. Bassgirl used hard black makeup and had colored her hair black as well. My first impression was that she was distant and rather detached and cold in her demeanour and speech. The aim of her therapy was to reduce anxiety, support selfexpression, and deal with difficult emotions. Dingo-man was 16 years old when he started therapy. He had rather difficult emotional problems and was very shy and fragile. One could describe him as a rare bird, a loner with few friends. I had no information about his domestic background when he began therapy. One day he just entered an open music therapy group and asked to listen to his favorite band, called Dingo. He loved to live in a fantasy world created around Dingo, and identified himself with the singer of the band. Soon afterward he started individual music therapy, the aim of which was to consolidate his self-esteem and support his growth in general. Assessing Clients for Music Therapy It is still not common practice to use specific, standardized music therapy assessment methods in Finland. Many music therapists advocate the use of non-structured methods, utilizing a range of data in the process of assessing the client (Ala-Ruona, 2005). Ala-Ruona (2007) developed a model of music therapy assessment that is very helpful in providing a framework for assessment with adolescents. This model consists of four interrelated phases, each of which will be briefly described: 1) First contact/referral, 2) assessment meetings, 3) conclusions, and 4) reporting. 1) The first contact always begins through a referral. In some situations this may be made by the adolescent themselves, but it may also be made by a relative or other health care professional. While it is often the case that documents about the client’s illness, history, previous treatment, and goals are included with the referral, in some cases this information is gathered anecdotally. The less information readily available to the therapist, the more he/she has to rely on intuition and experience.

2) During the assessment meetings--the number of meetings may vary from two up to six meetings (usually 45 minutes each) depending on the setting--the therapeutic possibilities of music tend to utilize as much as possible. I am interested in the musical interaction between the client and myself, and in the client’s overall relationship to music. Therefore, in addition to interviewing the client, I also focus on music making whenever possible. I have termed the phrase creating contact to describe an important element of this part of the assessment process. Creating contact serves two important functions: It helps in establishing a relationship with the client and in planning the appropriate musical activities and detailed goals of the therapy. 3) Drawing conclusions about the client and his/her therapy involves analyzing the data collected from the previous two phases. It is utilized to make a final decision about the suitability of music therapy for the client, and to frame the content and goals of therapy. Supervision and multidisciplinary meetings are often part of this decision-making process. 4) Reporting involves making a written or oral report about the conclusions. Here the client’s opinion is also taken into consideration and reported. These kinds of statements are more general in today’s music therapy practice--in particular because the initial assessment is often made by an independent music therapy expert who is not supposed to be the clinician, and will not do the clinical work if therapy contract begins. The Therapeutic Process Creating Contact The music therapy room creates a musical environment that often helps the young client orient him/herself at the beginning of therapy. There are instruments, equipment, CD’s, etc., available--in other words, something to focus on and somewhere to start from when making contact. This kind of environment makes music therapy different from other therapeutic contexts, and it is often a good way to motivate the client. For instance, with all three clients discussed in this chapter, there was already a specific relationship to a musical style or band. The first important task of the therapist is to take advantage of this and do his/her best to find out as much as possible about the client’s musical preferences, values, and attitudes. Hard-core punk fascinated Punker, and he carried the external signs of that sub-culture, seen in his black leather clothes, studs, and piercings. Bassgirl loved heavy-rock music and wore the clothes that could be immediately connected to specific bands. She always wore black with striking, dramatic make-up. Dingo-man was not as easy to define because his presence and appearance did not reveal much about his values or orientation. However, he wanted to listen endlessly to the Finnish rock band “Dingo.” In this way the first meetings were relatively easy, where the music (and even clothing) worked as a kind of a bridge between the client and the therapist. None of the clients spontaneously took the initiative to mention their problems during the first sessions. Nor was it sought out by the therapist. The music itself facilitated contact and fostered the possibilities of a therapeutic relationship.

Creating contact takes a varied amount of time. Punker did not need many sessions (only three or four), because he soon knew what he really wanted to do. With Bassgirl and Dingo-man it took longer because, unlike the Punker, they had no previous experience playing an instrument or making music. Thus, engaging them in creative musical activities, and supporting them in finding their creativity, took more time. Furthermore, their own therapeutic issues were reflected in a longer period of creating contact, in particular with Dingo-man, who showed fragility and insecurity. Searching for Creativity Punker had played drums in a hard core punk band, and when he noticed that it was possible to record music with a multi-track system in therapy, he soon expressed his desire to make his own hard core punk songs. After a few sessions, he had created a method wherein I had a recording engineer’s role, while he acted as a song-writer and musician. With Bassgirl, we spent many sessions ‘opening’ the creative channel. She wanted to play bass guitar but first had to learn it. We devoted these sessions to playing songs with an easy bass line while I gave the necessary technical instruction. After approximately 10 to 15 of these sessions, Bassgirl brought in a lyric sheet, in English, of a song she had written. She was ready to take the next step--to write the music to these song lyrics. My help was still needed at the beginning of this process, in order to give structure and form to the songs. Importantly, though, the creative process had begun. Dingo-man was fixated on his favorite Fin-rock band. He was, of course, not the only one in the country to have an obsessive interest in Dingo. But his dedication, and associated fantasies that emerged through listening to the band’s music, were somewhat alarming. He was not interested in playing any instruments, or learning to play them. His favorite activity was to stand in front of the loudspeakers, sing along with the music (he had memorized all the lyrics), and ask the therapist every now and then whether his voice and movements were good. I tried to encourage him to focus on other musical activities, for example, introducing different instruments and ways of playing them creatively. However, he remained noncommittal about actively playing any instrument. It was not until later on that he started to compose and sing his own music. That is to say, Dingo-man found a rather unique way of using session time. Of his own initiative, he developed a numbered notation system, wherein he simply gave a number for each key of the keyboard and created a series of numbers (his own kind of notation) that represented a melody. He would then ask me to play the notes in numbered order. If he was not happy with the melody, he made some changes, until he was satisfied. Once completed, he allowed me to help him find structure and harmony for the songs. As this work developed, he began writing songs on the ward using his notation system, boosting our work in music therapy. In my clinical thinking, I associate creativity with the ability and willingness to operate on the preconscious level, which is the arena of emotions, metaphors, symbols and associations (see Figure 2). When the client feels secure enough, the activated preconscious processes can be transformed into a concrete object such as a song, lyrics, etc. This kind of zigzag movement between the conscious and the preconscious often exceeds the boundaries of the actual therapy sessions. Often the real creative work happens in the clients’ private time, when they

are writing lyrics or producing ideas for their songs. Thus, it might happen, as was often the case with Punker that the real therapy session was rather functional; mostly staying at the conscious level because it was centered on ideas that were actually created elsewhere. It does not matter where the ideas come from, as long as the creative process occurs within the overall therapeutic experience. Working Phase The early stage of the working phase may be rather “cognitive.” In other words, it may stay on a more or less conscious level (see Figure 2). I have never seen this as a problem because attaining trust, developing a working alliance, and focusing the content of therapy all need time to develop. I have found that creative, emotional work (i.e., the preconscious level in Figure 2) often starts when the roles between the therapist and the client become clear, and when work becomes “automatic.” By automatic, I mean the situation where both parties know their roles and tasks and there is no need for verbal planning of the sessions. With Punker, the first clear sign of this change was when he brought his first lyrics to the session. The lyrics were surprisingly personal, emotional, and sensitive, and dealt with issues such as loneliness, anxiety, love, dreams, and family relationships. It was also interesting to see how all this sensitivity was hidden in the very noisy and fast music, and how his singing style (more like shouting) actually covered all the content. It was an absolute paradox, yet also a powerful example of how symbolic distance can be utilized. From that moment on, and for a long time thereafter, Punker did the work and I stayed in the background--still present and available, but not intrusively so. With Bassgirl, it was a somewhat different process. The songs she wrote were perhaps not the most important part of her process--more like a bridge to something else. Her appearance and her songs reminded me of an imitation of how a heavy-rocker should look and sound, rather than a true musical passion. She did not express too much of her inner world in the music, but what really happened was that, outside the musical activities, she became more and more talkative and open. Her fixation on hiding behind a hard heavy ego decreased as well. The latter part of her working phase was based more on open discussion than on making music. There was a motivational shift from making music that was, to some extent, disconnected with her real inner world, to open, emotional discussion. In her case, music partly served as a mask that helped her to keep something inside (symbolic distance) because she was not ready to open her inner world to anybody. Although I have emphasized the idea of symbolic distance and avoiding direct talking about problems when working with adolescents, the therapist must also be ready for that if the client is willing to talk. In the working phase, Dingo-man wrote songs that were musically and lyrically very original. He’d had long bouts of illness with lengthy periods at the hospital. His ego was still forming, and he had rather unrealistic thoughts about himself. Song-writing was, for him, a window to a normal world. When we made music, he was more structured--more like a normal adolescent-- and able to deal with issues typical of his age group. As a pubescent boy, he was interested in girls and becoming aware of his sexuality, all topics that he dealt with in his songs.

Closing It is sometimes difficult to work as a therapist with in-patients, because it is often impossible to know the exact length of their hospital stay--something that may endanger a long-term therapy process. Both Bassgirl and Dingo-man were in-patients and their closing phases were not overly prepared or “planned,” as the therapist was informed that they would be leaving the hospital only a few weeks before their discharge date. This meant that the closing phase began whether it was appropriate or not. Fortunately, in both cases, the music therapy process had formed a relatively solid structure, which made the premature ending possible and not too damaging. However, for Punker this was different because he was an outpatient, enabling a systematic therapy process with four phases. When Punker’s music therapy was approaching the closing phase--which we both knew--he started to speed up the song-writing process because he wanted to get all the important songs finished. Here, he was very systematic. When listening to the songs made during the working phase, it was easy to hear a change in his musical style. The last songs were in slower tempo, more melodic, and with some words distinguishable. A real surprise for the therapist was when he asked him to play a keyboard track on the last song. I felt really honoured to be invited--for the first time--to undertake such a demanding and important task. I also felt that this may have been a way for Punker to thank me for all that we had shared during the process. However, after the first take, my playing was clearly not what Punker desired and he said “Man, this is not f---king jazz music!” So we recorded the track again, this time successfully. After the last session, Punker invited me to his home for coffee. The feeling of this meeting was relaxed, friendly, and mutually respectful. I was able to leave feeling as though this young man would now cope with life. With Bassgirl, we did not really have time to make a clear closing or resolution to her therapy. When she left, she appeared to be more resilient, and we made an agreement that she could return at a later stage--which she did, several months later. Interestingly, I did not recognize her immediately when she returned. Her dress code was totally different, with no dramatic make-up and more of the appearance of “a girl next door.” She gave the impression of being much more mature and talked very openly about her current life. Amongst other things, she also told me that she was planning to go to nursing school. I had the feeling that her crisis was more or less resolved, and that music therapy had made some contribution to that process. As Dingo-man’s music therapy ended when the therapist stopped working in the hospital, we had our time to prepare closure. The therapist could not see dramatic change in Dingo-man’s condition in either direction. Perhaps this was related to the fact that he was used to being a “patient” and had already lost touch with a normal adolescent’s life some time ago. I have not see him since I left this work setting, and I can only hope that music therapy was positive for him. I think that the most important aspect of his music therapy was dealing with his developmental issues (pubescent) and the factors linked to these issues. Music therapy offered the possibility for purposeful, creative functioning instead of getting stuck in his inwardlooking thoughts and behavior.

Summary Both Punker and Bassgirl had essentially healthy psychic structures beneath their problems. However, the extent of their trauma, and the problems this created for them in their lives, meant that they needed therapeutic understanding and support. They had both created a kind of defensive wall between themselves and others (due to the effect of their traumatic experiences), and this had caused various emotional and/or behavioral disorders. It seems that such symbolic walls are something that prevents one from opening oneself to anybody, and which keeps one’s inner feelings and emotions safely inside. The primary task of music therapy was to dismantle this wall, using the therapeutic possibilities inherent in music, combined with the therapist’s own personality, experience, and skills. Dingo-man had more severe psychiatric problems. His ego structures were unformed, and his self-concept was unrealistic and undeveloped. In addition, he had been isolated from society for a long time due to his illness. His therapy probably did not include such rewarding moments of improvement and recovery, but it was possible to work with him in a similar way to the two other cases, despite the fact that his condition was more challenging. With all these cases, music served as the context for functioning, as well as a general framework for the content and shape of sessions. Most of the psychic work and development could also be seen in the music and musical processes themselves. Music enabled selfexpression and helped these clients to describe their own personal reality, attitudes, and values. Music was a meeting point between the client and the therapist, and also an irreplaceable motivational factor for the clients. However, this is true only when we speak of the clients’ music, because the therapist must respect the client’s musical world, accepting it unreservedly. Päivi Saukko (2008), the Finnish music therapist and researcher, wrote that the most important thing for a music therapist working with children is unconditional acceptance, meeting the child in the here and now. I would suggest that this holds true for adolescents’ music therapy as well. My role as music therapist with these clients was as a kind of empathic companion, who enabled their creativity and supported the therapeutic process whenever needed. As such, I had to be ready to step aside or enter in a more active role whenever appropriate and necessary. Seldom does the therapist engage in therapeutic conversation with an adolescent. More often than not, s/he has to keep their interpretations inside and trust the functionality of the process, placing meaning and importance on the client’s creative expression. Sometimes young clients test the therapist. For example, telling dubious and shocking facts about their experiences and life. Sometimes these facts are true and sometimes they are a “flight of fancy.” Either way, their real meaning is probably to find out the therapist’s attitude and responses. It may also be a type of test where the client’s real purpose is to find out the therapist’s trustworthiness. In my experience, it is important for the therapist not to cling to these revelations, or overestimate their meaning; they may be of relevance for understanding the client, but the role of a moralist does not fit well to the therapist working with adolescents (Lehtonen, 1999). In my experience, when working with adolescents, the music therapist has to take different positions in relation to activity and proximity issues. This may be sometimes

challenging for a therapist, in particular, when the client is overtly productive and is carrying most of the responsibility of the session content and activities within it. The therapist may feel unprofessional or helpless if s/he does not understand the meaning and power of inactive presence. In my experience, working with adolescents requires that the therapist understands the significance of his/her presence for the client when s/he is not actively contributing to their way of being. To summarize, the biggest moments of insight for an adolescent’s music therapy are perhaps not found in spoken words, but in shared musical moments in which non-verbal interactions and shared experiences form the core of therapeutic change. References Ahonen-Eerikainen, H. (1998). “Musiikillinen dialogi” ja mutita musiikkiterapeuttien tyèoskentelytapoja ja lasten musiikiterapian muotoja. Joensuu: University of Joensuu. Ala-Ruona, E. (2005). Non-structured initial assessment of psychiatric client in music therapy, Music Therapy Today, 6(1), 23-47. Ala-Ruona, E. (2007). Alkuarviointi kliinisenä käytäntönä psyykkisesti oireilevien asiakkaiden musiikkiterapiassa – Strategioita, menetelmiä ja apukeinoja. (Unpublished Dissertation). University of Jyväskylä, Jyväskylä. Baker, F. & Wigram, T. (2005). Songwriting. Methods, Techniques and Clinical Applications for Music Therapy Clinicians, Educators and Students. Philadelphia, PA: Jessica Kingsley Publishers. Bruscia, K. E. (1998). The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Erkkilä, J. (1997). Musical improvisation and drawnings as tools in the music therapy of children. Nordic Journal of Music Therapy, 6(2), 112-120. Erkkilä, J. (2004). From signs to symbols, from symbols to words - About the relationship between music and language, music therapy and psychotherapy. Voices, 4(2). Eschen, J. T. (Ed.) (2002). Analytical Music Therapy. Philadelphia, PA: Jessica Kingsley Publishers. Gold, C., Voracek, M. & Wigram, T. (2004). Effects of music therapy for children and adolescents with psychopathology: A meta-analysis. Journal of Child Psychology and Psychiatry, 6(45), 1054-1063. Lehtonen, K. (1999). Rap-artisti JJ Kelan tapaus. Musiikkiterapia, 2, 71-92. Lehtonen, K. (2007). Musiikin symboliset ulottuvuudet. Jyväskylä: Suomen musiikkiterapiayhdistys r.y. Levin, C. D. (1989). An Essay on the Symbolic Process. (Unpublished Dissertation). Concordia University, Montreal, Canada. Priestley, M. (1994). Essays on Analytical Music Therapy. Phoenixville, PA: Barcelona Publishers. Saukko, P. (2008). Musiikkiterapian tavoitteet lapsen kuntoutuksessa. Jyväskylä: University of Jyväskylä. Wampold, B. E. (2001). The Great Psychotherapy Debate. London: Lawrence Erlbaum Associates. ___________________________________

1

Symbolic process may be understood as an emergent property of the interplay of a variety of psychobiological functions and psychological capacities in the context of body, object, and interpersonal relations (Levin, 1989, p. iii). 2

Several authors (Bruscia, 1998; Erkkilä, 1997, 2004; Eschen, 2002; Lehtonen, 2007; Priestley, 1994) have dealt with the concept of pre-conscious in music therapy.

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers. .

CASE FOUR Crossing the Divide: Exploring Identities within Communities Fragmented by Gang Violence Sunelle Fouche Kerryn Torrance Introduction This case describes six group music therapy sessions that took place with adolescent boys who attended school in the Heideveld area, outside Cape Town’s city centre, South Africa. This so-called ‘colored’1 community was established in the 1960’s as part of the Apartheid Government’s Group Areas Act and many of the older residents of Heideveld can still remember being forcefully moved here from inner city suburbs. Heideveld is plagued by a range of social problems including violence, poverty, unemployment and substance abuse. In the foreground of these depressing social features is ongoing gang violence that has been part of this community for many generations and impacts every aspect of life in Heideveld. The boys who attended these music therapy sessions are part of the Music Therapy Community Clinic’s2 (MTCC’s) Music for Life program. This program takes place after school in one of the local school buildings and is facilitated by both community musicians and music therapists. Approximately 120 children come from the surrounding schools at least once a week to take part in a group of their choice. Currently, we have a choir, two marimba groups, and two drumming groups. The boys featured in this chapter are members of two of these groups. During school time, the very same classrooms are used by our music therapists to conduct music therapy sessions with children and youth referred by teachers. While the focus of this case is the six music therapy sessions that took place with this group of boys, it is only a small part of the ongoing therapeutic work in the Music for Life program. It is therefore not possible to consider the work without understanding the broader context of the Music for Life program, the surrounding schools, the community of Heideveld, and even the townships that surround and impact the Heideveld community. Foundational Concepts Understanding the context in which our work takes place and the ways we have adapted our music therapy approach have been central to the development of the MTCC. When we founded the MTCC in 2003, our music therapy program was limited to individual and closed group sessions for children traumatized by incidents such as the death of a close family member, exposure to violence, abuse, neglect, or abandonment. We adopted the ‘traditional’

role of a music therapist and turned the room that the school provided us into a sacred music therapy space, where short-term clinical interventions happened once a week. However, children would bang on the music therapy room door, and could not understand why only some children were allowed to partake in this new “music therapy thing.” We realized that we were only reaching a small group of children in our music therapy program and that there were countless others who were confronted with the negative effects of living in a community ravaged by poverty, gang violence, and substance abuse. We decided to offer an after-school music program that provided children with a space to learn musical skills, as well as a space where they could explore different experiences of themselves within this community. Children began to ‘self-refer’ and soon we realized that our music therapy practice seemed to be crossing the boundaries of what we perceived music therapy to be. At a similar time, dialogue was beginning to take place within the music therapy community about the emergence of something called “Community Music Therapy” (Stige, 2002; Ansdell, 2002). While those talking about it were reluctant to give it a definition (Ansdell & Pavlicevic, 2004), one thing emerged that resonated with many of the discussions we had been having--Community Music Therapy’s basic premise was that it was a context-and culturesensitive practice (Pavlicevic, 2004; Stige, 2004); meaning that it needed to be able to adapt to the ever-changing needs of the community it served. It also implied that the whole community can become the music therapy client (Stige, 2004), rather than addressing the individual alone and out of context. One of these adaptations, discussed by Stige (2002, 2004), is the importance of collaboration and the need to expand music therapy practice “beyond the triad of client, therapists, and music.” As such, we began to include community musicians in our team. Our music therapists also began to take on roles not traditionally associated with music therapy clinical practice: supporter, organizer, co-facilitator, relationship builder, group process director, and mentor, as well as using conventional music therapy skills in new and innovative ways (Oosthuizen, Fouche, & Torrance, 2007). Our community musicians have not been an “added extra” to our project teams. Rather, they have been essential in being able to offer a culturally sensitive service. The children in Heideveld lack role models from their community. The boys, in particular, lack male role models as many of them have lost their fathers to violence, AIDS, long work shifts away from home, or even the local jail. As “white” females from completely different communities, there was little we could do to fill this gap. Furthermore, these musicians bring with them musical skill and knowledge that is very specific to their culture and which we view as vitally important to the development of the children’s cultural identity (Stige, 2004; Oosthuizen et al., 2007). Stige (2002, 2004) also spoke of Community Music Therapy’s different venues for practice that included semi-public and public arenas of performance. This resonated strongly with the MTCC’s practice, where clients often moved between the private arena of the music therapy room and the public arena of our Music for Life program, which affords opportunities for concerts and “showing off” developing talent. We believe that both the private and public arenas provide different, but equally important, opportunities for the development of individual and group identities. As the Heideveld Project has developed over the past eight years, we have found that most of the music therapists find working with groups (rather than individuals) more valuable.

We suspect that this could be because the majority of our referrals are for socially-based issues that are best addressed in groups--reflecting the community at large. We use a variety of activities in our sessions, including improvisation, song-writing, movement, storytelling, and listening. We found the guiding principles expressed in McFerran and Wigram’s (2002) review of current practices in group music therapy improvisation very valuable when reflecting on the therapeutic potential of music with this group of boys: • • • • • • •

Music offers the opportunity to express ideas and feelings that are abstract and vague, whereas words are exact and specific. All group members are able to speak together at once because music works both in time and on time. Music can be safer than words. Music can be used as a defense, or as a place to hide, by avoiding the kind of specific expression that words demand. Music is able to provide a way of expressing feelings that people are not willing to express verbally because it involves some risk. Group music-making is experienced as an interactive entity that overcomes individual issues, a joint creation that can be stepped into and shared by all participants. Each group becomes a miniature society. The Clients

The twelve boys around whom this case study revolves are all between 12 and 15 years of age. The marimba group consists of six boys from the community of Heideveld. The drumming group, also consisting of six boys, contains two from Heideveld and four from the neighboring Xhosa3 community of Gugulethu. A few of the boys referred themselves, as the opportunity to take part in a music group was appealing. However, the majority of the boys were referred by their teachers for constantly fighting on the playground and general aggression toward teachers and peers. While their aggression may be more overt than that of other boys in their class, they are not unlike many of their peers. At this critical age, when they are beginning to form their adult identities, they are at risk of being inducted into local gangs. Gangs have been part of the social structures of both these communities for many generations. They impact every aspect of the lives of their residents. Heideveld is divided into different sections that gangs proclaim as their territory. Children often “inherit” their gang membership from their parents or older siblings and, armed with knives and guns, these young boys are prepared to lay down their lives to protect their gang’s pride and territory (Dissel, 1997). Forced racial segregation—a legacy left by the Apartheid Government—is still playing itself out in the country, even though South Africa is 16 years into its democracy. Gugulethu is a “Black,” Xhosa-speaking Township. Heideveld is a “colored,” Afrikaans-speaking community. For the past few years, some Xhosa children have been attending local Heideveld schools. We have noticed that territorial thinking, the notion of “us vs. them,” is playing itself out in the schools in what looks like racially motivated fighting. As our Music for Life groups naturally reflect the

larger communities from which the children come, we were not surprised when one afternoon a fight occurred after the two groups had finished rehearsing. Their perceived differencesdifferent music groups, different cultures, different communities, different languages--had caused a divide, and they were responding to this in the only way they knew. After some discussion amongst the MTCC’s music therapists and community musicians, it was decided that these two groups would benefit from coming together in the music therapy room, while simultaneously continuing with their Music for Life groups. For this reason, it was difficult to define where the therapeutic process began or ended with this group of boys. While they had only six “official” music therapy sessions together, we took a more holistic view of what was therapeutic, viewing both the Music for Life program and the music therapy sessions as crucial to their process. Later in the chapter, we will reflect on the six music therapy sessions within the broader context of the MTCC’s approach to therapeutic intervention within the community of Heideveld. Assessment A key learning for us in the MTCC’s Heideveld Project has revolved around flexibility in order to respond to the ever-changing needs of this dynamic community. The process of assessment and reflection is, therefore, a crucial and continuous part of our practice. However, how, where, and when our assessment takes place is not bound by conventional norms and means. Due to the fact that we work within the midst of communities, our assessment tools and procedures involve more than just the therapist and client. We rely on the community at large. The fact that the MTCC team witnessed the fight that broke out between the boys meant that we could respond immediately. Furthermore, working in this community week after week, and having worked with the boys in weekly music rehearsals, meant that we had some sense of how these boys presented themselves within their communities. We also had a sense of how the community--teachers, parents, peers--perceived them, and we had first-hand experience of the “troublesome” behavior that the community was informing us about. In an assessment meeting that included the community musicians and music therapists, we discussed the incident and the possible reasons and “meaning” behind it. The fight was racially motivated, rooted in the boys’ preconceived ideas about each other. We suspected that these perceptions had been passed on to them by the older generation that lived within a very different political and cultural world than that of present day South Africa. One of the goals of our Music for Life program was to offer these children the opportunity to celebrate diversity through music. It was decided that bringing the two groups together in a music therapy space could offer opportunities for experiencing themselves and each other in a different way. At the following rehearsals, the idea of bringing the groups together was discussed with the two separate groups. While they were aware that the reason behind the temporary amalgamation was due to the fight, the discussions revolved around the musical potential of joining the groups. In typical adolescent style, they nonchalantly agreed to our proposal. The Therapeutic Process

The following two vignettes (1a and 1b) are a depiction of the two separate groups at their weekly Music for Life rehearsals before the amalgamation for music therapy sessions. Vignette 1a--Thursday Afternoon, Djembe Drumming Group The boys walk into the room. They don’t have much to say. They’re from different schools, different communities, and it all feels a little uncomfortable. They respond with monosyllabic grunts and a cautious nod to the community musician’s questions. The music starts--it provides a relief to the awkwardness. The drums are all the same size, with the potential to make the same sounds--it’s almost as if the drums make everyone equal. But there are still moments when each person has a chance to play a solo--to be heard as the individual that he is. The drumming begins to grow into something quite raucous. It feels as if there is very little silence for the rest of the session. The drumming is loud and powerful and noisy--its potential is limitless. The music therapist leaves with a headache. Vignette 1b--Thursday Afternoon, Marimba Group The boys are walking towards the Music for Life room and the energy is palpable-they’re excited, eager to get going, mocking and swearing at other children along the way. They enter the room and pass a cheeky comment to the music therapist. There’s no time for talking as this keeps them from playing. The community musician hasn’t even arrived yet but there is no way to restrain them--someone starts playing and very quickly everyone is playing on their own marimba. It is immediately clear that playing these instruments is physically demanding and the music absorbs the high energy that the boys exude. It is also obvious that each group member has a role to play, and each role is respected. Someone needs to play the bass, someone else the melody, and each part is equally valued. The above vignettes paint a picture of how the Music for Life rehearsals are able to elicit and contain the high energy levels of these boys. The community musicians who run the sessions are skilled at teaching marimba and djembe drums, understanding the cultural significance of these powerful instruments. We believe that the instruments themselves have played an “important role in these boys’ development of self and identity in relation to their community” (Stige, 2004). In both communities where the boys come from (Gugulethu and Heideveld), musicians are highly respected and valued role models. This is one of the many reasons that the MTCC’s practice includes these community musicians. The role of the music therapist in these sessions, however, is still of great importance. She needed to assist the community musician in managing group dynamics and therapeutic process to ensure that the rehearsals were not about transference of musical skill only. This collaboration has been a vital part of providing a service that is both culturally and contextually sensitive. Vignette 2: ‘Step into the Circle,’ From Session 2 of the Music Therapy Sessions

The week after the two groups had the fight, a discussion was held between the involved music therapists, community musicians, and the boys from both groups. After they all agreed to the amalgamation, the groups came together for music therapy sessions the very next week. The first session consisted of introductions, greeting rituals, and semi-structured group improvisations. The following vignette describes a pivotal moment and an activity from session two, which was then used and developed each week. The group members, consisting of the twelve boys, two community musicians, and three music therapists, are seated on chairs organized in a circle with four big drums placed in the centre. The atmosphere in the room is tense… but I expected this. Bringing these two groups together usually causes tension, which has on previous occasions led to fighting. Today I have decided to do an activity that will confirm the group members’ differences, but hopefully also highlight similarities. I ask them to step into the circle and play on the drum if they live in Gugulethu. Two boys and one community musician stand up and they beat on the drums. I then ask them to step into the circle and beat the drum if they live in Heideveld. Four boys respond. I ask the members to step into the circle and beat the drum if they have lost a parent. Several boys and adults stand up and I notice that as they beat the drums, they also take a moment to make eye contact with the others in the inner circle. I ask the group to step into the circle and beat the drum if they have seen (in their communities) people who are older than them fighting, stabbing, or shooting each other. The majority of the group stands up. I ask the group to step into the circle if that scares them sometimes. I am surprised that the ones who often boast about not being scared of anything stand up and beat the drum. I ask that they beat the drum if they are sometimes bullied, and I am very proud of Luvuyo, who is usually the “underdog,” when he stands up and beats the drum with conviction. I ask that they beat the drum when they are sometimes the ones doing the bullying. At first, no one moves, and then two of his closest friends indicate to Damian that he will have to stand up…which he does. I ask the group to step into the circle and beat the drums if they like playing music. They move as one, and the sounds coming from the drums are boisterous. This activity was very structured in order to provide safe and containing guidelines for the group members to participate. On reflection, the directing music therapist commented that she felt the need to address the division as early on in the therapeutic process as possible and in a direct manner. Her sense was that in order for the boys to shift their preconceived ideas about each other, they would need to enter into a potentially vulnerable space where they would be quite exposed in front of their peers. Her role now was to finely attune to the nonverbal cues and decide on the right moments to ask the ‘heavy’ or ‘light’ questions. This, combined with music as the buffer, and the fact that everyone, including the other music therapists, and community musicians were responding, resulted in a rich and rewarding experience for all. The activity described above was used in each subsequent session as it was a powerful way to “sound out” similarities and differences between the boys. It gave musical expression to things that were difficult to talk about. Being able to play their answers seemed much safer than speaking them. On the other hand, moving into the circle was a brave and bold act, giving

physical expression to their answers and allowing the others to witness them. Group members could “speak” at the same time in the music, which for a group of awkward adolescents can be a less risky option than having to talk. Furthermore, due to the fact that music has the ability to express abstract ideas, the manner in which they played on the drum was able to express something of the complex emotions surrounding the particular question to which they were responding. Also evident from the above vignette is that there were three music therapists and two community musicians present in the six music therapy sessions. What may not be so clear is the reason why. One music therapist was responsible for running the sessions. She was not linked to the two groups of boys and was thus able to take on a neutral role. The other two music therapists and the community musicians were now seen as part of the groups as they facilitated the marimba and drumming groups each week. In the music therapy sessions, the community musician’s roles shifted and instead of being “teachers” and “leaders,” they simply became role models--fellow community members--with little expectation of the boys to “perform” or behave in a particular way. The presence of the music therapists (from another cultural group) meant that there were five adults present in the sessions who could model healthy relationships across different cultures. Sessions also included free improvisations, but the music therapist sensed that these either felt quite superficial or became “messy,” and the boys did not feel secure enough (as you can imagine) to reflect on them. The “Step into the Circle” activity, on the other hand, provided sufficient guidance to contain the group members, while allowing more and more flexibility each week as the boys began to trust the structure. By the last session, they had made it their own song. Vignette 3: Last Session Song We are about 20 minutes into the session. This will be our last session, as a threeweek school vacation is starting tomorrow. There is a lot of excitement in the room. We are all sitting on chairs in a big circle. For the past 20 minutes we have been working on putting a rap song together. The chorus repeats the line ‘Step into the circle and play on the drum if....,’ and then each group member has a turn to respond with a line that has become meaningful to them over the past few weeks, which the rest of the group then repeats. Kyle, from the marimba group, is keeping the beat on a djembe drum and Vuyo, community musician from the drumming group, is accompanying with a shaker. The style of the song is Hip-Hop and some of the boys fall right into the groove--tapping their feet, moving their bodies and making hand gestures--imitating their idols like Eminem and Tupac. Their contributions to this communal song include the following: Step into the circle and play in the drum if.... You love the people, You’re happy, You love peace, You’ve lost a friend, You live in Heideveld,

You’ve been in love, You love your mother, You’ve lost your dad, You love music. The song ends and Damien gets up to get a drink of water from the tap in the corner of the room. He comes back with a glass of water for Abongile who is sitting next to him. Two months ago, Damien and Abongile were the instigators of the fight outside the music room that set this whole process in motion. The above song was written by the whole group, and it was obvious that it developed from the second session’s “Step into the Circle” activity. As the weeks progressed, the activity began to change and develop organically. Each person brought something to the creative process, be it a contribution of words, how it was orchestrated, who should say or sing what and when--the boys, the music therapists, and the community musicians all contributed to this closing session product. The sentiments expressed in the song include the desire for peace, the issue of loss, as well as typical adolescent topics of being in love and their relationship with their mothers. In all likelihood, this song was a message to their broader communities, who were struggling with violence, untimely death of children, siblings and parents, and gender issues. Moments like these are common in our music therapy program, and songs such as these often find their way into Music for Life performances, where the applause reveals that there are others who agree wholeheartedly with the message. We view this group of boys (and other groups like them) as a micro-representation of the societies from which they come, and it is clear to see why the MTCC resonates with the Community Music Therapy idea that the whole community is, in actual fact, the client (Stige, 2004). Vignette 4: End of Year Concert The hall is packed, and it’s been a raucous evening of performances and audience participation. Parents, from Heideveld and Gugulethu, peers, some teachers, and curious residents from the surrounding area have been cheering, dancing (some a little inebriated), and supporting the children on stage. It is the annual end-of-year Music for Life concert that is held in a local church hall, 500 meters from the school that the MTCC works from. It is the final item on the evening’s program, and all of the Music for Life groups have combined for the “Grand Finale.” To those who don’t know the background, the fact that the drumming group is perched on the stage, directly above the marimba group, is nothing to be noted. But there they are, uncomfortably close, both groups playing their instruments with conviction and great skill. The occasional taunt flies from one group to the other, but it is more lighthearted and sibling-like. Apart from playing together for some of the verses, each group gets to accompany the choir on their own. No doubt, there is an air of competition about whose accompaniment sounds better – but they function as two units of the same whole, and their pride is obvious.

While we are very aware that this process did not magically heal the divide that exists between these boys, we believe that in the moments of creating music together (and especially as they experienced their joint product), the metaphor of musical interaction made a lasting impression on how they experience both their individual and group identity. The end-of-year concert took place five months after the final music therapy session with these twelve boys. The groups continued with their weekly Music for Life rehearsals, and as the concert drew closer, there was more emphasis on perfecting the music for their performance. Moving into the arena of performance had its own therapeutic value for these boys. More willingly, they began to focus their energy on creating something that sounded “good.” Being received and validated by their communities as talented and skilled musicians stood in stark contrast to the identities that they may have portrayed as “trouble makers.” Once again, this is where viewing the community as client holds immense value. This concert was a celebration of some of the successes of the therapeutic journey that these boys continue to make. We also hope that it was of therapeutic value to disillusioned parents, teachers, principals, and community members as well as an opportunity for them to hear (in musical form) the intrinsic possibility of community unity. Summary This case study has described the therapeutic journey of twelve boys from our Music for Life project. These boys were involved in a fight on the school premises that was rooted in racial tension and perceived differences between the members of two separate after-school music groups. While the after-school music groups and therapy sessions described in the chapter took place on the premises of a local primary school, we are more inclined to describe the context of our work as the broader community of Heideveld and the surrounding townships. This is because we view the children and the issues with which they present as a micro-representation of the communities from which they come. The twelve boys discussed in this chapter moved between two of the MTCC’s programs as the need arose. In fact, some of the boys are still involved with some of our community musicians and music therapists as part of the Music for Life program. The six music therapy sessions discussed made use of semi-structured improvisations and song-writing. The structure contained the boys and their adolescent vulnerability, while the music provided opportunities for them to sound out and express their similarities and differences in a way that was more abstract and less threatening than verbal discussion. Lastly, we could not discuss this case study without referring to the journey of the music therapists and community musicians. We believe that we could not have provided a culturally appropriate service without collaborating with community musicians from the local communities. Our roles as music therapists have also been challenged and extended as we adopt a less traditional role in order to ensure that we maintain a practice that is sensitive to the ever-changing needs of the community within which we work. We believe that the above observations of collaboration, adaptation and flexible spontaneity are in line with the principles of Community Music Therapy practice. By employing this practice, we believe that we have provided different opportunities for these boys to

develop both their personal and social identities. The dream is that healthier identities will lead to healthier communities. References Ansdell, G. (2002). Community Music Therapy and the winds of change. Voices: A World Forum for Music Therapy, 2(2). Dissel, A. (1997). Youth, street gangs and violence in South Africa. In Proceedings of International Symposium: Youth, Street Culture and Urban Violence in Africa. Abidjan, Ivory Coast. Erasmus, Z (Ed.) (2001). Coloured by History, Shaped by Place. Cape Town: Kwela Books. McFerran, K. & Wigram, T. (2002). A review of current practice in group music therapy improvisations. British Journal of Music Therapy, 16(1), 46-55. Oosthuizen, H., Fouché, S. & Torrance, K. (2007). Collaborative work: Negotiations between music therapists and community musicians in the development of a South African Community Music Therapy Project. Voices: A World Forum for Music Therapy, 7(3). Pavlicevic, M. & Ansdell, G. (Eds.) (2004). Community Music Therapy. London: Jessica Kingsley Publishers. Pavlicevic, M. (2004). Learning from Thembalethu: Towards responsive and responsible practice in Community Music Therapy. In M. Pavlicevic and G. Ansdell (Eds.), Community Music Therapy. London: Jessica Kingsley Publishers. Stige, B. (2002). Culture-Centered Music Therapy. Gilsum, NH: Barcelona Publishers. Stige, B. (2004). Community Music Therapy: Culture, care and welfare. In M. Pavlicevic and G. Ansdell (Eds.), Community Music Therapy. London: Jessica Kingsley Publishers. ______________________ 1 In South Africa, the color of our skin is directly related to our cultural identities. In this chapter we therefore do refer to people as being ‘Colored,’ ‘Black’ and ‘White. Although the term ‘Colored’ might be seen as an offensive term to an international audience, in South Africa it is a term comfortably used by many ‘people of color’ to describe their specific cultural group. The writers agree with Zimitri Erasmus when he says: “There is no such thing as the Black ‘race’. Blackness, whiteness and colouredness exist, but they are cultural, historical and political identities” (Erasmus, 2001 p .12). 2 The Music Therapy Community Clinic (MTCC) is a non-profit organization that provides music therapy services and other music activities to previously disadvantaged and underprivileged communities in Cape Town, South Africa. 3 The Xhosa people are one of South Africa’s multiple cultural groups.

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE FIVE The Boy that Nobody Wanted: Creative Experiences for a Boy with Severe Emotional Problems Fran Herman Abstract This case describes weekly sessions over a fourteen month period with a nine-year-old boy with severe emotional problems. The approach combined music with play and creative experiences in the other arts aimed at dealing with his depression, impulsivity, and hyperactivity. By providing soothing media in concert with music, he was able to gain confidence from his own strengths, and to modify some of his destructive tendencies. Background Information Robbie considered himself “The Boy That Nobody Wanted.” He often wondered whether he would be better off as a government boy of the United States rather than a government boy of Canada. Given up at birth to be a ward of the Children’s Aid Society by a teen-age mother, his history was dotted by transfers from one place to another with little opportunity for bonding or for building relationships. Robbie was nine years old when he first began his sessions in music therapy. He was a handsome, wiry, likeable little lad who had been through twelve foster homes and two treatment centres before his admittance to a children’s psychiatric hospital. He was an aggressive “acting out” child who seemed unable to accept authority, and he had frequent temper tantrums where he would display destructive behaviour. He could neither read nor write and had never been able to stay in school despite many attempts and approaches. He lacked concentration due to his hyperactivity, exhibited frequent non-goal directed activities, appeared to have severe learning disabilities, was disruptive when other children were around, and had difficulty being compliant. He was an unhappy little boy who felt unloved and unwanted. Robbie had been in the psychiatric hospital for ten months with little progress reported. School, occupational therapy, pottery, woodworking, swimming, and other sports, as well as weekly visits to his psychiatrist were considered “tried and failed.” Robbie had become resistant to doing anything, showed signs of deep depression, and often refused to eat or get out of bed. He felt unable to face a new day, having given up hope of things ever changing for him. It might be said that Robbie lacked a sense of identity, often asking “Who am I?” The need for an ordered life is universally important, whether or not this is understood consciously by the child. This search for an identity was a fundamental part of Robbie’s

difficulties. One day in rounds, when staff were feeling rather desperate about him, one team member commented, “The only new thing here that hasn’t been tried is music therapy. Robbie always taps his toes when he hears music. Let’s try it as a last resort.” Everyone agreed and a few hours later Robbie was brought to the music room. Treatment Process The Opening Wedge: Sessions One and Two When Robbie first entered the music room he began racing around, plinking and plunking on the piano, banging on the drums, and tooting slide whistles and recorders. He circled several times in random fashion then spotted the autoharp on a small table in the middle of the room. He went to it and asked what it was. I explained the instrument and showed him how to strum it as I pressed down on the chord buttons. Robbie was intrigued. We then played some children’s songs in this manner, and he sang and enjoyed our music making. He wanted to repeat the songs over and over again, until I finally told him the session was finished. He was reluctant to leave, but was invited to return the next morning after breakfast. His sessions were planned for that time as an attempt to get him out of bed to face his day. At 8:05 the next morning, Robbie was there, bright and eager. He flitted around the room several times in the same manner as the previous day, and then once more settled down to playing the autoharp. We played the “Farmer in the Dell” several times, at which point Robbie requested that he press the chords and strum by himself. He proceeded to do this with the correct two chord changes and was very pleased. However, on the second playing he made a mistake, threw the pick on the floor and headed for the door saying, “I made a friggin ‘Boob’ and I’m going.” Robbie had demonstrated a pattern of leaving at the first sign of frustration and he never returned to a situation once he had abandoned it. Knowing it was essential to keep him there, I fell to the floor and began crawling around on my knees, smacking my lips, flicking my fingers, sniffing, looking under the radiator, peering into the piano bench, lifting up the mats on the floor, opening and closing the window, etc. All of this was sufficiently bizarre to have stopped Robbie in his tracks. He began following me around the room asking repeatedly, “What are you doing…hey...what are you doing?” Finally I answered, “I’m looking for your Boob!”. He was completely taken aback and muttered, “Hey Lady, are you crazy or something?” “No Robbie, I really am looking for your Boob!” I began to fire questions at him: “I can’t see it. Can you?” “No.” “I can’t touch it, can you?” “No.” “I can’t taste it or smell it, can you?” “No.” “I can’t even hear it anymore, can you? “No!”

I continued: “And you know what kiddo, I think it just got away on us. But, the important thing is that you know you made a boob. Not many kids in this place would ever be able to do that. That means you are a very musical boy, indeed.” I went on to explain that musical mistakes don’t matter because one cannot even remember them after a few seconds. This was a very important concept for Robbie to understand. He had discernible problems with the permanence of drawings or modeling in plastic media. The visual impact of such efforts reminded him of how poorly he did things. “Music mistakes” that floated away became acceptable to him. For weeks afterwards he would deliberately make mistakes, then go through all the motions that I had previously made. Finally, he would declare, “Well, that’s another one that got away.” For those of us working and caring for special children it is essential that we find ways of filling up their “metaphorical pots” as described by Virginia Satir (1988). They must be filled with creative experiences that are fulfilling and contribute to the child’s growth. Specific techniques for helping expression through music therapy and the expressive arts are endless. Regardless of what activity you and the child choose to do at any specific time, the purpose remains the same--to nurture and help the child become aware of himself and his existence in this world. Each therapist will find his or her own style of achieving this delicate balance between directing and guiding the child on the one hand and following the child’s lead on the other. As nurturers, we know that change in children is a gradual evolving process. We delight in their smallest gains, knowing that they have been accomplished with considerable patience, support, energy, and insight. What takes place inside the therapist and what goes on inside a child, is a gentle merging resulting in growth and change. Once Robbie decided that I was a person that he could relate to and trust, his defensiveness lessened. It is important to realize that some children are resistant and defensive for good reasons. They do what they have to do to survive. They have learned from the chaotic worlds in which they live and from homes or institutions that are often harsh, uncaring, and unseeing that they must do what they can to take care of themselves. They need to protect themselves from intrusion. As Robbie began to trust, he allowed himself to open up and to be a little more vulnerable. I had to move in easily and gently, always maintaining a sense of unconditional acceptance and an uncritical attitude. Gaining Expressive Freedom: Sessions Three to 24 Robbie’s sessions were to be immediately after breakfast each week day. They were scheduled for thirty minutes, but the length varied depending on his moods and frustration level. The first goal was to help Robbie sit still while focusing his attention on a specific activity. Sometimes music was in the background, at other times it was the focus of the activity. Mirroring, echo responses, moving, and stopping to various cues were the techniques used, usually at the beginning of the session. These were followed by soothing materials for Robbie to explore; first water, then sand. Robbie had never been allowed to play with water, and took much delight in simply pouring it from one vessel to another, using tubes, funnels, ladles, and sprinklers. He reveled in

squeezing sponges and playing with objects that float like ping-pong balls, corks, or boats made of Styrofoam. At other times he would simply move his hands in warm water to the rhythm of the music playing in the background. For the large sand table in the room, I made several different sized combs by cutting plastic lids from margarine containers in half, then cutting the straight edge to make large or small tines, waves, and zigzag patterns. Robbie was encouraged to make designs in the sand. As he took a comb and made a wavy pattern to the music, I would comment on the rhythm of his design. This was usually enough support to keep him trying out more and more elaborate patterns. We also used water with sand so that he could make rivers, tunnels, and castles. With buried sea shells and sea music playing in the background, Robbie would make all kinds of seascapes in the sand. He was beginning to take pleasure in moulding shapes and forms with his hands, creating his own miniature worlds. Often when he would create a scenario, I would improvise music to augment his need for movement. Using pieces of sheer blue nylon he would soar like a seagull, thrash around like waves in the sea, or roll unto the beach like a seashell. Enjoying Self-Expression: Sessions 25 to 40 Leading Robbie to a slowly dawning appreciation of his own creativity was a long and tedious process. Early traumatization appeared to have produced a fateful block in many areas. Expressive activities which allowed him freedom of expression without involving the expectation of any end product became meaningful in the treatment process. Once Robbie became aware that there were no preconceived ideas of how these activities should turn out, he was released from the anxiety of facing failure. At this point clay was introduced. Its flexibility and malleability suit it to a variety of ends. It can be messy, mushy, soft, sensuous, or hard. The sensuousness of clay often provides a bridge between a child’s senses and his feelings. Children like Robbie who are insecure and fearful, can feel a sense of control and mastery over clay. It is a medium that can be “erased” and it has no clear-cut, specific rules for its use. When Robbie had been exposed to clay before, he had rejected it. However, at this point in his therapy, with the success he was beginning to feel in his other efforts, he was able to accept this medium and use it to good effect. Finger painting using paints, semi-jelled Jell-o, or chocolate pudding was also done to musical accompaniments. To Brahms’ Lullaby, Robbie would make quiet undulating motions, which would change to straight lines in all directions when a march was played. Both finger painting and clay proved to be very valuable media for him. They lent themselves to many manipulations with their fluent and inviting textures. They were used at varying levels and to fill varying needs. In both media Robbie could explore the value of creating and expressing his feelings on a nonverbal level. Slowly, but surely, Robbie’s attention span was increasing so that he was able to stay with an activity and have some satisfaction from it. When he had difficulty focusing, I followed his quick changes by helping him experience what he was doing more fully. Returning his attention to task at hand was accomplished by speaking softly, touching his hands gently, giving him a hug, and by encouragement and praise for the smallest accomplishments.

Learning Structure: Sessions 41 to 70 Now that Robbie had begun to channel his own self-expression, he was ready for activities that would help him to pay attention and adhere to a structure. His inability to do so had greatly hampered his ability to learn several things, including how to read. Developing a child’s ability to move his eyes from left to right and to trace an idea from beginning to end can be helped by using a coloured note system of music. The concept of teaching piano using coloured notes is not new. However, in most of the prevailing books available on the subject, the cluttered quality of the page can deter a poor or non-reader from even attempting to follow the music. I therefore attempted to develop a simpler system. In it, the three middle octaves are similarly coded with brightly coloured dots. To give the child an awareness of orientation, the middle octave remains plain while the upper octave is designated with a small black “V” on each note. The lower octave is marked with a small black “X.” No more than three octaves should be used. In order to keep the music sheet as uncluttered as possible, a coloured stroke is used to designate a tonic chord, and a coloured stroke with a “7” under it is used for a dominant 7th chord. The prime purpose of this system is to give the underachieving child a successful reading experience, with immediate satisfaction for his efforts and with the least amount of possible frustration. Fingering, phrasing, and note values are ignored; however, bar lines are used to provide an anchor point for the eye. Using notation can be quite helpful in developing eye-hand coordination and directionality. For a child like Robbie who had problems with sustaining attention, this type of structured activity also provided him with training in concentration, patterning of work habits and motivation. Robbie was intrigued with this new direction in his music sessions. He was determined to learn to chord to the melodic line. Since we were using folk songs which he knew, his musical ability came through, once he was secure with the notes, and he would play the piece in the appropriate rhythm. At all times his playing was referred to as “reading music” in an effort to emphasize to him that he was indeed able to read one language and soon would be able to read another. He was quite pleased and proud of the special book that we created of the songs we had color coded for him to read and play. Being Himself with Others: Sessions 71 to 120 A child has to learn self-awareness and self-respect before s/he can learn how to be aware of and show respect for others. As Robbie’s tolerance for stress increased, his capacity to persevere at a task lengthened. His “pot” was filling up. He became more aware of and pleased with his accomplishments, and this prepared him for sharing his music experiences with other children. Until this point, Robbie lacked social skills, and became belligerent at the slightest frustration. He was unable to play with others and was too impulsive to wait his turn. Membership in a group of peers is a matter of vital concern to most children. Making friends and learning to set up satisfying relationships with others of the same age are important parts of growing up. A group will begin to form when the children begin to feel, think and behave differently because they are members of the group. The therapist must observe when

children begin to “interact” with one another, and when their relationships begin to influence their behaviour. As this takes place, a feeling of “bond” or a “we-feeling” will develop, and the group will emerge as a recognizable entity distinct from the members that comprise it. A little girl whom Robbie liked was introduced to the sessions twice weekly. When this began to work, two more youngsters were added. Through music games involving conducting, music bingo, reflection, drumming, rhythm work, mime, puppetry, and dancing, Robbie began to develop greater tolerance, and to learn how to interact with his peers, both of which were basic life skills that he needed. Just as there was progression in creative activities from the simple to the complex, as the children learned to tolerate frustrations and postpone satisfactions, so my role as group leader progressed from one in which I carried a great deal of responsibility for keeping the group together, to one in which I helped the group members assume responsibility for leadership of their own activities. Robbie managed to weather this sometimes stormy period and emerged from it with a better ability to handle himself in a group situation. Such skills were necessary as the time to enter school was approaching. A remedial reading specialist was brought in, and together we collaborated in helping Robbie learn to read. Eventually he was able to attend school for short periods of time, which increased as his tolerance level allowed. Downs and Ups Throughout the time that I worked with Robbie there were occasions when he entered the music room in a very despondent mood, wanting only to lie on the mat and curl himself into a cocoon with a sheet wrapped around him. His sheet provided a special space all his own—a space he could lie in, roll on, and fantasize with, and a space he could use to protect himself. At such time I would play quiet, lyrical music which, nonverbally, let him know that I understood, I was in his corner, and that he was safe there. Robbie often spoke about the music room being his “peace room,” his “safe room.” As Robbie lay there, he had time to calm his inner turmoil until ready to rise up and move to a new energy within him. He was encouraged to dance to his own inner music which I followed on the piano. He created his own drama and his own dance as he twisted and twirled experiencing many sensations and emotions. Afterwards he was sometimes able to articulate why he was upset and we could deal with it. At other times, he merely finished saying, “I’m okay now! See you kiddo!” Robbie was learning to cope with his anger, frustrations and anxieties in a more constructive way. Conclusions Robbie, a severely damaged little boy made significant gains in the combined modalities of music and related arts. The following summary of outcomes demonstrates his growth over the course of his music therapy sessions. It goes without saying that these changes were supported programmatically by other members of the team.

1) Before music therapy, Robbie had a short attention span and was easily distracted, he frequently failed to listen, and was unable to follow directions; afterwards, his attention span improved, he could stay on task up to 15 minutes without distraction, and he could follow most directions if presented clearly. 2) Before music therapy, he was physically disruptive, endangered his own safety, and required constant supervision; afterwards, his difficult behaviours decreased, he was able to stay with others in the room without disruptions, and he was more aware of safety considerations. 3) Before music therapy, he talked constantly, but was non-communicative most of the time; afterwards his verbal communication improved in content and clarity. 4) Before therapy, he refused to take turns, verbally interrupted others when speaking, and displayed poor social judgment; afterwards he was able to wait for his turn without frustration, became more aware that each person needed space and time to communicate, and demonstrated better social skills. 5) Before he was easily frustrated when things did not go his way, and had daily temper tantrums which required holding techniques; afterwards, he tolerated his frustrations more appropriately and his tantrums were reduced to a few times weekly. 6) Before he was so depressed that he often refused to get out of bed or eat; afterwards, his depression lessened, he no longer stayed in bed, and his eating problems disappeared. 7) Before he had very little self-esteem, and was considered so damaged that most of the staff felt he was unsalvageable; afterwards, his self-worth blossomed as his creative energy found alternative ways to construct his personal reality. Robbie was adopted two years later.

References Satir, V. (1988). The New People-Making. Palo Alto, CA: Science and Behavior Books.

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE SIX

Group Music Therapy with a Classroom of 6-8 Year-Old Hyperactive-Learning Disabled Children Julie Hibben Abstract In this case, the author recounts the progress toward group cohesion of an early elementary special education classroom. Most of the children are described as Attention-Deficit Hyperactivity Disordered. In the twice-weekly sessions during the year, the therapist uses active music making and movement to engage the children in interactive play, and to develop intimacy and cohesion in the group. The instruments, props, and songs serve as objects which encourage and contain the children’s action and feelings. Developmental stage theory provides a framework for anticipating and planning group interactions, and for evaluating individual progress. Group activities are described in terms of five dimensions: interaction, leadership, movement, rules, and competency. Background Information The eight children in this self-contained classroom had chronological ages of 6-8 but in most cases they were academically at pre-first grade level. Many of the children had disruptive behavior disorders associated with Attention-Deficit Hyperactivity Disorder (ADHD) as well as Learning Disabilities. In some cases the children were at risk because of the severity of their anti-social behaviors and/or the lack of support from their family systems. Some of the children were on psycho stimulant drugs, such as Ritalin, which controlled their hyperactivity to some extent. The children lacked developmental experiences such as nurturing play and spontaneous game playing with peers, either because of environmental deprivation or because of their learning or behavioral disorders. Their behaviors ran the gamut from excessive activity, interruptive talking, and physical aggression to negativism, lethargy, and introversion. The brief description of the children below points up the diversity of their needs and behaviors: Paul came from a special needs preschool, and at age 6.5, had just entered the classroom. He had no reading skills and had expressive and receptive language disabilities so severe that auditory aphasia was being considered as a diagnosis. Paul learned visually. Perceptual motor disabilities were apparent in his awkward maneuvers around the classroom. His relationship to his father was close and active. Arnie had a history of depression and low self-esteem. His interaction during the music therapy assessment showed him to have ability (fluency, memory, and originality) and confidence in expressing himself musically.

Al was moody and sulked a lot. Because of his lack of boundaries, he felt threatened by others in the group, even when the threat was not warranted. His voice was often raised in complaint. Nathaniel had a history of passive aggressive behavior. He used his intelligence and verbal skills to manipulate those around him. Nathaniel, 8 years old, left the class after the first month. Ken was dependent and passive, encouraged in this by his doting parents. He was medicated with Phenobarbital which slowed him down motorically. His thinking was very concrete. Ken was not able to verbalize his feelings, which often led to violent outbursts. His body was overweight and flaccid, and he showed signs of perceptual-motor disabilities. Michael was anxious, hyperactive, and intelligent. During the middle of the year his cousin was taken to court for continually sexually abusing him. Jose was humorous and friendly at times, and at other times was negative and depressed. During initial music therapy assessment, Jose was in control of the interaction, though he interacted only with expressive mime and eye contact. Jose left the classroom at mid-year. Hattie (the only girl) was 6 years old. She was defiant, and deliberately annoyed others. Her behavior led to consideration of a diagnosis of Oppositional Defiant Disorder which was later withdrawn. She was quite seductive in her efforts to get attention. Ted arrived in the class in mid-October, and buried his head in a book during his first music circle. He was the youngest in the class, and, notwithstanding his verbal intelligence, he did not read. Ted had a large body, and people mistook him for older than his 5.11 years. Ted loved to dance and play music with his family. Daniel came to class in February from a period of hospitalization for depression and suicidal ideation. He was on anti-depression medication. He was very intelligent and quickly was recognized as having the highest academic ability in the class. He was 7 years old, and read at third grade level. Individual music therapy assessments were conducted during the first week of classes by two music therapists, the author, and a colleague also working at the school. The assessments involved one therapist observing while the other engaged each student in two play-like interactions using improvisation on simple percussion instruments. The students were rated on scales measuring interaction with the tester, self-control, self-expression in music, and motivation. Only three of the students described above were available for assessment on that day and all three showed no difficulty in any of the areas. Method The author worked with this classroom in half-hour music therapy sessions, held twice a week for a total of 59 sessions during the school year. The classroom space was very small. The children had two classroom teachers who attended the music therapy sessions. Both were wellversed in behavioral techniques needed to manage explosive behaviors. These included negative reinforcement (a progressive system of “time-outs” for inappropriate behavior), and intermittent token economy or star systems for encouraging positive behaviors. Although the

primary role of the teachers was instructional in nature, they also supported the goals of the counseling staff in dealing with the children. All of the children were required to have individual counseling, and family counseling was available through a social worker. The progress of each child in meeting educational and therapeutic goals was monitored through Individual Education Plans. The music therapist attended regular team meetings and case conferences. Several techniques were integrated into the therapeutic plan. Games were used to stimulate the children to spontaneously develop their own rules and variations (Orff, 1974). Musical instruments and props were used to help the children express themselves. An adaptation of Dalcroze’s techniques was used to encourage the children to express musical ideas through natural body movement (Hibben, 1984). Music was used to enhance, motivate, identify and contain the children’s movement and play. In concert with the philosophy of the school, the therapist helped children identify their behaviors in the here-and-now, and conscientiously reinforced positive actions and interactions. The children’s histories showed a lack of stimulating or “good enough” environments (Winnicott, 1971), and in some cases, the ADHD disorder meant that normal or “good enough” mothering was not enough. The approach taken in music therapy, therefore, was to use music (e.g., songs, instrument, stories, and props) as transitional objects to help the children, through their play, to bridge their inner psychic experiences with the outer world. In many of the sessions described below the song, story, instrument, or prop became a container for action. As the year progressed the children became better able to use these concrete objects or, in the case of songs and stories, predictable time-lines to experiment with and share ideas and feelings. Goals and Orientation The goals of music therapy were different from classroom instructional goals. During classroom instruction, the children’s behaviors were monitored on an individual basis, and interaction between children was discouraged. The children worked at individual desks with one-on-one instruction as much as possible. During music therapy sessions, the children were encouraged to experience group play, and to work at developing play behaviors such as taking risks, tolerating ambiguity, using abstract thinking and sharing ideas. The academic classroom can be thought of as a task oriented group in which there is submission of individual needs and styles to learning goals. The music therapy group sessions were intended to be different since the focus was on the reorientation of the children toward group awareness, intimacy, bonding, cooperation, and the problems of ego support and ego defense. The music therapist also brought a different perspective to team meetings. Usually, team discussions focused on the individual child’s progress, as manifested in short-term events and their specific impacts on the child’s emotions and learning. The music therapist, although sharing concern about short-term events, looked at the long-term evolution of the group and evaluated the children’s social and emotional growth in terms of expectations for the children relative to the stages of group development. From the music therapist’s perspective, individual growth had to be viewed in terms of the norms for group behavior. Only the neediest children would continually resist or defy group consensus.

Group theorists describe the stages through which a group progresses in various ways (Garland, Jones, & Kolodny, 1976; James & Freed, 1989; Lacoursiere, 1980; Schmuck & Schmuck, 1979; Siepker & Kandaras, 1985). All agree that the more cohesive a group becomes, the more possible it is to attain individual goals. A cohesive group is one in which the children trust each other enough to risk exposure, in which individual differences are accepted and where children can experiment with roles and alternate modes of behavior. The year long story of this classroom is one in which the children move from a group stage in which few are willing to risk exposure to one in which self-learning through action is possible and positive. The stages of group development proposed by Garland et al. (1976) are used to describe the changes in this classroom. Treatment Process Pre-Affiliation Stage The Pre-Affiliation Stage is a time when children vacillate between approach and avoidance, and when they struggle to avoid pain and disappointment in the group. The therapist needs to allow distance, to invite trust, and to facilitate activities which do not have set rules that require interaction, competency, touching, or even eye contact. On the first day, the class was calmly seated in a circle with Nancy, the teacher who had worked with most of them last year. The therapist began the session with a song that used the children’s names, but slightly altered for rhyming purposes. The song, intended to identify and affirm everyone in the group, was ended prematurely. Arnie had disowned his name and said he wasn’t going to stay in the circle. He had shown so much confidence in playing during the music therapy assessment, but he did not have the ego strength to be singled out in this group of peers. Ken’s name brought teasing from several sources; Michael, guarding against psychic contact with his fellow, abruptly left the circle; Paul covered his ears. Fear and anxiety spread contagiously. Only Nathaniel, who had approached the music therapist on several previous occasions, handled his anxiety by allying with the therapist. In fact, Nathaniel, who seemed to have all the answers, used the therapist to help him keep distance from peers. Approach/avoidance was normal for this stage of group development and thus the behaviors of the children (in retrospect) were understandable. This beginning pointed up the importance of using a theory of group development as a framework for planning activities and for identifying those variations from the norm that had diagnostic or evaluative significance for the team. For instance, in the first few weeks, Nathaniel’s need to establish close identity with the music therapist to the exclusion of his peers was an interesting deviation from the norm, one which perhaps gave indication of a disordered personality. Knowing now that the group was not, as it seemed with Nancy sitting at the helm, ready for sharing, the therapist came to the next session with a story song, “I had a Rooster.” The song provided a safe container for the children since it did not require interaction, and it gave them time to develop some trust in the therapist. The therapist began with drawings of the various animals to incorporate in the song. “This is a baby song” someone said, but the group soon became mesmerized. They were safe. No participation or interaction was required,

although guessing was encouraged. In the next two weeks, similar activities followed, allowing the children to engage in parallel play and to contribute to the group at their own rate. At the end of September, Nathaniel was permanently moved to the next classroom to make room for a new student. At the same time, the children learned that Nancy, their teacher, was leaving in several weeks. The rooster song could now serve another important purpose. It could provide a vehicle for the children to talk about Nathaniel, to draw him, sing about him, and acknowledge ambivalent feelings at the loss. This time the need of the children to share feelings propelled them into a period of greater intimacy, which foreshadowed movement to the next stage of group development. The last two weeks with Nancy were a like a honeymoon period for the group. The children brought to the music circle several sea creatures which they had picked up on a field trip. The name-rhyme song used on the first day provided the ideal structure for incorporating everyone’s creature into a group activity, and the children responded so well that the song became their new opening ritual. Nancy left in mid-October, about the same time as the arrival of a new student, Ted, and the new head teacher, Katherine. Katherine was faced with a regressed group, one in which each child was dealing with the threat, the hurt, and the insecurity of these changes. On the first day that Katherine had the class by herself, the music therapist observed the following: Ted was yelling and grabbing his toy from the nearest desk; Arnie was morose and not meeting the therapist’s eyes; Hattie ran up and begged for permission to leave; Michael played compulsively at his desk with a few Lego’s; Ken colored obliviously; and two others were in Timeout. No one greeted the therapist. Jose acknowledged, in disappointed tones, that he thought that it was lunch time. How would it be possible to help these isolated individuals learn to express their anger and disappointment and to find, if not solace, at least common identity in each other? Was it possible to help these children, each so desperate for friends, to interact as a group? How could the therapist change the children’s view of the classroom (and the world) as a hostile, threatening environment? In their minds and hearts, they fear they had been dumped because nobody cared about them and because they were dumb. Certainly time and consistent caring would help. The therapist hoped that, through playful activity under the umbrella of music, the children would release their anxiety and be more able to share their feelings and increase their sense of self-worth. But this day, Arnie and Michael refused to come to the circle. The therapist put a big paper sheet on the easel and began the rooster song. Groans, fidgets, and epithets of despair greeted the therapist’s question about how they could talk about missing Nancy. The rooster song was Nancy’s favorite, and now the therapist began to draw Nancy to elicit verses about her. Gradually the children got caught up in the tangible figure developing before their eyes. Each child took a crayon to draw what he/she remembered about Nancy: shoes, pencil, and hair (drawn by Paul not near the head, but nobody criticized his contribution this time). Everyone sat dazed by the growing portrait and mesmerized by the guitar and singing, growing as it did with each contribution. Suddenly, Michael jumped up from his desk, overwhelmed by need, and pushing aside the last child, drew and drew and drew, unable to stop covering the page with undecipherable feelings about Nancy.

The children gradually began to accept the idea that their group would continue. But for several weeks the children could not be enticed into the circle, and if one did form, it would erupt into physical or verbal aggression. Interactions were either aggressive or non-existent. The therapist’s attempts to give controls or leadership to the children through individual turns often backfired because the children would refuse to take any risks. Power and Control Stage By November, the children were no longer avoiding contact but were beginning to jockey for positions of power and status, both among themselves and with the therapist. The children in this stage were struggling with the need to form alliances for protection or aggression, and were not yet ready to try out new roles. The therapist planned songs and rules for turn-taking to provide the structure and safety in which the children could negotiate their power struggles and develop their ego strength and self-control. Instruments and other concrete objects were used for the children to act upon. These objects became receptacles for the children’s self expression. In a session worth describing, the therapist brought in combs and tissue paper, enough for everyone to make a kazoo (humming into the tissue) for accompanying one of Jose’s favorite songs, “Turkey in the Straw.” The activity became cacophonous as issues of power, control and scapegoating took over. “Why can’t we have real instruments?” “Mine doesn’t work.” “Look at Arnie combing his greasy hair” “Who wants this song, anyway?” At least everyone was participating. Ted, who knew how to make his kazoo sound, began to help another. Before the end of the half-hour the song was sung many times with a wooden jumping jack (dancing Appalachian doll) and a washboard passed around the circle for added rhythmic flavor. In this activity, the therapist gave controls to the children as much as possible. The children had to negotiate to keep the group together so that everyone would get a turn with the jumping jack, but the therapist had to protect individuals by establishing the order of turntaking. The music acted as its own reward: if they did not play, the music would not be as good; if they did play, they would have a greater sense of pride in making their own music. The therapist purposely introduced the kazoos as a task requiring a moderate amount of competency, hoping to encourage positive leadership to emerge. The group tested the therapist’s tolerance: Is it o.k. to reject the instruments she had provided? The therapist helped the children be aware of the impact their behaviors had on the group, and to sort out issues, such as: “It’s o.k. to be angry, but it’s not o.k. to hit Jose”. In the days before the December holidays, the children’s anxiety reached new peaks. It was no longer safe or possible to go to the circle, as close proximity would trigger aggression. On one particular occasion, when Arnie and Ted were in an in-school suspension (out of the room) for inappropriate behaviors, the therapist played a tape for the children to draw to individually at their desks. This regression to the need for parallel rather than interactive play was not surprising during this stressful time before the holidays. In January, the room had been rearranged and the circle of chairs was around a low table. The therapist encouraged the group to use the table as a bonding instrument, by introducing a chorus/verse song which had spaces in the chorus in which to “play” the table in what became known as “The Boom-Boom Song.” Although not everyone could coordinate this

auditory/motor task, there was at once a feeling of being an ensemble: a metaphor, the therapist hoped, for the New Year. Paul never got in synchrony with this rhythmic game, even after much encouragement from the group, and despite his interest and focus in trying to get it “right.” The evaluation made from this highly motivated behavior was valuable for the team’s treatment planning for Paul. Intimacy Stage During this stage, the children began to use the group session to practice and try out new behaviors. The children were ready to risk taking control and being a leader. Even if several children were not able to play by the rules, the whole group would not fall apart. The children now wanted others to know them, and were therefore more willing to show intimate feelings through their playing, moving, and short verbal comments. The therapist’s aim was to move the children to take more responsibility for the group activities, to urge them to make the rules, to be the leaders, and to share their intimate selves. To raise the level of affective involvement in the group, the therapist now intentionally introduced activities which encouraged individual gross motor movement. The “Boom-Boom Song” became the vehicle and the structure for a movement game. At first the therapist supplied a choice of hats to inspire the movement, but later the children did not need such inspiration. The music gave the children’s movement both context and beauty, since the therapist, using guitar or drum and voice, matched the quality of the music to the physical and emotional quality of their movement. The returning chorus of the song (Boom-Boom) helped focus the group. Each child used this game for his/her own needs, and indeed each child’s needs became apparent in the process: Ted got to display his rap dance for all to admire; Arnie refused to take a turn but played an accompaniment throughout on the claves; Paul showed that he could dance backwards (It was Hattie’s idea and Paul was successful only in short spurts); Michael got “crazy” in his dance, his hyperactivity spiraling, and had to be called back to the table; Ken didn’t want a turn at first, fearing that he might be ridiculed for being fat, but later he put on an army hat and marched in and out of the desks, drawing a few positive comments from his peers. The children had taken control of the activity by choosing their movement and thus influencing the music. And, by confining their movement to the length of time of the song, they demonstrated remarkable self-control and an ability to sublimate their needs to those of the group. Only Michael had lacked the ability to self-regulate to which the therapist commented, “It looks like the movement brought up feelings which made you speed up your action out of control.” Each child had discovered something new about his/her self and had been supported in that expression by the music and the group. One day in early March, after Daniel had been in the room for two weeks, Katherine stopped the music therapist conspiratorially in the hall before class to say that the children were all hiding in the room, playing a hie-and-seek game. Upon entering the classroom, there was not a sound and the therapist had to search out each child—except for Hattie who stood up and said, “I’m over here.” The children showed great strides in trust, risk taking, and cooperation in this play, though the play was typical of much younger children. That day Ted brought his book, Frog Went A-Courtin’ and let Hattie hold the book while the therapist sang and the others were caught up by the pictures. By teasing the therapist about the “ahummm,

ahummm” at the end of each verse, the children showed that they were now viewing the therapist more intimately (“You remind me of my uncle”) and were, in their new strength, no longer fearful that the therapist would desert or rebuke them. The classroom atmosphere was changing, although there were many setbacks as each child succumbed to the pressures and anxieties that arose. Katherine, their teacher, was also able to engage the group in learning games in which interaction was the stimulus. This was an important step in implementing a language based curriculum. With time, the group began to develop its own agenda. In each session, one child or another would request a new “subject” for the opening riddle/song. Individual children would ask to lead the closing ritual. Some children brought in instruments or songbooks from home to share during the session. For the first time, the class asked what the other classes were doing during music, as though they suddenly were aware of themselves as an entity, possibly even a music group. They talked of taping a song for Jose (who had recently moved to the next class) so that they could share it with him at lunch time: “Yeah, Ted can use his keyboard thing and I’ll get the Congo,” or “Yeah, man, we can show him our instruments.” During March and April the class developed a number of games that required cooperation, interaction, and skill. In one bean bag tossing game, there was team play, pleasure, tolerance of frustration, and negotiating (pleading) for turns. A song was still there to keep the action going and to bond the group, while also lessening the anxiety of being unnoticed or unconnected. The song was a container for the group action as other songs had been before. Michael tried hard to sabotage this game by getting everyone to laugh at his acting out. For him the closeness of the group encouraged a negative bonding based on sexual inferences. Daniel (the new student) emerged as a leader, and Ted, who wanted desperately to be a leader himself, regressed to struggles more typical of the previous stage of power and control. At the beginning of May, the group created a drama that was a high point in their growth toward group cohesion. The drama was based on the story song, Frog Went A-Courtin’. Daniel, as the moth, laid out the table cloth and each child chose a part and danced the action using props he/she improvised from the room. They did the song in its entirety two times and when Ted, as the cat, came to disrupt Mister Frog’s and Miss Mousie’s wedding party, there was a chase. The children, responding to Ted’s symbolic aggression or to the real fear of being caught, found hiding places. Of course, there was dissension and arguing and occasionally a need for the therapist to set limits, but there was also negotiation and new roles for just about everyone. Although each child was able to try out new behaviors during this drama, the child’s investment in defending his/her ego blotted out awareness of the action of others except when it was threatening. The group was not able to discuss or to mutually identify individual needs or actions. But the children experienced themselves in new roles, and were beginning a positive cycle toward development of feelings of self-worth. The school year ended before the group reached the Separation-Cohesion Stage (Garland et al., 1976). The children were too young and too needy as individuals to tolerate and accept individual differences and to support each other in the open forum of group play. In the next year they would develop individual ego strength that would allow them to mutually support their differences and to grow further.

Discussion and Conclusions A major issue in music therapy group work with this population (as in all counseling work) was one of closeness and trust. In this group it was difficult to address individual goals without the emotional support and trust of the group. The therapist was concerned with accelerating the move toward intimacy (reaching group cohesion), and therefore planned interventions that encouraged growth in sharing and trying out of new roles. There was always a tension between the therapist’s efforts to encourage intimacy and the group’s readiness or stage of development. A schema for thinking about the structure of music therapy activities was helpful (Hibben, 1991). The activities were thought of in terms of five dimensions: the amount of interaction required; the controls or leadership (how much control the children had); the level of movement; the rules; and the competency expectations (Vinter, 1974). During the year, the children progressed in their abilities to handle these various dimensions, and the therapist responded by gradually increasing the levels required in each dimension in order to achieve group cohesion and to facilitate individual growth. During the first stage described above, the therapist (through the music) controlled the activity and the children were not able or expected to take leadership roles or to tolerate interaction, movement or complicated rules and skill requirements. In the next stage the therapist gave impetus to the move toward cohesion by encouraging interaction, responsibility, and leadership in activities such as the kazoo/instrumental improvisation. In the third stage the therapist planned an expanded movement dimension, encouraging the children to greater intimacy, sharing, and expression of feelings. The children negotiated rules and roles and they took control of the games through their movement. The therapist purposely increased the competency dimension in the “Boom-Boom Song” by requiring the booms to be played in the right spot. This served to challenge the children and to strengthen pride in accomplishment, a factor influencing group solidarity. The level of competency required was never so high that the children became task oriented in lieu of practicing social/interactional skills. If the year had been longer, the children might have begun to interact with more intimacy, giving support to each other. Individual children might have begun to risk leadership roles such as planning or conducting a group improvisation. As it was, in May the children still needed the rules, structure, and controls inherent in songs or games to sustain their interactions. In terms of the activity dimensions, the interaction, movement and competency expectation dimensions were intermittently at high levels. The children’s ability to lead or control the activities by deciding the rules was limited by the lack of ability to defer gratification of their own needs and by their inexperience with other play behaviors. The music therapist used group developmental stage theory as a context for evaluating individual progress in social, emotional, cognitive, and perceptual-motor areas. As the year went on, the group music activities stimulated more actions and interactions that were in themselves corrective emotional experiences. These experiences were made possible by the children’s ability to tolerate longer periods of closeness and by their ability to accept responsibility for their behaviors. The music helped move the group toward greater cohesion by holding the children together in its sound. Many times the music acted as structure for the group activity; the music provided boundaries in time such as repetition and closure, allowing

the children to experiment safely within. The children entered into a kind of social contract through music-making and were rewarded by the music itself. The music inspired the children in many ways, through: the movement of the beat, the associations with familiar songs, the metaphors for something funny, beautiful or lofty, and the messages within the lyrics. Glossary Attention-Deficit Hyperactivity Disorder (ADHD): A disruptive behavior disorder, described in the DSM-IIIR, in which a person has developmentally inappropriate degrees of inattention, impulsiveness, and hyperactivity. Weisberg & Greenberg (1988) suggest that between 3-5% of school aged children have this disorder. These children do not put judgment between impulse and action, and tend not to feel responsible, because they do not believe they have the control that they do. The following features are associated with ADHD: emotional ability, low frustration tolerance, poor school performance, poor peer relationships, and low self-esteem. Auditory Aphasia: An inability to understand spoken words due to a dysfunction of the brain centers. Individual Education Plan (IEP): A requirement of Public Law 94-142 (Education for All Handicapped Children Act, 1977), the IEP is a written statement which includes annual goals, short term objectives and services for any handicapped child (up to age 22). IEPs are prepared jointly by the child’s teachers, therapists, and parents under the supervision of the Public School Special Education Administrator. Learning Disabilities: A general term indicating defects in the ability to learn basic school-taught skills such as reading, writing and mathematics. The diagnosis is found in the DSM-IIIR under Academic Skill Disorders (Specific Developmental Disorders, Axis 11). Children with learning disabilities may have normal intelligence but exhibit difficulty with sequencing, with symbol recognition, in attending to or isolating visual or auditory information, and with certain perceptual motor skills, all of which are necessary for academic achievement. Oppositional Defiant Disorder: A disruptive behavior disorder described in the DSM-IIIR as showing a pattern of negativistic, argumentative, hostile and defiant behavior, but without serious violations of the rights of others. Transitional Object: An object which can be used by the infant in place of or to simulate the comfort of the mother’s breast (Winnicott, 1971). A child whose nurturing is constant and “good enough” is able to use the object (such as the thumb or, later, a song) as a replacement for or a bridge over to the desired object (the breast or the presence of the nurturer). With the transitional object the child moves from magical, passive control (cry and the food comes) to active manipulation. The development of the capacity to use an object in play as representation or replacement of something else depends on a facilitating environment, it is not inborn. References

Garland, J., Jones, H., & Kolodny, R.L. (1976). A model for stages of development in social work groups. In S. Bernstein (Ed.), Explorations in Group Work: Essays in Theory and Practice (pp. 17-71). Boston, MA: Charles River Books. Hibben, J.K. (1984). Movement as musical expression in a music therapy setting. Music Therapy, 4, 91-98. Hibben, J.K. (1991, in press). Identifying dimensions of music therapy activities appropriate for children at different stages of group development. Arts in Psychotherapy, 18. James, M.R., & Freed, B.S. (1989). A sequential model for developing group cohesion in music therapy. Music Therapy Perspectives, 7, 28-34. Lacoursiere, R.B. (1980). Life Cycle of Groups: Groups Development Stage Theory. NY: Human Sciences Press. Orff, G. (1974). The Orff Music Therapy: Active Furthering of the Development of the Child. St. Louis, MO: MMB Music. Schmuck, R.A., & Schmuck, P.A. (1979). Group Process in the Classroom. Dubuque, Iowa: W.M.C Brown. Siepker, B.B., & Kandaras, C.S. (1985). Group Therapy with Children and Adolescents. NY: Human Sciences Press. Vinter, R.D. (1974). Program activities: Their selection and use in a therapeutic milieu. In P. Glasser, R. Sarri, & R. Vinter (Eds.), Individual Change through Small Groups (pp. 244257). New York: The Free Press. Weisberg, L.W., & Greenberg, R. (1988). When Acting Out Isn’t Acting: Understanding Child and Adolescent Temper, Anger and Behavior Disorders. Washington, D.C.: The Psychiatric Institutes of America Press. Winnicott, D.W. (1971). Playing and reality. New York: Tavistock Publications.

Taken from: Hadley, S. (Ed.) (2003). Psychodynamic Music Therapy: Case Studies. Gilsum NH: Barcelona Publishers.

CASE SEVEN Growing Up Alone: Analytical Music Therapy with Children of Parents Treated Within a Drug and Substance Abuse Program Juliane Kowski Abstract In this case study, I will present my work as an analytical music therapist with a group of eight- to 12-year-old children who attended an afterschool program at a family health and support center within a drug and substance abuse program in Brooklyn, New York. The children, who were seen once a week for forty-five minutes over a period of eight months, are emotionally disturbed and exhibit behavioral problems; some exhibit tendencies of attention deficit disorder or post-traumatic stress disorder. I will discuss the ways in which I have adapted analytical music therapy methods and techniques, developed by Mary Priestley, to this population. I will use musical examples to explain the methods and techniques that I employed within a framework of structure and free-flowing improvisation. Furthermore, I will describe an “improvisational attitude” and the consequent challenges that arise for the music therapist. Introduction I was hired to develop music therapy at a family health and support center within a drug and substance abuse treatment center in Brooklyn, New York. The children were picked up after school by counselors who supervised their homework. They attended dance, music, and art therapy sessions while their parents received therapy or other services provided by the center. I worked with the children, who were divided by age into two groups, once a week for forty-five minutes for twenty-seven sessions in total. I will describe the group music therapy with the older children aged eight to 12. Eight to ten children attended the group. Before I explain my work, I would like to describe my theoretical background. I am a humanistically-oriented music therapist. I use a client-centered approach, which means that I rely upon the client for direction within the therapeutic process. I believe in the concepts of self-actualization and peak experience that are elaborated upon in the writings of Carl Rogers and Abraham Maslow. The analytical music therapy (AMT) music therapists Mary Priestley and Benedikte Scheiby are the main influences on how I understand and practice AMT. I have been in training and supervision with Benedikte Scheiby for the past five years and I have developed an eclectic, dynamic style that allows for my techniques to evolve with the circumstances. I work with individuals, groups, and families, and am always challenged by AMT. In this case study, I will focus on the therapeutic process itself and my own evolution within the process, rather than on the results of the process.

Priestley’s writings have helped to guide my work with children. She offers some interesting thoughts in Essays on Analytical Music Therapy about what she calls “Preliminary Music” with so-called “normal” children even though she declares herself too inexperienced to write in-depth about how AMT works with children. She writes: Children are acting out their fantasies in this way all the time, working them through in play. It is only when they get trapped in them and cannot develop any further that their learning and behavior suffers and they need help. Therefore the analytical music therapist’s aim with a child-patient is to restore to her, or introduce to her, the ability to involve herself in the important “work” of self-healing play, together with the freedom to use her natural curiosity and creativity (Priestley, 1994, pp. 275-276). Reflecting on when music therapy with children ceases to be analytical, Priestley writes: ...I would say it is when the use of words becomes wholly superfluous because of the child’s lack of comprehension due to mental handicap. But even when there is no interpretation by the therapist because the child is already working and playing in a self healing way, the analytical music therapist’s exploratory approach will influence the way he helps to shape the movement of the therapy. With his assistance, the child will be led into controlling his environment in a creative way. As Winnicott (1971) wrote: “To control what is outside, one has to do things, not simply to think or to wish, and doing things take time. Playing is doing” (p. 47). And analytical music therapy can provide an opportunity for such playing (1994, p. 284). Grounding myself in AMT, and adapting its techniques to the needs of these children, has provided a basis for analytical in-depth work in conjunction with music that maximizes therapeutic potential. Under normal circumstances these children have very little control over their lives. Under my guidance, within the framework of AMT, they had an opportunity to work and play creatively, to control how and what things were done. Background Information Ninety percent of the children at the center were of African-American background; 10 percent were Hispanic. Some lived with their parents; others had been separated temporarily until the parent graduated from the program. Many had been in and out of foster care or spent time with relatives. Most had one or more siblings. Due to histories of drug and substance abuse the parents were mandated to attend this program in order to keep their children. The children lived with issues such as neglect, emotional, and/or physical abuse, lengthy separation from their parents and homes, exposure to drugs and, as a consequence, meddling with the law and being involved with legal authorities. They trusted hesitantly, had poor communication skills, and harbored lots of anger and frustration. Their frequent inappropriate behavior resulted in constant problems at school and within the program. I worked with these children over a period of one school year. I met regularly with the program director, dance therapist, and counselors to coordinate goals, and to share thoughts about the therapeutic process and the children’s progress. It took time to establish trust and to lay the foundation that would enable us to reach the goals set by the team.

Working within AMT with this population in a large group setting required an improvisational attitude. Many challenges arose which forced me to adapt more traditional AMT techniques; however, there were moments in the music and in the verbal processing that demonstrated AMT at work with this population. Treatment In this case study, I will use two sessions to describe my work with these children. In the first example, near the beginning of treatment, I am using the AMT techniques: the holding technique and patterns of significance. In the second example, near the end of treatment, I am using the therapeutic technique of songwriting. In each example, I will discuss my work in terms of transference, counter-transference, and resistance. Therapeutic Goals: Throughout my work with this group of children, the main goals were: Acknowledgment and expression of feelings Anger management Increasing self-esteem Developing communication skills Helping with conflict resolution. Example 1: Free-Flowing Improvisation Description of Session 5 “What are our Christmas wishes?” suggested itself as a theme after we had sung several Christmas songs and I suspected that this direction might be a fruitful avenue of pursuit. Choosing this theme corresponds with the AMT technique, “Patterns of Significance.” This technique involves the therapist and the client(s) choosing a theme that characterizes a significant event in the client’s life. They improvise music together and process verbally afterwards. “This technique is used to discover the inner patterns and feelings surrounding significant events in life,” (Priestley, 1975, p. 141). Priestley recommends using this technique with individuals who are post middle-aged adults; however, I was able to adapt it successfully to my work. When adapting it, I tried to provide a common musical basis for interaction and to develop therapeutic musical and verbal interventions for a group setting. Sometimes, at the very beginning of the session when the children could not settle down, I asked them to just play what they felt and how they perceived these beginnings. They played and called it “chaos.” This was a recurring theme, an undercurrent in their lives that I felt I could substitute for a specific “significant event.” We did this repeatedly and it helped them to settle down, to expel the chaos, organize, and contain themselves. They grew more aware of how this “chaotic” musical interaction inhibited their ability to communicate.

When I initiated the improvisation with the title, “What are our Christmas wishes?” I felt a heavy mood come over the group and I could only imagine what these children might miss at a time when other families celebrate. The choice of this theme included a significant risk that I might touch upon something that would be very difficult to process within the group setting. So, I made sure to keep some time available afterward to process with a child alone if necessary. Christmas was obviously a difficult time for these children. In the following sessions, they initiated more thematic playing. Some even wanted to play alone. Issues such as neglect, loneliness, and the longing for a healthy and harmonious family surfaced. Seven children, whom I will call Andy (cymbal), Bert (kid’s djembe), Carl (snare drum), Dan (triangle), Eva (buffalo drum), Fanny (small conga drum), and Gladys (marimba phone), picked instruments. I prohibited the use of the big floor drum because I was afraid it would dominate the music. I encouraged everybody to express what they felt and to listen to the other group members. Gladys started playing the marimba phone very quietly. Fanny responded and went along with Gladys on the small conga drum looking at Gladys briefly and then down to the floor. Andy, at first grinning and looking at Carl for reassurance, hit the cymbal once pretty hard. I started playing the guitar, strumming D minor, A minor (picking up the pentatonic scale of the marimba phone: F G A C D), establishing a holding environment. I tried to send the signal that I was there to hold (using the AMT “holding technique”1), protect and encourage them, and not to stop them unless somebody acted in a destructive manner. Eva started playing the buffalo drum in a 4/4 rhythm, joining the girls. I felt that they were really trying to get together and to support each other. Bert sat quietly and scratched away on his drum. I could not tell yet if he was with the group or if he was demonstrating resistance. Andy picked up on Bert’s scratching and made screechy sounds on the cymbal. Carl laughed. Eva gave Carl an angry look and her playing became louder. The rhythm became more intense, like strong heavy footsteps in 4/4. I was not sure whether to intervene or to let this dynamic play itself out. Carl picked up Eva’s stronger buffalo drumbeat on the snare drum. Gladys established a melody that she repeated over and over again. Transcription:

An image elicited from the music of Gladys sitting all alone on Christmas Eve crying out for her mother arose in my mind. I supported her with gentle strumming on the guitar and gave her a reassuring look. Bert picked up the rhythmic pattern of Gladys’ melodic playing as if he were joining her, although he avoided looking directly at her. Others followed this rhythm. For a short time the group developed a strong musical message. I looked at Dan. He sat there, seeming spaced out, holding on to his triangle, swinging it back and forth, not playing it. Where was he? Neither the group nor I seemed to reach him. Meanwhile the group sounded as if they had composed their own little “Klagelied” (German word for wailing song) until Carl started

hacking away on the cymbal, purposefully destroying the unity. The girls stopped playing and the other boys joined Carl. The group had split. I accompanied the boys’ emerging power by playing sliding bar chords moving in half steps on the guitar. The 4/4 rhythm fell apart. The boys played a loud, angry sounding chaos. They were laughing, looking at me for reassurance. I kept following them, “telling” them that it is o.k. to play chaos. Perhaps chaos is what they had experienced at Christmas? I tried to encourage them to vent their feelings. They kept laughing. I felt their anger very much, and their resistance as well. They were hiding behind that musical chaos. Their laughter seemed to protect them from feelings that really hurt deep inside. The girls withdrew. I raised my hand to initiate the end. I wanted to give the boys some space for their male energy, but also to return to the girls with their female energy that was obviously quite different. I encouraged a few seconds of silence in order to let the music settle in, but the boys were unable to calm down so I moved on to verbal processing. These 2 1/2 minutes of music had passed so quickly. I asked Gladys what she thought of the music. She said that she had liked the first part more. I asked her why and what she had tried to say musically. She replied, without looking at anybody, that her wish had been to be with her whole family for Christmas. The room got very quiet. I responded that her wish was entirely normal and that Christmas should be celebrated with the whole family. I acknowledged her sad feelings and uncertainty over whether her wish would come true. I also let the group know that she had demonstrated a lot of courage by sharing her thoughts musically and verbally. I asked the group if anybody shared these feelings and if they had heard these feelings in her music. Fanny said that Gladys’ melody had made her feel sad and that she had played along with her. I asked her what she was trying to say and she said that she did not know, but that she wanted to be happy. The boys started giggling again. I was feeling the group falling apart anew. What could I do to keep them together? I mentioned to Andy that by scratching his cymbal he had demonstrated that he had not wanted to join the girls at the beginning. He replied that that was girls’ stuff and not for him. I asked him how he had tried to express his wishes for Christmas. He said that he had wanted to have fun and I told him that that also was a viable wish. I asked the group how they felt when they were together musically for a moment, and what it had sounded like. Fanny said that it had sounded sad, like a sad Christmas song. Eva supported her, nodding. Andy and Carl started giggling and talking again. I felt angry; the “teacher” was arising in me. I felt powerless to handle the situation. It seemed that whenever we were getting somewhere we had to stop. I decided to ignore the troublesome boys to some extent and asked Dan why he had not played at all. Dan said he had not known what to play. I asked him what he had wished for. Very quietly he said that he had wished that no bad stuff would happen. Bert and Carl laughed loudly. I asked them to explain their response to what Dan had to say. They kept giggling, enjoying the attention. Bert said that Dan never participates. I said that Dan was probably shy and that the group needed to help him to feel more secure. I decided to get back to the music and asked Carl what he thought about the second part of the music when the girls had not played. Carl said it was fun to play like that. I tried to dig deeper by asking him to describe the character of the music. Carl said that it had been fast

and happy. I passed this on to Andy, asking him what he thought. Andy said that he thought that the music was very strong, happy, and wild. I asked who else agreed with this description. Gladys said it had sounded like guns and that that was why she had stopped playing. Eva agreed with a confirming facial expression. Fanny said that she had felt scared. Andy and Carl laughed again and acted as if they were proud of what they had accomplished. I felt I needed to react, to let them know that I think that everybody has a right to express their feelings and that we ought to respect each other. I also acknowledged what the girls were feeling and why they had stopped playing. I mentioned that I might have heard anger in the chaotic part and I wondered if others were feeling the same. I could tell that I had hit a nerve. A wall of resistance sprang up. I repeated myself, stating that I did think that it would be very normal to feel angry because one had not had a nice Christmas. The boys began to hit the drums randomly. Were they trying to stop me? I asked for their attention, struggling with the bad feeling of having lost them. They refused to pay attention and I knew that I had to wrap this up. I acknowledged everybody’s active participation as well as the importance of listening. I realized that this was only Session 5 and that I should not expect too much from these children at such an early stage. I did not want to scare them off. I wanted to give them some time to process individually before we had to end the session so I suggested that we continue exploring these Christmas themes next time around. Feelings of sadness, anger, abandonment, and loneliness surfaced in subsequent sessions related to Christmas. I heard stories from children who received no gifts, saw sad eyes talk about missing family members and celebrations. Unfortunately, I was usually aware that we would probably be unable to work through these issues and feelings sufficiently to bring about real and profound change. There was simply not enough time, too many children bearing heavy burdens, and the constant interruptions caused by the ever-present and powerful resistance emanating from several of the boys. Discussion of Session 5 As transference, counter-transference, and resistance are integral to my work, let me first provide descriptions of each as I understand them. Transference: Priestley describes transference as follows: Freud referred to the phenomenon of transference as “wrong association,” as he recognized that some of his patients were regarding him with emotions that were relevant to previous relationships in their lives, usual parental.... The therapist, however, does not react in the way that earlier object — whether parent or parent substitute — did in her early life, and his response and interpretations enable the patient to liberate herself from her repetition compulsion and begin to experiment with new ways of acting and responding (1994, p. 77). Countertransference: The following is a clear and simple definition of countertransference: “Broadly speaking, countertransference describes the emotions that the

therapist develops toward the client in response to the client in sessions,” (Pavlicevic, 1997, p. 166). Priestley describes it further: The therapist may find that either gradually as he works, or with a suddenness that may alarm him, he becomes aware of the sympathetic resonance of some of the patient’s feelings through his own emotional and/or somatic awareness. Often these are repressed emotions that are not yet available to the patient’s conscious awareness (1994, p. 87). Resistance: Austin and Dvorkin describe resistance in psychoanalytical terms: “...a paradoxical phenomenon regularly encountered in the course of insight oriented psychotherapy” (1998, p. 423). Priestley’s work with resistance is based on the classical psychoanalytical model. She described how levels of resistance surface in music and are used diagnostically in work with psychotic patients. I found the following definition by Bruscia to be useful for my description and analysis of the resistance that occurred in my work. “Like defenses, resistance is healthy when it serves to protect the client from a harmful or premature lifting of repression and it is unhealthy when it prevents the client from benefiting the most from therapy and living a full life,” (Bruscia, 1998, p. 41). Transferences in Session 5. Transference was continuous within the group. The neglect and abuse that normally occurred in the children’s lives was reflected unconsciously in the music and expressed as constant chaos. They came from chaotic situations; they had no consistency in their lives, no limit setting, and no stable parental love. They were abused. In return they needed to do the same to the group, and to me. Perhaps this familiar pattern made them feel safe. The music helped to translate this transference, to bring it alive and into awareness. When I started working on this case study I listened once again to all of my recordings. I found it shocking how chaotic most of the sessions had been. Many began with children yelling at each other, laughing, and cursing. It usually took me a long time to focus their attention. I had this picture in my head of wasps flying around the room frantically trying to sting each other. I had to find ways to break through the resistance and chaos, to show them different ways of interacting, to create a comfortable place for them without the chaos. In this session, my role shifted, or was two-dimensional. For the girls, I took on the role of the “good mother,” providing them with a supportive shoulder, embracing their sadness, and encouraging them to express it. I chose the guitar as a harmonic instrument of soft presence in shape and sound. I strummed D minor and A minor, providing a holding musical container that represented the “good mother.” I chose the minor mode as a response to the open, sad sounding melody that had developed. For the boys, I was sometimes the “bad mother” who neglected them and upon whom they therefore projected a message of anger and frustration. I struggled during the moments of interruption and obvious resistance. I felt powerless, anxious, and at times angry. Was it all their anger that I felt, or was it my own anger that had been triggered by them that I needed to work on? In supervision I learned that I did experience some of their anger expressed in the music or verbally, sometimes to a point where I felt tense physically. I had to keep my focus, to accept

that it was not my own anger, to take a deep breath, pause, and relax and then to go on. To reiterate, it seemed that the children, especially the boys, had to “transfer” their “abuse” onto me because that was the method of relating that they knew and understood. I had to look at my own memories, my past. Before my present incarnation as a music therapist I had been a schoolteacher and I had to discipline the children. I remembered feelings of inadequacy. I struggled with the idea that their expressions of anger had not been directed at me personally, but at that point in my life I lacked the training to properly evaluate this dynamic. I am now able to comprehend it intellectually, but still need to revisit this issue in supervision. The girls brought in different dynamics by choosing to express their sadness. In some sessions they joined the boys in the musical expression of anger although they often needed encouragement, which implied to me that they were normally afraid to bear the consequences of expressing their true feelings. Over time, I learned how to flow with this resistance and what the resistance symbolized for these children. Countertransference in Session 5. My own countertransference emerged. At times I wondered, “Am I a ‘good enough mother’ for them?” These feelings stem from my own personal struggle as the mother of two little boys. I always want to be the perfect mother and have had to learn that there are limits, to accept my weaknesses, and to let go of my overly high expectations. There were times when the children’s verbal or musical actions mirrored their feelings of low self-esteem and inadequacy. When projected by the music these feelings made me, the therapist, feel inadequate. Often I was unsure how and why I ended up feeling this way. I am aware that this explanation might sound diffuse and leave the reader dissatisfied, but, eCountertransference, as Priestley calls it, is a very difficult countertransference to describe or analyze in measurable terms. Working with Resistance. Resistance occurred verbally and musically in this session with these children. Their resistance protected them from getting hurt where they had been hurt before, i.e., a healthy form of resistance. I observed verbal resistance when the children were laughing, interrupting, and opposing during moments that opened up issues that addressed family life, home, holidays, and parental love. Whenever musical or verbal interventions touched their vulnerability, the children responded with healthy resistance, banging aggressively on drums, cymbals, and triangles. It was not always clear to me whether these were expressions of pure pain or resistance. Sometimes they played their resistance in raps and blues in such a way that they used funny words and metaphors to represent serious, sad issues. I had to find ways of working with their resistance in order to keep them protected. At times, I just let them play or state their resistance. There is a method, explained by George J. Thompson (1983), called “verbal judo,” which I tried to incorporate into my work, based upon the idea that in order to break resistance one has to go with it. This can be done verbally as well as musically. I allowed them to play “chaos” which sometimes resolved the tension, and gave ways for them to work together. When Andy “resisted” at the beginning of our musical example by hitting the cymbal like a warning after Gladys initiated the soft, sad melody on the marimba phone, he needed

reassurance from his friends. He needed to couple up with Bert and later with Carl He clearly stated in his music: “Not me! I am not going there.” He was not ready to expose himself and/or his feelings. He was protecting himself. He showed healthy resistance. The children have needed this type of self-protection in order to survive their worlds. To do away with it, they would have to go through an extensive learning process in which they would have to be taught how to meet their needs. I sent a message of sympathy to him by letting him be, and to the girls by joining and staying with their music at the beginning. Giggling and laughing are very common resistance behaviors. Unfortunately, this behavior often led to group conflict. Children who felt laughed at shut down, and it sometimes took a substantial amount of negotiation by the therapist to enable both sides to express themselves. That is why I would identify this as unhealthy resistance. It obstructed the therapeutic process for individual children, as well as for the group as a whole. How do I work with this resistance? When Andy’s “resistance” first surfaced, I focused my musical response on the girls, hoping to draw them out. I tried to encourage them not to back down through facial and body expression. Later, when Andy and Carl coupled up, I let the group take responsibility. When Eva gave Carl an angry look, I decided not to intervene, but to let things flow until a moment of musical and emotional togetherness developed. When Carl’s cymbal smashing, a sign of resistance, interrupted us once again I was hesitant, not knowing what to do. The girls stopped and the boys kept on. I did not want to end the music entirely. I felt that perhaps the boys had a different message to convey, or needed to explore their resistance, so I went with them. In retrospect, I feel certain that it would have been a mistake to stop them. They needed to express their anger even though they were not able to acknowledge the feeling. I pointed out, in the discussion that took place during verbal processing, how unhealthy resistant behavior can hurt others’ feelings and prevent them from sharing any issues in the future. The children stated their resistance in the music by expressing emotions, but they were usually unable to connect these expressions to their thoughts afterwards. Often there was a disconnection between what had been expressed musically and what was said verbally. Some children played very repetitive motifs, melodies, and rhythms demonstrating resistance. Others stopped precipitously or refused to play at all. Sometimes the tempo, or a sudden change of tempo, indicated resistance. In summary, the children often expressed healthy resistance in order to prevent a premature and potentially harmful lifting of repression at this early stage of therapy. Unhealthy resistance surfaced when the children acted very disruptively and prevented the most basic exchange of ideas or feelings. At times, this unhealthy resistance triggered feelings of annoyance and anger in me. I had to address this issue over and over again in supervision, to look carefully at my own anger. Reacting in the moment required an ability to identify the type of resistance and to apply suitable interventions. When I felt overwhelmed, I often just took a deep breath, spoke to myself, and went on. Resistance is a very big issue in my work with these children and a constant field of battle. Example 2: Song Writing Description of Session 25

In this session I started talking about termination. We improvised on the emotional issues involved with saying good-bye. At the last session I suggested that the group create a rap with the title “Good-Bye.” I split the group in half and asked a few boys to write the lyrics and the other half to create the music. Here are one boy’s lyrics. I call him U. and chose his lyrics because he was leading this group and his lyrics were most significant. It’s Hard to Say Good-Bye It’s hard to say good-bye Why? Because it seems like the person You say bye to gonna die Some people will cry when they say bye, Just be strong and say “Hi” Just be like me And don’t cry Act like as if you was gonna see the person again and say bye Chorus: It’s hard to say good-bye Afterward I acknowledged U’s courage and ability to put his thoughts and feelings into rhyme. The group had supported him nicely by providing a tight rap rhythm. They had worked independently, but as a group, on a piece of music communicating their ideas. I asked the children what they thought about what U had to say. One of the boys (W.) said: “He is right, we just say bye and know that we see you again some time.” I had to explain that I would not be coming back and that only the accidental chance of running into each other remained. I could tell at this point that they were hoping for some reassurance that this was not in fact the end. I shared with them how I felt saying good-bye and that I would miss them. They wanted to know exactly why I had to leave, and once again an angry dynamic surfaced. The group started acting out, children were laughing, screaming at each other. When I mentioned that my two little boys needed attention too, some children quieted down a bit. We ended the session with a long “good-bye” song wherein everybody again expressed what they had to say. I realized afterward that it would have taken years of trust and relationship building with them in order to process their feelings in a more profound manner. Discussion of Session 25 Transference. I again took on a role of an adult in their lives who had abandoned them. I accepted and understood their feelings of anger. I thought mentioning my own responsibilities as a mother of two boys helped them in accepting my parting. Countertransference. When the children played the rap and this boy rapped his own words, tears came into my eyes. Their good-bye pains were completely conflated with my own feelings. How well they had learned to not allow themselves to feel the pain of saying goodbye. Here I was “abandoning” them, a presumably recurring phenomenon in their lives. And I,

too, could relate to their feelings. My mother worked full time during my childhood and was an elusive presence. I had also to face my own feelings of guilt and responsibility. I tried to find a good replacement for myself to help alleviate some of these feelings. I used supervision to take a fresh look at other partings in my past. I live an ocean away from my own family. Being separated and saying good-bye to them over and over again has spurred a whole set of personal issues. While attempting to “rescue” these children, I needed to attend to my own neglected inner child, to concentrate on these issues in order to enable myself to feel and understand the countertransference that surfaced repeatedly in my work. Resistance. Again the children expressed a lot of anger, sadness, and healthy resistance when acknowledging any feelings of pain. Some children laughed paradoxically while playing and singing. Some looked rather sad. It was a strange dynamic in the room. I wanted to help them to experience the feelings of a real good-bye, but I understood and accepted the denial that allowed protection. Other Challenges. Lastly, I would like to mention another challenge that arose in this work, the cultural gap between the children and myself. I had to learn about their values and cultural upbringing, which are very different from mine. Many of these children grew up in religious homes, where music is always an important aspect of their lives. Many of them have such a good feel for rhythm and bring a natural understanding of the blues, gospel, jazz, and rap into the work. I suspect I did not feel much resistance to me, even though I am a white person, because I brought music, and because I knew their music. The underlying issues of whether I understood or could accept the way in which they were brought up, the way they interacted, remained. I feel that music can really be a wonderful bridge between cultural groups. The implication of these cultural issues for music therapy is a topic unto itself and should be discussed and researched separately. I can only refer to the writings of Joseph Moreno (1988), who contributed much to my understanding of cultural issues arising in my work with these children. Discussion This case study has shown how AMT techniques can be utilized, with adaptations for a group setting, with this population. Through this work, it became clear to me that these techniques were essential for in-depth work. They helped the children to become more aware of their feelings and conflicts, to develop better communication skills and to express their feelings appropriately. My method fluctuates between free-flowing improvisation and structure. Structure is absolutely necessary in this work. It gives the children a feeling of belonging, containment, and safety. The structure was provided by the use of pre-composed songs, and creating blues and raps. It offered a musical container in which the children learned how to express themselves. The free-flowing improvisations usually had a theme to begin with. When less structure was provided, the children had to learn how to express themselves appropriately.

The challenges I faced in this work were varied. I had to learn to develop an “improvisational attitude,” by which I mean that I had to dispense with rigid plans and be willing to let the session flow in a more spontaneous and extemporaneous fashion. Every session was different and often started out in chaos. Children came in with a whole spectrum of energies after a long day at school. It often felt as if everything was out of control, which was very difficult for me because I like to be in control. There was no way to prepare or to have a plan. I had to find ways to ground them. I solved this problem by drumming and chanting at the beginning of the session which then developed into a natural way of inquiring about their day and how they felt. They often responded by saying that they felt either happy or sad. The children did not seem to know subtle shades of feelings and I believe that the music helped them to better express these nuances. Over time, I developed a typical session structure: 1) Hello, 2) Drumming and chanting, 3) Use of pre-composed songs/songwriting (blues or rap), 4) Free flowing improvisation, and 5) Good-bye. I often wished that I could see some of the children individually in order to meet their needs more effectively. So many issues arose that never had a chance to be sufficiently processed within a group setting, both musically and verbally. Statements of resistance too often interrupted moments of deep musical connection. On the one hand, the group’s dynamics did not always support a real therapeutic outcome, and yet, on the other hand, the group setting protected children from being overly exposed. They had a chance to model and to learn from each other, to develop a strong bond and community that might be of help in times of distress and loneliness. Conclusions I will end now with some thoughts and conclusions about some of the positive outcomes for the children and myself. Music therapy came to be a special time for the children, a safe place where they were allowed to express what they had been suppressing. They probably showed affection toward me because I was one of the few adults in their lives who did not yell at them and who treated them with respect and love. Music is clearly a meaningful medium of expression for them, since they bring a rich, strong musical background with them. All of them were talented and music gave them a field of immediate gratification as well as a base for practicing their communication skills. For this kind of work, my organizational strengths and love of control seemed not to do me any good. I had to learn to improvise constantly, to feel comfortable having no plan and to let go. I learned to enjoy that side of the work. It is delightful to experience the spontaneity of a child. Slowly, I was able to “go with the flow,” to read body language, to react quickly to very subtle expressions, and to turn them into meaningful therapeutic events. These children contributed immensely to my understanding of how AMT works. I had never wanted to work with children on the verge of adolescence because I was afraid of the challenges, but I have become convinced that this work can be very gratifying and fun. It was a joy to see them grow and change, and it has motivated me to seek work with this age group in a public school system in the near future.

References Austin, D. & Dvorkin, J. M. (1998). “Resistance in Individual Music Therapy.” In K. E. Bruscia (ed.), The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (1998). “The Dynamics of Transference.” In K. E. Bruscia (ed.), The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Kowski, J. (2002). “The Sound of Silence--The Use of AMT-Techniques with a Non-Verbal Client.” In J. Th. Eschen (ed.), Analytical Music Therapy. London: Jessica Kingsley Publishers. Moreno, J. (1988). “Multicultural Music Therapy: The World Connection,” Journal of Music Therapy, 25 (1), 17-27. Pavlicevic, M. (1997). Music Therapy in Context. London: Jessica Kingsley Publishers. Priestley, M. (1975). Music Therapy in Action. St. Louis, MO: MMB Music. Priestley, M. (1994). Essays on Analytical Music Therapy. Phoenixville, PA: Barcelona Publishers. Robbins, A. (1994). A Multi-Modal Approach to Creative Art Therapy. London: Jessica Kingsley Publishers. Scheiby, B. (1998). “The Role of Musical Countertransference in Analytical Music Therapy.” In K. E. Bruscia (ed.), The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Thompson, G. J. (1983). Verbal Judo: Words as a Force Option. Springfield, IL: Charles C. Thomas Publisher. Wigram, T., & De Backer, J. (eds.) (1999). Clinical Applications of Music Therapy in Psychiatry. London: Jessica Kingsley Publishers. Winnicot, D. W. (1971). Playing and Reality. London: Tavistock Publications. Yalisove, D. L. (1997). Essential Papers on Addiction. New York: New York University Press.

_______________ 1 In my work with these children I often used the “Holding Technique,” which is described by Priestley as follows: “This technique is also sometimes called “containing.” Its purpose is to allow the client to fully experience her emotions right through to its climax through emotional sound expression while being held emotionally by the musical matrix of the therapist” (1994, p. 38). I played D minor and A minor at the beginning to establish a musical container, holding the children musically, allowing them to express their feelings. I then switched to playing sliding chords in half steps symbolizing tension in order to follow the more chaotic character of the music, but also to give the boys the opportunity to express their feelings in a holding environment. I used this technique in almost every session to provide containment.

Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE EIGHT

All Her “Yesterdays:” An Adolescent’s Search for A Better Today through Music Claire Lefebvre Abstract This is the story of Melissa, a teenager who was admitted to an Adolescent Day Treatment Program due to a sudden onset of school phobia, combined with questions of drug abuse, and unmanageable behavior at home. She received weekly individual music therapy throughout the school year. Active and receptive techniques were used to encourage emotional expression and to gain insight into affective components of her behavior. As a result, Melissa made progress in self-esteem, had more appropriate peer relations, and could better organize aspects of her life where she previously experienced loss of control (school attendance, drug abuse, etc.). Background Information This case study is about a sixteen-year-old female, Melissa. She was referred to the Adolescent Treatment Program of the Children’s Hospital by the family’s social worker at the beginning of the school year. The reasons for referral were that Melissa had refused to attend school for the last half of the previous school year, and because her behavior was out of control and oppositional at home. Melissa states that she was referred to the program because she was also abusing drugs, including marijuana, LSD, and cocaine. The Adolescent Treatment Program is unique in its multidisciplinary team approach. The team includes a psychiatrist, psychologist, social worker, teacher, coordinator, and a full complement of creative arts therapists (Art, Movement, Drama, and Music Therapists). When the program receives a referral, a screening follows to determine if the client will be admitted, and to determine which of the arts therapies is best suited to meet the client’s interests, needs, aptitudes, etc. Upon admission, each adolescent must sign a contract in which they state goals they wish to work on during their stay. Melissa expressed two goals: to express more how she is feeling, and to overcome whatever it is that makes her stay away from school. Records of her personal history show that Melissa has not had consistent parenting from infancy. Melissa’s mother comes from a wealthy family of five children. She married when she finished high school, and she and her husband were reportedly very happy until they had their children. Melissa was the second of two daughters. Her mother describes her as a healthy baby who was a little shy and who cried a lot. Both sisters have a long history of psychiatric treatment. Melissa was referred at age three for self-abusive behaviour (e.g., severe hair pulling) and for exhibiting signs of depression. At the same time, her older sister (age five) was

referred for inappropriate behaviour. She chewed things constantly, including the back seat of the car. The family stayed together until Melissa was three years old, when her parents divorced. The mother then remarried, but the second marriage lasted only nine months. She remarried for the third time in 1982. Presently Melissa is living with her mother and stepfather, and does not get along with her stepfather. Her sister is staying with her natural father in another city. The family was seen in family therapy between 1984 and 1987, and Melissa began individual psychotherapy last year. Melissa is an attractive young female who is healthy except for mild asthma. She is a bright, personable girl. She has friends, some of whom are close, and she has been dating. Several months ago she went to live with her natural father, but left after a few weeks because of his violence in the home. Upon returning home, she felt rejected by her father and feared rejection by her mother. To avoid this, she stopped going to school so that she would not have to be away from her mother during the day. After acceptance to the program, Melissa took an Academic Achievement Test and a Wide Range Achievement Test. Results showed that she was “high average” in reading and sight vocabulary, “superior” in spelling skill and “average” in arithmetic computation. Her scores placed her at the eleventh grade level, though she was in the ninth grade at the time. Melissa was referred to music therapy because of a strong background and interest in music and also because she played piano. Treatment Process Phase One: Assessment The purpose of our first meeting was to introduce ourselves, and to familiarize Melissa with the music therapy room. I also explained to her some basic concepts of music therapy, and began asking her about herself. Although teenagers do not always respond well to verbal interviews, Melissa was intrigued by all the questions, and was particularly fascinated by how music is used in therapy. According to Ivy (1981), taking a history of an individual’s family background and involvement in music “may help diagnostically to decide the form of music therapy which might be most beneficial in treatment, and also the attitudes, values and feelings which may be influencing an individual’s progress in Music Therapy” (p. 35). I began the second session by asking Melissa to do a family music tree. This is accomplished by filling in a genogram with information about the musical involvement of each of her family members (See Figure 1). At first, Melissa said that her family was not very musical, except on her father’s side. However, after talking with her mother, Melissa discovered that the maternal side of the family also enjoyed music. She was surprised to discover that her mother had studied piano for about 12 years, and that she and two of her aunts had been active in choirs. Sometime later, Melissa’s mother remembered that in late adolescence, she composed her own “death march” in the styles of Debussy and Chopin. Apparently, music was “always” in her mother’s household: Melissa’s grandmother (who was of Irish descent) loved to sing, and whenever they had guests

for dinner, classical music was played on the stereo. Melissa’s mother sang lullabies to both of her daughters. When asked about her own music background, Melissa said that her only formal musical training was in recorder, but that she did not remember any of it. She received her first radio when she was in the sixth grade, and really started to listen to music at that time. When she would go to her father’s house, he would play piano and she would pick out various melodies by ear. In high school, he bought her an electric guitar, but it was stolen (or lost) one month later. Melissa likes all musical styles except disco music. Her favourites are: the Stones, the Eagles, the Beatles, Bob Dylan, and as she would say, the “old stuff such as Be-Bop, etc. She also mentioned the group, “AC/DC,” and a couple of heavy metal bands that she likes to play whenever she wants to get attention. She added that since she had gone to a French summer camp for five years, she knows many French “camp songs.” In the third session, Melissa was presented with various instruments and asked to experiment with them. I presented her the following: drum set with cymbals, piano, guitar, recorder, metallophone, and various small percussion instruments. Melissa did not show much interest in the percussion instruments. She tried the guitar, but felt that it was too complicated, and associated it with the one that had been lost. She liked the sound of the metallophone but preferred the piano. Melissa was very decisive in choosing her instrument. Throughout the year she played only the instrument she had initially chosen. In the fourth and fifth sessions, Melissa was given the opportunity to do whatever activity pleased her most, as long as it related to music. Previously, I had encouraged her to bring her favorite tapes to the session. Melissa had two wishes: to play the piano, and to learn how to read music. Her first activity was playing the theme from “Star Wars” which was the first song her father had taught her on the piano. She enjoyed playing it very much. She also tried to play several traditional French songs that she had sung (e.g., Alouette, Ala Claire Fontaine, fire camp songs). Melissa was very conscious of her mistakes, and whenever she stumbled she would move on to the next song. Afterwards, I began to show Melissa the rudiments of music therapy. She was intrigued by how music was built—the melodies, rhythms, and combinations thereof. At the end of the lesson, she asked for homework, as if she was learning music in a regular classroom. Melissa and I agreed that for the next couple of weeks, each session would begin with a fifteen minute lesson in music theory. Phase Two: “Pain and Pause” When Melissa arrived on Monday morning, she had a bruised lip. She claimed that her mother had hit her. The agency for Youth Protection was then notified, and Melissa was taken to the Emergency Room for an examination. Upon her return to the unit, we started our music theory lesson at her request. Melissa seemed to enjoy visualizing what she could play by ear on the piano. She was intrigued by the different designs, what they stood for, and the general organization of music. She participated fully and asked questions. After the theory lesson, she played the piano in a very unstable way. Whenever she made the slightest mistake she would automatically switch songs. When I pointed this out to her, she mentioned that she never could play them “perfectly anyway” and that it “bugged” her

to start over. She seemed to want to keep up the image of showing only what was perfect in herself, thus masking her low self-esteem.

Figure 1: MUSICAL GENOGRAM OF MELISSA

The following week, Melissa told me that she had given a piano lesson to another girl in the program. She was happy and excited about it, and seemed in a very good mood. She played the piano very softly, while explaining the different ranges of the instrument. Whenever she played an incorrect note, she would give a glance towards me and then start over without showing any signs of tension. When I complimented her on her perseverance, she smiled and turned her head in embarrassment. During that week, she did not attend the program for three days. On her return the following Monday, she told me that she had not attended last week because she was angry at her mother, and because she did not want the staff to see her in this state of mind. I responded by asking Melissa if she wanted to express her anger on the piano. She refused, saying that the “piano should not be banged on” and that she “liked it too much to play it this way.” Since she had already started to learn Bach’s Prelude #1 from the Well-Tempered Clavier, she asked if we could continue working on it. We worked by rote, with her repeating each phrase after I played it. During the piano lesson, she sat very upright, facing the piano as she played in the middle range. At the end of the session, she said that she had not worked on the theory, because it was getting too complicated. Since she was “starting not to like it as much,” we agreed to put it on hold. From then on, Melissa showed more of the “dark” side of her personality. She was no longer the “perfect” teenager that she tried to portray. When playing the piano, she would play without energy or dynamics and at a very, very slow pace. When I reflected back the way she was playing, and expressed concern over her “state of mind,” Melissa confided that she was worried about her mother’s future and her own. Her feelings about her mother were quite ambivalent. At times she enjoyed talking to her, and on other occasions, she would try to provoke her (by drinking, for example). Melissa liked to “test” her mother’s limits, and then observe her reactions. On the other hand, Melissa talked about wanting to change her own name back to her mother’s maiden name, so that she could pass it on to her children—whom she had already decided she would give the first names of “Payne” and “Pause.” Melissa would not elaborate any further about these two names. I asked if they were related to her actual condition of suffering and her search for peace when she plays the piano very quietly. She said she did not know and changed the subject. Melissa then asked me to play a quiet melody for her. I played “Jeux Interdits” (Forbidden Games). The melody has two distinct parts, one in a minor key and the second in a major key. Melissa loved this melody so much, that I asked her if she would like to put words to it at the next session. She agreed. The following week Melissa had changed her mind. She said: “If a melody doesn’t have words, it’s because it was intended to be left as such.” She also refused to play the piano or any other instruments. Instead, she complained throughout the entire session: about how tired she was; about how she did not like to go to the hospital to meet with her social worker; how the social worker’s office is next to the psychiatric unit and that passing it by makes her uncomfortable. She wondered if the kids on the psychiatric unit were “weird” and if it was because of family problems. She added that one of her friends had tried to commit suicide because she had broken up with her boyfriend. After further discussion, Melissa realized that her friend’s motives for attempting suicide were deeper than the boyfriend. In all likelihood,

she had not sought the help she needed, or perhaps nobody heard her cry for help so she found another way to get attention. Phase III: “Yesterday” We were now at the beginning of December, and anxieties regarding the holidays were starting to show. Melissa was more engaged in the program and was expressing her anger verbally with both staff and peers. However, in her music therapy sessions, she seemed to guard against anxiety attacks or any other kind of emotional crisis. Melissa had been going through a piano book of “oldies,” and she became interested in learning how to play songs by the Beatles. The first song she chose was “Yesterday”. She memorised it without difficulty and played it well. She was very concentrated throughout the song and sat very straight. After the completion of the entire song, she became less talkative and was evasive. She refused to express feelings related to the song, said she did not know why she liked this song, except that she did. Melissa never seemed to be interested by the faster songs of the Beatles, and in fact, stated that she preferred the quieter ones. The following week she started with “Hey Jude,” and mentioned she was going to see her sister and father during the holidays. She was looking forward to the holidays and was also worried about how it would go. Her sister had told her friends that Melissa was “wild” (into drugs and liquor), and Melissa wondered how they would react to her now that she had changed. Melissa then began talking about her first name, that it came from a character of a book that her mother was reading when she was pregnant. This girl was pretty and had several boyfriends (Melissa had difficulty maintaining a stable relationship). I suggested that Melissa might benefit from trying to express all these different emotions through the piano; however, she refused, explaining that when she plays the piano it makes her feel more peaceful and, therefore, better. I told her that what she was in fact doing was a form of “relaxation,” and that there were other ways of relaxing with music. Melissa then told me that during the summer, in the movement therapy group, she had done some relaxation exercises using imagery, and that she would be willing to try again in January— “maybe.” Phase IV: “Star Wars” Melissa returned three weeks later, after spending the Christmas holidays at her father’s house. She was glad to be back in the program, but still felt that she was not ready to face school on the outside. She spoke of difficulties she had while with her father. Everything was not as great as she had expected. In fact, her sister had even asked for placement in a group home. After returning to her mother, Melissa said that she was bored, and that she played a lot of piano because “there was nothing else to do.” During the session she played “Star Wars” (the first song her father had taught her). She had not played it since the assessment.

The following week Melissa mentioned how tired she was and the difficulty she had sleeping. At home, she and her mother either fought or ignored each other, and tension was rapidly building up between them. On the unit Melissa had become very provocative; she had started to sing very loudly whenever she was angry at her peers. They, in turn, reacted by becoming angry at her. She said she was ready for relaxation. Phase V: Depression We moved to a quieter, more comfortable room for the relaxation sessions. Melissa started giggling immediately, explaining that she was nervous and felt as if she had to move. So, we started off by standing up and shaking the different parts of the body. We then began breathing exercises, followed by “tension-release” exercises starting from the head down. Melissa followed the instructions and “tried hard” to relax. After a very slow relaxation induction, Melissa eventually settled down on the floor and proceeded to hide her whole body, including her face, underneath the blanket. I had her listen to an excerpt from “Escale 84” by Claude Léveillée, a piano solo with orchestra and nature sounds. Melissa had a positive experience and was able to talk about it afterwards. The following week, Melissa was again using her provocative “voice” on the unit. She admitted that she was “hyper.” During the session, she did an imitation of Bob Dylan but in a high pitched, squeaky, female voice. While doing this, she sat in a slouched position, and ate her own hair. She then moved to the piano, and did a mocking version of “Greensleeves,” emphasizing the words, “Winter is here and the leaves are gone.” Phase VI: Abandonment Melissa’s relationships with her mother and stepfather were worsening, and the team recommended that she be placed in a shelter while continuing to attend the program on the unit. At the same time, I had to cancel our music therapy sessions for an extended period, due to a prolonged illness. Melissa and I did not see each other for two months. Resuming sessions after such a long absence was very difficult—for both of us. The rapport that I had established was now on very shaky ground, and Melissa’s confidence had diminished. Melissa spent the first session only wanting to talk and reconnect loose ends. Phase VII: Relaxation At about the time that Melissa was placed in the shelter, and music therapy sessions were resumed, a change was noticed in her behaviour: Outbursts on the unit occurred less frequently, and instead Melissa would often go to the music room and play piano. We resumed the relaxation training, and by this time, Melissa was better able to pay attention throughout the entire relaxation process. The induction I used was a “Ball of Energy” moving through her body. Melissa reported that she felt the warmth of this ball, especially as it touched her stomach. She also reported that whenever she experiences stress or tension, she feels it as a knot in her stomach.

Melissa had now returned to live with her mother, and her behaviour was more appropriate, both at home and with peers on the unit. Her mother had promised her a piano, if she proved and maintained her interest in it for two months consecutively. As the program was drawing to a close for the summer, Melissa began to sever links with everyone she had known on the unit throughout the past school year. Relaxation also became more difficult as the time for termination approached. At first, Melissa seemed to be able to reach her “favourite place” (a meadow with a lot of horses), however her reflection and discussion afterwards were meagre. Then she began to refer to relaxation as “time to go to sleep,” and would become oppositional about imaging her favorite place, saying that she did not want to go to there anymore, and that she did not want to think about anything. Phase VIII: “Today” At this session, Melissa tried to evade the piano. She talked about taking piano lessons once she left the program, so that she would not feel lonely and act out. During the week, Melissa had heard “The Rose” and started to play the song. She did not want to talk about the sadness, however. In the next session, Melissa tried to cut herself off from all emotions. She did not feel like doing anything. She eventually played the piano in a very detached way; rapidly (which she never did), and playing through everything she knew. She played only in the upper register of the piano, and did not use any contrast. At the end of her recital, she said she was looking forward to the summer and she was hoping she and her mother would get along. At Melissa’s request, I brought piano books so that she could select a couple of songs for her to learn over the summer. At the end of the session, Melissa mentioned she had learned things about herself, and concluded: “It’s up to me now as to how things are going to be from now on”. Discussion and Conclusions The music therapy assessment was significant in Melissa’s treatment process for several reasons: it gave a clear picture of her family’s past and present living situations; it revealed that music had always been part of Melissa’s upbringing; and that, although she never realized the importance it had in her life, Melissa used music to provoke others, to get attention, and to soothe and relax herself. Music therapy provided opportunities for Melissa to express her feelings, and to gain some insight into how her emotions affected her behavior. As a result of this, and other aspects of the program, Melissa made progress in self-esteem, had more appropriate peer relations and could better organize aspects of her life where she previously experienced loss of control (school attendance, drug abuse, etc.). Considering Melissa’s unstable upbringing since infancy, it is amazing that she was able to show this kind of progress in such a short amount of time, and especially if one considers the unavoidable interruption in her music therapy sessions. Undoubtedly, the staff working as a team provided the stability that Melissa needed during my absence. Being in a safe and supportive environment was also crucial to Melissa’s personal growth.

After working with teenagers for a certain amount of years, and witnessing the ups and downs of Melissa’s therapeutic process, I have discovered how important the following points are for effective music therapy with adolescents: 1) Listen, Listen, Listen! Adolescents need adults who will hear what they are trying to say. As music therapists, we should be particularly sensitive to a client’s need to be heard. 2) Know your client, musically. It is important to know their musical past, their current preferences and orientations, and their musical goals for the future. A thorough assessment which combines both active and receptive techniques is essential. As when assessing anyone else, it is important to respect limits that a teenager places on selfdisclosure. 3) Teenagers have to take an active part in their treatment plan. It is important for them to set goals for themselves, and to evaluate their progress as they go along. 4) Begin every session with something the teenager wants to do. Teenagers need to be motivated by activities that are relevant to their interests and needs. 5) Be flexible. Teenagers are so unpredictable, and their lives are often in such upheaval, that it is unreasonable for a therapist to stick to a single plan or use the same approach regardless of what happens. 6) Know clinically and musically when it is time to empathize and when it is time to challenge them to forge ahead in their therapeutic process. This means that the music therapist has to be aware of the usual ploys of adolescents at manipulation. 7) Time can work for or against the therapist, the client, and the process. It has to be used to greatest advantage. 8) “It’s up to her now!” It is important for music therapists to give responsibility to the teenager for his/her life, and to trust in both the therapeutic process and the teenager. Despite the interruptions in Melissa’s music therapy, these eight points provided a framework for helping her to search for a better today and tomorrow. In a follow-up contact, I learned that, during the last several years, Melissa has completed high school and is now involved in career education. References Ivy, V. (1981). The Music of your family Tree: Insights for Music Therapist and Music Therapy Practice. Proceedings of the Eighth Annual Conference of the Canadian Association for Music Therapy, Woodstock, Ontario.

Taken from: Hadley, S. (Ed.) (2003). Psychodynamic Music Therapy: Case Studies. Gilsum NH: Barcelona Publishers.

CASE NINE The Knight Inside the Armor: Music Therapy with a Deprived Teenager Simona Katz Nirensztein Abstract Eli is a fifteen-year-old boy, who arrived at a boarding school for maladjusted teenagers, after an attempted suicide. At his arrival he refused to speak to anybody. Due to a premature birth and to a deprived family environment, Eli’s Self was fragile and not coherent. Anxieties, splitting, and emotional isolation made it impossible for him to adapt to normal life. The present chapter describes how Eli’s Self was “restored” during the process of music therapy he went through at the boarding school. Improvising in a holding environment, experiencing a continued “affect attunement” with his therapist, and being mirrored in an empathic way allowed Eli to get in touch with his feelings, to express them--in music and in words--and to feel the vital sensation of being understood. Finally, some ethical/theoretical issues about the pros and cons of the depth of this kind of intervention in such a limited setting are considered. Introduction The case study that I am about to describe has as its protagonist a fourteen-year-old boy who arrived, one cold December, at the boarding school where I work. This is a hostel for maladjusted teenagers. The boys, aged between 14 and 18, can be classified as deprived and with an anti-social tendency. The life of these boys is marked by deprivation, both material and affective. Their parents did not know how to, or could not, provide them with the experience of growing up in an adequate holding environment, nor did they protect them from traumas linked to material poverty, exclusion, drugs, violence, or sexual abuse. Many of the boys have serious learning problems; some of them have a psychiatric history. Their attitude toward other human beings and to their environment swings between violence and avoidance. D. W. Winnicott (1956), in his article on the antisocial tendency, stresses the fact that the antisocial act is an expression of hope, a plea to the environment to provide what is lacking. But he himself tells of the difficulty of taking up the role of providing a therapeutic response for these deprivations. It is not easy to have stones thrown at the windows, to have to interrupt a client that strikes with such violence as to tear the drums or burst the therapist’s eardrums, nor to face endless silences that express total void. But Eli, the subject of this case study, was not at all a typical personality within the school. His frail and introverted look made him seem younger and more fragile than his companions. The violence of the environment represented a further threat to him. His success

in his school studies accentuated his dissimilarity. Upon his arrival at the school, he closed himself inward and seemed determined not to open up either with his peers or with adults. Background Information Eli came to the boarding school after six months in a psychiatric day hospital, where he had been admitted because of a suicide attempt. He had locked himself in his home with a brother two years younger than he, and had threatened to jump from the fourth floor. Police came to avert the tragedy. In the hospital, Eli had been diagnosed as suffering from “Dysthemia. Primary type, early onset.” The family did not provide an environment suitable for dealing with Eli, so the psychiatric and social services decided to permanently separate him from them. Eli’s father suffered from a grave form of progressive muscular dystrophy that contributed to making him unstable, even from a psychological point of view, subject to frequent attacks of anger and violence. Even before his illness he had not held a permanent job. In his past he had had another family, wife and children, with whom he had no contact whatsoever. Eli’s mother, a woman with a weak personality and physically fragile, bore the economic and practical burdens of the family, working for a cleaning company. Eli had two older sisters and a brother two years younger than he, who all had serious behavioral problems. The family lives in great economic hardship and need the help of social services. During her pregnancy with Eli, his mother had suffered from pre-eclampsia (pregnancy poisoning); Eli was born prematurely at the seventh month, weighing two kilograms, and was in danger of dying. His mother tells that while he was in the incubator she prayed continuously. She made a vow that he would be given a name, which, in Hebrew, means “God has helped.” From that moment on, she says, Eli was her only hope, a hope that had not sufficed to give the child a happy childhood. The parents did not provide information on the first years of Eli’s life--his development is defined as normal in general terms. His school and social services had long realized that the boy was suffering--isolated at school, distracted, physically restless, and afflicted with facial tics. His scholastic performance had deteriorated visibly during the year preceding his hospitalization. Efforts were made several times to distance him from the family, but a complex bond of mutual dependence with the mother made this impossible. A report from the psychiatric hospital defined Eli as a boy with grave emotional problems: Where there is a need for emotional involvement there is a decrease in its potentiality reaching the loss of reality judgment. Painful emotions, such as depression, anger, and boredom, tied to thoughts of death, impose an enormous effort of containment, and threaten to overwhelm him and provoke anxiety attacks. In the effort to defend himself, Eli uses primitive defense systems, such as denial, repression, emotional insulation, isolation and splitting. Both the hospitalization and his admittance to the boarding school for maladjusted boys were carried out against his will. Eli refused to open his mouth in the presence of the

psychologist, which was the main reason he was referred for music therapy. The psychologist, being worried, asked for my help, but at the same time he told me, “Be very careful, his defenses are impenetrable and hard, but as fragile as a ceramic tile; if you touch it, you risk breaking it.” Theory, Methodology, and Techniques Working with adolescents whose life experience is one of severe deprivation has helped me to identify the influence of what is missing in the relationship with parental figures on the very early development of the self. In particular, I am convinced that much can be done by means of a psychodynamic approach within a music therapy setting. Music has, in fact, a series of characteristics which make it most adaptable for creating a type of therapeutic relationship whereby the client can express his own needs and what is missing and, at least in part, regain the use of psychological patterns that have atrophied or have never existed. According to D. W. Winnicott, “…a good enough environmental provision in the earliest phase enables the infant to begin to exist, to have experience, to build a personal ego, to ride instincts, and to meet with all the difficulties inherent in life” (1956, p. 304). What is missing for the boys at the boarding school is, first of all, that “good enough environment.” The concepts of “mirroring” and “holding,” as expressed by Winnicott (1960; 1971), are instrumental in my approach and have accompanied the entire therapeutic process with Eli. In Eli’s own story the holding was missing as much in the physical sense as in the psychological one, because of his premature birth, together with the extremely difficult family situation. We shall see how the sensation of having to, and wanting to, “hold” and “see” Eli was an integral part of the countertransference and his need to be “held and seen” constituted the transference. The “arms” and “eyes,” no less than their object, were created by the music: To listen and be heard, to express and be understood, even without words, was the backbone of the process. The music, and the silence as its alternative and container, permitted the creation of an unconditional holding that was adaptable for the various phases of development of Eli within the therapeutic process. The experience of merging with a maternal figure was the basis for the creation of the “transitional space” (Winnicott, 1971) where Eli could experience the feelings of creativity and omnipotence. Here, thanks to the presence of the therapist, he could feel his Self as an existing, significant, and valuable entity. The ability of the infant to participate in an interpersonal relationship from the very first days of life, according to Daniel Stern’s (1985) theory, is by its very essence amodal (without structure). All the senses are involved in the creation of a channel of communication between the personal experience of the child and the person who is taking care of him. The nonverbal character of music, the complexity of its components (united in their primordial character), its unavoidable physical counterpart, its capacity to address itself simultaneously to various senses, makes it an ideal medium for re-creating conditions comparable to the constitutive experience of the self. Music allows the therapist to provide a closeness that is suitable for the client at that given moment of his experience, without going through the process of symbolization and, in certain ways, of alienation of the experience in its totality, which is intrinsic in verbalization.

Stern’s theory gives a central place to nonverbal communication as a basic element in the creation of a relationship. The fundamental concept of the “vitality affect,” as the quality of the affective experience arising from the meeting with the other as early as the age of two months, in the sphere of the “sense of an emergent self,” (Stern, 1985) supports the basis for using a music psychotherapeutic approach, particularly because the feelings expressed are not verbalized and categorized in order to obtain a legitimization and a curative validation. On the contrary, the function of the music therapist becomes accentuated through the definition of one who can accomplish “the affective attunement,” the kind of act which is nonimitative, but absolutely regulated to the affect that lies behind the infant’s action. This process permits the sharing of the baby’s affective state and, consequently, the intersubjective exchange, which is indispensable for the construction of the “sense of subjective self.” One must keep in mind the fact that in the case of deprived teenagers the experience of affective attunement on the part of the adult is very often missing throughout the course of the entire life. In my work, I have been guided by the principle--which is more and more accepted by self-psychology (Kohut, 1984) and the intersubjective approach (Atwood & Stolorow, 1979)-that the mutative element in the therapeutic process is the relationship with the therapist, the therapeutic act, even more than the verbal interpretation. “‘Something more’ than interpretation, in the sense of making the unconscious conscious is needed” (Stern et al., 1998). In my understanding, music has all the characteristics to make it the vehicle for that “something more.” I have found the concept of the importance of “now moments” (Stern et al., 1998), those moments of authentic encounter connected equally to the life experience of the therapist as to those of the client, and which are capable of “modify[ing] the structure of the implicit relational knowing between the client and the therapist,” very illuminating. Furthermore, this is an experience that can, in turn, modify the “client’s implicit procedural knowing, his way of being with others” (p. 903). This is a situation in which the therapist must be in deep contact with his/her own countertransferential reactions, especially those that pass through and express themselves in such a way that they interfere with the client’s music (Bruscia, 1998, pp. 51-120). Therefore, in my approach, the energy is directed to be in maximum attunement with the client in the here and now. Through this particular type of attention, it is my intention to allow the client to integrate his experience and to insert it within the more complex framework of the bonds that tie the past to the present. The method in this case study, therefore, was absolutely nondirective and concentrated on the construction of a relationship that would allow for experiences that were lacking in Eli’s repertoire of intersubjective encounters. Free improvisation was the main musical vehicle, but other experiences included music listening and dance. Words and music alternated in a natural manner and, as far as possible, one that suited the needs of the client. The meetings, lasting fifty minutes each, took place once a week. The duration of the overall therapy was one year and seven months. The Treatment Process Daring to Be in the Presence of “An-other”

I must admit that the psychologist’s warning had alarmed me; I had an ambiguous mission--to create a contact, but without cracking the flimsy porcelain layer that separated Eli from the dangers inherent in any relationship; to be in touch with him without touching him. But Eli helped me. Right from the first session, he defended himself and opened up at the same time. He entered the room almost without looking at me; mumbling a greeting, he sat down next to the electric organ and began to play. A flow of sounds from his bony hands, the look on his face sharp, concentrated and intense, his body wrapped in a shapeless coat. From his hands came snatches of melodies that ran into one another; he liked to start from the high notes, to reach, descending progressively in thirds and fourths, to the low ones. Soon he moved over to the piano. He kept the right-hand pedal down, blurring and attenuating the limits of the melodic ideas that were taking shape. From time to time he played with both hands, creating hints of polyphonic dialogues. I listened and watched him with absolute intensity. Through the senses, I could perceive his existence and the obscure, confused, and painful nucleus from which that flow of music sprang. I could perceive the empty spaces. I could sense that nobody had ever looked at him this way, in an effort to reach his core-self. I perceived that music was an expression of something very authentic and very deep. Rich. I was struck by images of maelstroms, indistinct movements of dark and intense colors. The word “unintegrated” came to my mind. Speaking of the very first phases of development, Winnicott (1945) refers first of all to the process of integration and says “the tendency to integrate is helped by two sets of experience: The technique of infant care whereby an infant is kept warm, handled and bathed and rocked and named and also the acute instinctual experience which tend to gather the personality together from within” (p. 150). Perceiving Eli’s music as linked to a phase of integration, I felt I was providing him with a symbolic “infant care” by my looking and listening, while he dared to experiment and express his “acute instinctual experiences.” It seemed quite clear to me that my role should not be an active one. My listening and presence allowed Eli to exist and to begin to feel his existence in an environment that did not compel him to any act of change or adaptation, that did not threaten him in any way. His readiness to let himself go with the flow of the music can be seen as a demonstration of his life force, of his not giving up to the looming disintegration. During the second session, while I listened, I heard a fragment of melody that kept returning more and more insistently. I took some paper and noted the melody. Eli turned his head and asked for an explanation. I explained that I felt something taking shape and I did not want it to be lost. He nodded, satisfied. What reached through to Eli was an act of mirroring: I see you, therefore you exist, your music is noted down by me, I want to understand it and remember it; therefore, you exist. In a certain sense I offered him a mirror. Eli began to check whether my look continued to accompany him. “What does the baby see when he or she looks at the mother’s face? I am suggesting that, ordinarily, what the baby sees is himself or herself” (Winnicott 1971, p. 112). Daring to be with “An-Other” That fragment of melody developed into a real leitmotiv. In its structure there was something mirror-like, or, at any rate, in the nature of a dialogue, both in its rhythm and in its

melodic structure. To a theme based on a descending third, responded another, based on an ascending third. To the high C responded a low C that ascended gradually and attained it; all this at the very abyss of the end of the keyboard, toward the highest part, or, more rarely, at the lowest. One could suppose that Eli was expressing, through the very structure of the melody, his need for mirroring and relating and, also, his desire to bring the abysses of his anxieties into therapy. What was certain was that this melody became our common playground. The structure of the leitmotiv and the persistence of its regular reemergence, gave me the feeling that Eli had already been born in the relationship and was ripe for a musical interaction. Timidly, I began to play a sort of countermelody to his music, without trying to imitate it, but rather adapting my response to his proposal, in an effort to provide an experience of affect attunement. He replied to me. A wave of emotion engulfed us. I did not try to explain to myself in words what Eli was saying to me with his melody, or to categorize the feeling that he was expressing. I tried to “match” his melody and, above all, the affect that was behind it. In our musical dialogues, which from that moment on developed with ever greater freedom on both sides, we passed through a vast gamut of what Stern defines as “vitality affects.” “A quality of experience that can arise directly from encounters with other people.... These elusive qualities are better captured by dynamic, kinetic terms, such as surging, fading away... explosive, crescendo, decrescendo, bursting...” (Stern, 1985, p. 54). Not only did Eli have the sensation of “existing,” but in addition to this was the sensation of “co-existing” with someone who adapted her own vitality affect experience to his, rendering it a common one; someone who accompanied him within his dark maelstroms--those which may gradually be faced. The ceramic tile was not impenetrable any longer. Daring to Communicate with “An-Other” One day, after some improvisation together, Eli turned toward the stereo, looked at the discs, asked to hear a Mozart symphony, and began to talk. His words gushed out also in a “sottovoce e prestissimo” flood. It was difficult to understand him. To do so, I had to bring my ear close to his mouth, at times asking him to repeat. I was very moved. The quality of my listening and also my state of mind were complementary to those provoked by the music, but the introduction of words into our space had signaled another step toward “togetherness.” “In fact, every word...is the product of uniting two mentalities in a common symbol system, a forging of shared meaning” (Stern, 1985, p. 170). From then on our sessions assumed a structure. Eli would begin to play and sometimes I would join him in a shared improvisation. His leitmotiv would always appear and would at times undergo development and variations. The music helped him to get in touch with himself, reestablishing secure boundaries for our transitional space. My musical “arms” kept him warm and safe from the threat of disintegration, provoked by his own thoughts and feelings. But the music had another and not less important, function: to preserve the globality of Eli’s emotional experience, without submitting it to the inevitable fragmentation that language brings with it. As Stern (1985) states, “language is a double-edged sword...it drives a wedge between two simultaneous forms of interpersonal experience: as it is lived and as it is verbally represented” (Stern, p. 162). The music also reappeared at the end of the session.

In the middle there gushed out the flow of words with which Eli invited me to get to know his existence more objectively, more categorically. His life was presented from two deeply split angles. On the one hand, there was the home and a greatly idealized family, full of every kind of material good and affection without limit from parents, always full of goodness, obliged to send away their adored son against their will. The idealization made the reality bearable, altering it substantially, and it also expressed a need that had remained unresolved during Eli’s development. On the other hand, there appeared small episodes that spoke of sensations of abandonment, loneliness, boredom, desires that were not met, and unrealizable dreams. I interacted briefly, asking for clarification, pointing out connections, making comparisons, and, above all, expressing my presence which was authentic and felt. My presence, my listening, gave Eli a container, an “envelope” (Anzieu, 1989, p. 157) that embraced and united all the different parts of his self. Truth together with lies, desires together with disappointments, thought, and narrative. And, in this way, I felt myself to be a container ready to receive his words and his sounds. He began to take off his inseparable coat, in which his body was kept always hiding, and passed to a more symbolic and less cumbersome and less crushing protection--a pouch tied to his waist. Daring to Show Himself to “An-Other” We were drawing close to the end of the school year. Seven months had elapsed since the beginning of the therapy. When there were four encounters left before the vacation, on a hot day we began our session with a lazy improvisation on the metallophone. He began to sway to the rhythm and then, suddenly, he began to dance. His movements were surprisingly decisive, acute, and sharp--an orderly and very rapid sequence that certainly required some skill. He looked for highly rhythmical music and began his dancing anew several times. Every now and then he would glance my way to make sure that I approved. I was, more than anything else, stunned. His dancing did not resemble anything at all that I had shared with Eli until that day. From a certain point of view, I was amazed by the display of coordination and glad about the sudden involvement of the body in therapy--something I saw as a new important step. On the other hand, I felt very uneasy: There was something grotesque, exaggerated in that dance--a lack of vitality, flexibility. Observing him, I had a feeling that resembled shame. He told me, with a certain pride, that this dance was the fruit of hours and hours of hard work in front of the TV. He had been rehearsing it from the age of seven. Instinctively, I encouraged him to repeat it. I helped him find the most suitable music. But it was only later, and with the help of supervision, that I understood its significance. After seven months of therapy, Eli emerged from his coat with his “premature,” “inadequate” body, just as, after seven months of pregnancy he emerged from the poisoned womb where he began his existence. My bashfulness was a reaction to the inadequacy of his appearance. But, at the same time, I was deeply willing and happy to receive and accept him the way he was. On another level, Eli was showing me something very intimate, a picture of a child who, being totally deprived of models to follow, searched on the television screen for something to learn and with which to confront the world. It was not surprising that that “something” was

grotesque, especially now that that skinny body, already on the road to adolescence, performed it. The first to feel it, albeit unconsciously, as such, was probably Eli himself. In a certain sense I felt the shame for him. What, in another theoretical context, would have been called projective identification, I would define here as a “resonance with his unconscious feelings.” Only in our transitional space, suspended halfway between his internal world and a relationship with another human being, Eli the dancer could show himself and survive. At the end of the last session before the vacation, Eli also removed the pouch at his waist and forgot it in the room. Later, he showed his dance to his companions as well, eliciting admiration and amazement. Daring to Be Angry During the summer, I often thought about Eli and I wondered if our special atmosphere would survive the separation. Thus, I felt relieved when we met after the two months’ holiday and he began playing as though we had parted the day before. He immediately returned to his leitmotiv, but it soon became clear that the separation had left its mark. The soft minor third was transformed into a biting tritone. The sound, from being muffled, became percussive. My every intervention was refused and left outside his music; my questions remained unanswered. It was at the end of the first session that he told me simply, categorically, “I am angry.” The all too obvious explanation that the first object of his own anger was I myself, who had left him in his private hell for two months, was refused in words, but explored through the music; the percussive theme and the recurrent tritones became the leitmotivs for that period. Soon, another reason for anger was added: his sister, two years older, had been sent to the same boarding school. Eli was embarrassed and burdened down. He felt responsible and vulnerable. Most of all, he was concerned that his home had followed him here and he felt threatened that it could invade our private space. Parts of these feelings were expressed in words, parts I could feel between the lines, between the notes. In fact, the front of the idealization of the family was broken. The ceramic tile had cracked. One day, Eli did not find me in the room because of one minute’s delay: his anger imploded. Refusing my apologies, he started rehearsing his dance, but he was blocked after every two steps like a puppet whose strings had been cut. It was a despairing scene. Looking at me like a wet kitten he said, “I’ve forgotten how to dance.” The contact with his own feelings, which my lateness had “triggered,” had brought him close to a feeling of disintegration; the difference resided in the fact that now he could express this threat in therapy. A progress, in therapeutic terms, that had, however, a regressive character: the forgetting of the facade built over so many years of work. He tried and tried again, asking my help in finding the music that would enable him to re-create his dance. I felt that he was asking me to help him to be, even now that he felt his defenses were crumbling. I mirrored the anguish in not finding something so precious, I tried to be with him in his search. I also tried to encourage him in looking for a new dance, suitable for the Eli of the present. I tried to imbue him with my deep trust that he could find it. But we had to face the fact that this was not true. The music for Eli’s dance did not exist. He was not ready. Contact in Absence

Eli did not come for the next session--he was not even in school--nor a week later or the week after that. He refused to come back to school. The explanations I was given by the social worker were connected with a worsening of the situation at home and some negative episodes with his peers at school. The tension was dramatic because the parents, unable to force him to return to school, were also incapable of coping with him, together with the younger brother. Episodes of domestic violence happened day after day. At the same time, a court order calling for his compulsory removal from his home was hanging over his head, a removal which meant the risk for him of being held in a reformatory. But Eli seemed willing to fight the court order, and kept speaking of the school as a prison. I was pained and confused. I felt the void due to his absence and I realized that there was a message here also for me--the changes that Eli had confronted in therapy also threatened his relationship with external reality. His tendency toward self-protection forced him to slow down. If I wanted to give Eli a sign of the existence of our relationship in spite of his absence, and this was the only way I had to help him, I had to go outside of the setting and call him at home: To communicate, giving him a signal of the reality of our relationship, even giving up the transitional object provided by the music. I decided to do it. To telephone him at home gave me, at any rate, an important sound input. I heard the music in his house while I was calling him. I heard the sharp voice of his mother, the dominant television background, a fragment of rude and aggressive conversation. I imagined the unpleasantness on the skin of a “sound envelope” of this kind for a musical soul such as Eli’s. Our conversation did not tell me much. Eli was embarrassed and ill at ease on the phone. I confirmed to him that I was expecting him and that I would keep the hour free for him in the hope that he would come. He came the following week when I, alas, was ill. They told me that for a long time he sat, disconsolate, in front of my closed room. The week after, I called again and this time things were different. “The difficult thing for me,” Eli said, “is not so much facing life in the boarding school, and it is not as though being home is so pleasant, after all. What I can’t manage is to get away from here.” I felt that he was telling me something important about his tie to his mother, the dissolution anxiety that was hidden behind the act of separation. An aquatic image came to my mind and I told him about it: “It’s like being on the point of plunging into cold water, knowing that it will bring relief from the heat, but it gives you an unbearable shiver.” I felt through the telephone receiver Eli’s relief at being understood. Perhaps because the association emanated from my subjective life experience (my body, my hate/love for cold water), I believe that this was a “now moment” as defined by The Process of Change Study Group (Stern et al., 1998, p. 903). A week later Eli returned to the boarding school once and for all. The Return: Daring to Be “Real” in the Relationship Our telephone encounters had had an effect on the atmosphere of our meetings; they had imparted an acknowledgement of their link to reality. They had made our meetings more important and less magical at the same time. “After all, what are you?” Eli said, “You are a psychologist who works with music.” Not only had he uncovered my real identity, but also shreds of his true home were revealed to me. Music, however, remained the backbone of our meetings. First of all, through the improvisations Eli re-established his presence in the room and he let me understand his mood,

his deepest feelings. The “vitality affects” were released by his notes: rhythmic, biting, and obsessive repetitions, outbursts of rage, diminutions, and minorizations that pointed to thoughts of melancholy. the confluence of the two hands telling me of his longing for loving dialogues. And at times words, whispered and rapid, were introduced into the flow. Words: speaking about the inhospitality of the school, its unsuitability to give him the feeling of a real home. Words: speaking about sudden fantasies around death, cutting pictures of the father who raises his invalid’s cane to hit out, and the children who mock him, a grotesque Rigoletto, stealing the cane away from him, in order to threaten him in their turn. At times the vitality affects received a characterization: “What do you feel today in your music?” “I feel anger, sadness, boredom” “Anger towards whom?” “Towards mother, her voice that never stops, that gives me no peace, that follows me everywhere.” And, once again, we would enter the river of notes, to face together the unconfrontable. We reached the sixteenth month of therapy. The anger took the form of percussion. The piano was abandoned for the darbouka and later for the drums. There were two drums in my room: one beautiful and new, and one old and incomplete. He went to play sometimes on the one and sometimes on the other, giving me sometimes an accompanying role, and, at times the role of guiding him or even expressing, in his place, the fullness, the force, the anguish of that anger that he carried within him, also his repressed energy that was confined in the great overcoat of his defenses. On the old drum it was the little Eli, inadequate and too thin, who leaned on someone else to express himself. On the new one was big Eli in the process of becoming a man, who had the strength to face his own feelings. The last month of school came all too soon, after which we would have to part. We both realized that the longed-for release from the “prison” of the boarding school was accompanied by having to leave my musical arms. Eli, at first, denied this. It did not seem possible to him; it was too soon. And then, when he understood, he defended himself in his own way, turning away sotto voce, closing his coat slowly, button after button. He brought me a cassette to listen to together, so as not to have the time to play. He came late and even forgot our next-to-last session, for the first time in two years. For our last meeting he was not in school. Our real goodbye was over the telephone, emotional and almost silent. Diminuendo. Pianissimo. My own act of separation was later, painful, and outside the setting: I met the social worker of his place of residence to stress the urgent need for continuing to provide a therapeutic connection for Eli, possibly with greater frequency than the one provided by the school, and possibly music therapy. I stressed that Eli’s chance to continue to reconstruct his own self lay outside that particular school, together with youngsters whose problems were more similar to his. Eli was born, but he needed holding arms to continue his growth. Afterward, I felt as empty as an empty container, but with the feeling that I had done the right thing. Conclusion and Discussion

A process that had been so involving, and a finale in pianissimo! It would have been more satisfying to have had a beautiful cadence of twenty-four beats of dominant and tonic chords, with some drums and trumpets.... We know full well that the finales in pianissimo are sometimes accompanied by an indication of morendo (dying out), while others, on the other hand, by the moving sensation of something that had touched the soul and the results of which are unknown and laden with future. In asking ourselves into which category the finale of this story belongs, the question arises as to the validity and ethical quality of a therapeutic process that, in a certain sense, has brought the client to regress, relying on a relationship that contained its finite nature within itself. Some could say that having created such closeness, having brought Eli to lowering his defenses, only to abandon him to his fate may have had the opposite of the desired effect, recreating for him the sensation of abandonment and disintegrating loneliness. In order to confront this question I must, first of all, deal with my countertransference sensations connected with the end of the therapy. From the subjective point of view this separation was a real collision with the recognition of the inexistence of omnipotence on my part. In fact, I will go further, with the existence of my impotence. In the negotiations that I had to carry out with myself, I went through moments of pessimism, bordering on a sense of guilt; I then had detailed fantasies of adoption. It is from this point of view that the conclusion at which I arrived must be seen: the need to give up a future for therapy with Eli, which I wanted very badly, and the expulsive push I had given him toward a more all-embracing accompaniment in a less threatening environment. At the same time, if I ask myself the question as to whether I would do again what I had done, my answer is an unequivocal “yes.” First of all, for the simple reason that I could truly not have done anything else: The particular relationship between these two people, he and I, with our particular music, in that particular spatiotemporal context, could only be what it was and none other. And this, not anything else, was the context in which Eli was able to touch and share those dark maelstroms that threatened his integrity as a human being. It is my understanding that this type of relationship experience represents for Eli the indispensable basis for reconnecting with his own strengths and to set in motion blocked or atrophied mechanisms of psychological development. Only by being seen and accepted, and, let us say it, loved, in his entirety, can bring a human being as wounded as Eli had been, to want to live, confronting also his own dark feelings. It is true that experimenting with one’s own continuity of being within a relationship necessarily means exposing oneself to the dangers of suffering its disruptions, but the alternative can only be one of nonbeing, depression, void. A first sign of reconnection with his own strengths can be seen in the gradual way with which Eli was able to turn away from me, without drums or trumpets, and without allowing this umpteenth deprivation to shock him more than his defensive forces could bear. This faith in the person’s intrinsic capacity to develop and cure himself, given proper relational conditions, I also find in the most varied theories. One of Heinz Kohut’s central points in his theory of self states that the essential element in psychoanalytic treatment “is the opening of a path of empathy between self and self object, specifically, the establishment of empathic in-tuneness between self and self object on mature adult levels” (Kohut, 1984, pp. 65-

66). John Bowlby’s theory of attachment, which reexamines the central role of attachment to the mother figure in the formation of the self, reconfirms the importance of providing in therapy a relationship that constitutes a secure base as an indispensable starting point for the restructuring of one’s own representational and relational models (Bowlby, 1988, chapter 8). Then there is the transpersonal approach that stresses the curative value of the unconditional presence (Welwood, 2000). From another direction, the “music child” of Nordoff and Robbins also expresses, in an adequate musical environment, the tendency toward self-actualization through the reactivation of ego-functions, this in spite of the most serious handicaps (Bruscia, 1987, p. 57). To come back to Eli, I am convinced that the process I have just recounted was able to provide this for him--let us call it “good enough environment,” or “empathic response,” or “secure base,” or “unconditional presence”--without which a wounded self cannot be cured, just as our body can close wounds only in the presence of such basic conditions as hygiene and nourishment. For Eli, among other things, one of these basic conditions was represented by the music. I should like to stress that there is an intrinsic importance in the fact that Eli was able to discover the power of music as his personal transitional object, capable not only to unify his internal world, but also to serve as a communication bridge to another human being. His music and ours as well, stays with him, together with the feeling of having been understood. The gist of my thinking is well summarized in these sentences, taken from David Grossman’s “Words into Flesh” (1998): “Nobody had ever spoken to him this way. It is not only what you have written him, but the way you did it. Because this child was the object of attention, he had also received maternal care and tenderness... but only rarely had he experienced this pleasure: being understood. What a relief. The lifting of the armour that reveals within it the knight, still alive” (Letter dated the fifth of August). References Anzieu, D. (1989). The Skin Ego. New Haven and London: Yale University Press. Atwood, E., & Stolorow, R. (1979). “Faces in a Cloud: Intersubjectivity.” In Personality Theory. Northvale, NJ: Jason Aronson. Baker, S., & Baker, N. (1987). “Heinz Kohut’s Self-Psychology: An Overview,” The American Journal of Psychiatry, 144:1. Bowlby, J. (1988). A Secure Base. London: Routledge. Bruscia, K. E. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C. Thomas Publisher. Bruscia, K. E. (1998). The Dynamics of Music Therapy. Gilsum, NH: Barcelona Publishers. Grossman, D. (1998). Shetehi Li Hasakin (Words into Flesh). Tel Aviv: haKibbutz haMeuchad. Kohut, H. (1984). How Does Analysis Cure?. (Edited by A. Goldberg in collaboration with P. Stepansky). Chicago: University of Chicago Press. Stern, D. N. (1985). The Interpersonal World of the Infant: A View from Psycho-Analysis & Developmental Psychology. New York: Basic Books.

Stern, D. N., Sander, L. W., Nahum, J. P., Harrison, A. M., Lyons-Ruth, K., Morgan, A. C., Bruschweiler-Stern, N., & Tronick, E. Z. (The Process of Change Study Group), (1998). “Non Interpretive Mechanisms in Psychoanalytic Therapy,” International Journal of Psychoanalysis, 79:903. Welwood, J. (2000). Towards a Psychology of Awakening. London: Shambhala. Winnicott, D. W. (1956a). “The Antisocial Tendency.” In Through Pediatrics to Psychoanalysis: Collected Papers. New York: Basic Books. Winnicott, D. W. (1956b). “Primary Maternal Preoccupation.” In Through Pediatrics to Psychoanalysis: Collected Papers. New York: Basic Books. Winnicott, D. W. (1960). “The Theory of the Parent-Infant Relationship.” In The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. London: The Hogarth Press and the Institute of Psychoanalysis. Winnicott, D. W. (1971). Playing and Reality. London: Tavistock Publications.

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers.

CASE TEN Exploring Issues of Control through Interactive, Improvised Music Making: Music Therapy Diagnostic Assessment and Short Term Treatment with a Mother and Daughter in a Psychiatric Unit Amelia Oldfield Introduction Olivia was admitted to a child and family psychiatric unit in Cambridge, England, when she was ten years old. As with many of the admissions to this unit, Olivia and her family had complex needs rather than one clear diagnosis. Olivia was displaying difficult behaviors at home, hearing voices, and suspected of having mild Autistic Spectrum Disorder (Richer, 2001). During their eight week admission it became clear that the problems Olivia was experiencing had more to do with relationships within the family than specifically because of an underlying psychiatric condition. In this case study, I will describe Olivia’s initial Music Therapy Diagnostic Assessment (MTDA), her work in the weekly music therapy group with her peers, and the six family music therapy sessions Olivia attended with her mother. Although the MTDA and the group work were separate from the work with her mother, all three interventions informed and influenced one another. This clinical work takes place in a small community-based psychiatric unit funded through the United Kingdom Health Service. It admits children up to twelve years old who have a wide range of psychiatric difficulties. It is unique to the UK in that it admits not only the children, but also their families, on a residential basis. The thinking behind this practice is that children with complex psychiatric profiles need to be assessed and treated within the context of their family in order to best address their needs. Children usually have a combination of difficulties including Autistic Spectrum Disorder, Attention Deficit Disorder, eating disorders, Tourette’s Syndrome, attachment disorders and Post Traumatic Stress Disorders. This clinical work will be contextualised around Interactive Music Therapy (Oldfield 2006a; 2006b), an approach that I developed in working with children with a wide variety of diagnoses. In Interactive Music Therapy (IMT), non-verbal improvised musical interactions are central to the therapy. I focus largely on the enjoyable, playful and motivating force of musicmaking, helping children and parents to gain confidence through these positive experiences. Winnicott’s theories (1960; 1971) of “holding and caring” and being a “good enough mother” are often relevant to the work I am doing both with children and their parents: both of whom frequently require care and mothering. Stern’s writing (1985, 1995) on pre-verbal babbling between mothers and infants also comes to mind as a parallel to the non-verbal musical interactions I have with the children and the families (Oldfield, 2006a).

Foundational Concepts: An Interactive Approach to Music Therapy Music therapy has been an established part of the treatment milieu at this psychiatric unit for over 20 years. I take an interactive approach, using mainly improvised music (Oldfield, 2006a). Children and families are invited to play and make music that I support and take part in. Patterns and types of interactions that occur are reflected upon and analysed, sometimes in the moment, but more frequently after the playing, often using video analysis. (Oldfield & Franke, 2005; Oldfield, 2006b). Interactive music therapy enables families who are struggling to interact verbally to spend time playing instruments together without needing to make specific attempts at communication. Through the improvised playing, supported by the music therapist, tension can be released and parents and children may relax and re-discover how to be playful. The music therapist can then guide the improvisations to enable more specific exchanges to occur between the parents and the child. Issues such as “leadership,” “control” and “listening to one another” often emerge as themes in this stage of work. Every week the children and their families are discussed in a large multi-disciplinary management team meeting. It is here that the role of music therapy becomes clear, and how this role differs from, or overlaps with, the work taking place in other settings. I often find that I have a different impression or view of a family than the rest of the team in these management meetings. Improvised music making brings out skills and difficulties that have not been noted in other settings, making music therapy a valuable addition to other specialist interventions in child and family psychiatry. In addition to providing short term music therapy treatment for children and parents, I contribute to the diagnostic assessment of each child’s difficulties through Music Therapy Diagnostic Assessments (MTDAs) (Oldfield, 2004). Assessments consist of two half-hour individual sessions that occur at the same time on two consecutive weeks. I invite the child to sit down opposite me, having explained that all the children at the psychiatric unit usually have two music sessions with me at the beginning of their admission. The sessions begin with a “Hello” song that I sing to the child, accompanying myself by playing chords on the guitar. The session’s end with a shared percussion duet on the bongo drums where I say or sing “Goodbye” and sometimes discuss what we have done together. In between the “Hello” and the “Goodbye,” I explain that we will take turns to choose what to do together. I can find out a great deal from the ways in which the child chooses instruments and activities. When it is my turn to choose, I can set up situations and make suggestions that I feel will help me to understand and gain insight into the child’s strengths and difficulties. For most children six to nine of the following activities are included in the MTDA: “Hello” song Child plays drum kit and I play the piano or another set of drums Child and I play wind instruments such as a reed horn, melodicas, harmonicas, or Penny whistles (sometimes I will play my clarinet) Improvised stories accompanied by percussion and the piano Child plays the open strings of a violin and I accompany on the piano or the guitar

Child and I play small percussion instruments on the floor together or on chairs opposite one another Child and I share an instrument such as the bass xylophone or the autoharp Kazoo dialogue Piano dialogue Child plays an instrument such as the electric organ and I listen I teach the child a simple tune Rhythmic call-and-response on percussion “Goodbye” on the bongo drums (Oldfield, 2006b) Each of these activities will provide me with different information. For example, in our shared improvised music making, I will be able to assess how spontaneous a child can be, whether they tend to follow or initiate, and whether they get stuck in particular patterns of playing. The song stories may provide insight into a child’s inner world and their particular fears or concerns, while the kazoo exchanges can show me whether a child is able to pick up on different moods and emotions. Based upon further research into the MTDA (Oldfield, 2004, 2006b), I developed a scoring system that allowed me to compare the MTDA to the Autism Diagnostic Observation Schedule (ADOS) (Lord et al., 1989). In each category (autism, attention deficit disorder, emotional difficulties and learning disabilities) a series of questions are asked relating to symptomatic behaviors that might be observed in sessions. Scores for each question are added up and cut-off points for diagnostic categories are indicated. An ongoing weekly music therapy group takes place at the Croft for all the children on the unit (Carter & Oldfield, 2002; Oldfield, 2006b). This group enables the team to evaluate the children’s strengths and difficulties in a non-verbal setting, as well as addressing some of the children’s difficulties in a group setting. In these sessions, children will take part in a number of different musical activities that vary depending on the age of the children, how many children are in the group, and the children’s strengths and difficulties. The group usually starts with a warm-up activity where I invite the children to copy the rhythm I am playing on a tambour. This rhythmic exchange then turns into a greeting song which ends with the words “…..hello to the person….with pink stripes on their socks.” This particular child will then take over the leadership with the tambour, eventually passing it on to another child until all the children, and the staff in the group, have had a turn. Other activities involve group playing, where each of the children joins in on small percussion instruments while I improvise on the piano. My improvisations have several different purposes: to provide a clear rhythmic pulse; to make space for quiet instruments to be heard, and; to give playing an overall structure through instigating clear beginnings and endings. We might also take turns to play a particular instrument, or children may be invited to conduct the group in various ways. The group usually ends with a clapping game or improvised ‘rap’ where we might reflect on what we will all remember about a child who is about to leave the unit. We might also think about what we have done in the group on that particular day. The music therapy work at the Croft often makes it possible for families who struggle to interact to spend a positive time together, or to rediscover how to be playful. Many parents

find it easier to be part of a non-verbal group improvisation with their children than to engage in an activity where they have to communicate verbally (Oldfield, 2006b). The Client Olivia Ten-year-old Olivia was admitted to the Croft as an in-patient with her mother, Kath. The family was struggling with Olivia’s difficult behaviors at home and there was a concern that she might have an Autistic Spectrum Disorder. Kath felt she was sometimes unable to control her daughter’s behaviors. Kath had a history of depression for which she had taken medication on several occasions. Music Therapy Diagnostic Assessment Olivia seemed happy to come to the music room with me, telling me confidently on the way that she knew where the room was as she had been there already the previous evening. She appeared as a confident, grownup ten year old. I explained to her that she would have two music therapy diagnostic sessions with me, at the same time on two consecutive weeks. When I sang the “Hello” song to her, having explained that this was how I started the session, she smiled and then put her thumb in her mouth, emotionally responding as a younger child would when hearing a warm and predictable melody. She reacted in exactly the same way to the “Hello” song in her second MTDA session. After the greeting, I explained that we would take turns choosing instruments and asked her whether she would like to choose first. Olivia seemed to be stuck in her “young” mode. With her thumb still in her mouth she looked at me coyly and mumbled “Amelia choose.” I chose a large standing drum and a cymbal for Olivia, and went to the piano. Olivia immediately started to play loudly in fast regular semi-quavers. I picked up her rhythm on the piano and within seconds we were ‘jamming’ together. She had an excellent sense of rhythm and liked initiating ideas, noticing and delighting in the fact that I would play these back to her. She was also able to pick up rhythmical phrases that I initiated, showing that she could listen and adapt to my playing. Nevertheless, in our improvised exchange, I took care to keep putting her in control as I quickly realised that I lost the sense of connection with her if I expected her to follow me for too long. During this improvisation, Olivia seemed to have regained her initial confidence and was then able to choose the drum-kit for herself and a large conga drum for me to play. Her playing was very energetic and almost manic at times. However, she would occasionally stop her continuous loud playing to experiment with a rhythmic sequence on different drums and cymbals. When I imitated her rhythmic phrase, thereby inviting her to continue this experimentation, she kept going briefly, but then quickly went back to her energetic flurries, drowning out my responses. After about five minutes, I suggested that she might like to find a way to end our shared improvisation, which she was able to do effectively. Next, I chose a large bass xylophone for the two of us to play together, sitting opposite one another with the instrument between us. She immediately started playing in her fast energetic style, but when I suggested that we could have a musical conversation and take it in

turns to play, she was able to do this with ease. After a few exchanges, she started to hit the xylophone so the notes bounced off it, giggling at what she perceived to be mischievous behavior, or “startling” me with sudden loud beats on the wood at either end of the instrument. At one point I played the tune ‘I hear Thunder’ (Frères Jacques). Olivia was keen to learn to play and memorize this melody, focusing on the learning process and persevering when she made mistakes. However, it was noticeable that she always wanted to go back to the beginning when she made a mistake and appeared to want to play it perfectly from the beginning to the end. She seemed to gain a real sense of achievement from the learning of this tune and asked me whether she could play it to the other children on the unit. In the second MTDA the following week, I gave Olivia a large metallophone and a cymbal on a stand and went to the piano myself. After some free playing together, I suggested that we make up a story while continuing to improvise on the instruments. Olivia wanted the story to be about a white horse called Bella. Bella had a friend called ‘Ralph,’ who was dark brown. Together they went to a lake and took a boat. When a crocodile appeared (my suggestion) they kicked it away “as far as it could go.” They then came to a desert island and had a baby called Bambi who was chestnut coloured. Bambi was beautiful and very clever and they lived happily ever after. Throughout the story, Olivia’s playing was lively and loud, and she quickly filled in the dramatic silence I left after the crocodile made his appearance. She did not respond to my dramatic tremolos, but added some glissandos when the horses kicked the crocodile away. Later in this same session, Olivia and I both played kazoos. Olivia quickly entered into humorous vocal exchanges, laughing with delight at the funny noises we were making. She picked up on my sad and angry sounds briefly but quickly redirected me to silly or funny exchanges. Reflections Olivia’s responses during the MTDA did not put her into any of the following categories: autistic spectrum disorder, attention deficit disorder, emotional difficulties or learning disabilities (Oldfield, 2006a). I felt it was easy to have musical dialogues with her and that she was able to listen and respond to my suggestions in addition to initiating her own. She was also able to respond to and pick up on changes of mood and emotion during our improvising. On only one occasion during her entire admission at the unit did Olivia mention hearing voices. This seemed to be in relation to a stressful situation rather than a significant psychiatric symptom. In the multi-disciplinary management meeting that occurred after my second MTDA with Olivia, I reflected on the fact that I seemed to have encountered two very different Olivia’s. One was a “toddler-like” little girl who wanted to be looked after and directed by me; and one was an outgoing, energetic and slightly manic ten year old who liked to be in control and direct me. I wondered whether this need to control me, and her manic energetic playing, was a way of avoiding sad or reflective music, which might have brought up difficult emotions. Although the second Olivia appeared confident in some ways, I felt that in other ways, she lacked self-confidence, was desperate to get things right, and was only satisfied when things were perfect. In the story she created, I felt that she did not want to confront adversity (the

crocodile) and that perhaps she wanted to be a “perfect” baby who was beautiful and clever. In our kazoo exchange she showed she was capable of recognising different emotions, but was much happier remaining with the ‘safe’ ones. While the team had seen glimpses of Olivia’s toddler-like behaviors when observing her with her mother, it was only in the music therapy sessions that Olivia had clearly switched from one extreme to the other, and shown us her need to be in control. This was probably because Olivia was very motivated to play the instruments and engage in music making, and because I was able to assess her need for control through non-verbal musical interactions. We decided to offer Olivia and her mother six joint music therapy sessions, with a view to helping the two of them to have fun together, enabling Olivia to find a middle ground between being a dependent toddler and needing to control her mother. In addition, we felt that these sessions would potentially provide opportunities for Olivia’s mom, Kath, to experience and develop more self-confidence in her abilities to parent. Olivia also continued to attend the weekly music therapy group with the other children attending the Croft. The Therapeutic Process Group Music Therapy In the music therapy group, Olivia was excited and engaged, enjoying playing and interacting through free improvisation. She was constructive and helpful with her younger peers and a very positive influence on the group, clearly wanting to be part of the group music making. She did not display any of the shy and baby-like behaviour she showed in the individual sessions, and if anything appeared a little “high” and overly confident. She enjoyed conducting and playing solos but was also able to wait and listen to others. In the fourth and fifth group sessions, Olivia would occasionally get a little stuck at the beginning of session, quietly making a point of opting out or not quite conforming. This might have been because she was frustrated with younger peers’ slightly disruptive behaviors, and felt that she could not influence or control the group in the way that she wanted. However, as the sessions progressed, her enthusiasm for music making took over and she once again became very engaged in the playing. Although she did not appear to have the same need to be in control of her peers as she did in the sessions with her mother and myself, I did feel that her opting out in sessions four and five was a way of controlling the adults and making sure we gave her special attention. Family Music Therapy with Olivia and Kath Olivia was delighted at the prospect of having music sessions with her mother, Kath. Kath was also happy with the idea and I explained to her that we would make music together and then she and I would have a chance to talk about the sessions after they had taken place. Olivia did not appear to mind that Kath and I would review our sessions without her. Olivia. Although Olivia was willing to come, she became the “toddler-like” Olivia when I went to collect them both, talking in a young voice and putting her thumb in her mouth. Once in the music room, she was initially very shy, sat very close to her mother, and put her arm

through her mother’s arm. Olivia did not answer when I asked her whether she would like to choose instruments for us to play, so I went to get some large drums and a cymbal, which I placed in front of her. I offered Kath two beaters and put two on the drum in front of Olivia. I then went to the piano and started playing a rhythmic 12-bar blues. Kath immediately joined in following my beat, clearly enjoying playing. Olivia picked up both beaters in one hand (the thumb of her other hand was still in her mouth) and played briefly without enthusiasm. Suddenly, after her mother and I had been enjoying improvising together for several minutes, Olivia played very loudly, startling her mother, who laughed and looked at me to see what I would do. I immediately incorporated some loud and sudden chords into my playing and the three of us became louder and faster together. Olivia’s second hand came out of her mouth and she once again became the more confident and engaged ten-year-old whom I had seen in previous sessions. This pattern remained similar throughout the six sessions. However, as the sessions progressed, Olivia’s young behaviors became less obvious and pronounced. As Olivia and Kath both became involved in improvised music making, Olivia would always become more and more spontaneous and engaged in her playing, shedding her coyness the more involved she became. Once Olivia joined in with our playing, she had clear ideas about how she wanted to play, often repeating short phrases and requesting that we stop playing together so she could perform her creations for her mother and me to listen to. She seemed to gain a sense of achievement from these performances and I felt they were a way of boosting her self esteem. I also felt that she was showing us that she liked being in control and organizing us. The big sudden beat she had played in our first session was perhaps a sign that she was bored, wanted our attention, and wanted the playing to be on her terms rather than the two adults playing together without her. In the third session, I pointed out to Olivia that she seemed to enjoy leading and being in control. Olivia immediately looked cross and sulky and put her thumb in her mouth. She did not seem to want to be seen to be in control and I wondered whether in the past she’d had to be in control at home when her mother had been depressed. It occurred to me that reverting to toddler behavior was a way of being dependent on adults, a safer position than being responsible for her mother. In the fourth session Olivia chose to make up a song story in the same way she and I had done in the earlier Music Therapy Diagnostic Assessment. In this story, Olivia chose Chris (the name of her older brother) as the main character, as well as his mate Trevor. In the story, they defied authority and attacked the police. Olivia was clearly excited by this idea, as well as indicating that she felt this was what one might expect from 13-year-old boys. During the story, Kath tried to make the two boys come home and protested that they didn’t attack the police. However, Olivia was adamant that her version was the one we should use. When we improvised around Olivia’s suggestions, Kath was evidently ill at ease, making placating comments to me such as “he’s not really like that…” It was clear that during the story, Olivia was aware of and possibly mischievously enjoying the fact that her mother was embarrassed by this account. In this story, Olivia was bringing up a sensitive family topic relating to events in which her mother had lost control. Interestingly, she did not allow her mother to modify her version of the story. Perhaps it was safer for Olivia to take control as the adults clearly weren’t always in control of her brother.

In spite of this moment when Olivia enjoyed embarrassing her mother in a slightly adolescent way, Olivia was at ease playing with her mother and was thoughtful and caring toward her. In contrast, Olivia was quite sensitive to even mild criticism or constructive suggestions. However, she could easily be diverted from these upsets through humorous, playful interactions, or engaging in rhythmic patterns. In the last two sessions, I introduced several conducting activities where we alternated between following Olivia and Kath. Although Olivia clearly much preferred leading herself, she was also able to enjoy following her mother and was more able than previously to acknowledge that this was something she sometimes found difficult. Although the focus was on the musical interchange, both Olivia and Kath were aware that we were experimenting with issues of control, and we reflected on parallel situations at home where either Olivia or Kath were in charge. Kath. Overall, Kath enjoyed playing the instruments and had no difficulty being playful with Olivia through our musical improvisations. She was a little diffident at first, saying that she had failed grade one cornet as a child and that the rest of her family was more musical than she was. However, this did not stop her enjoying playing freely in the sessions. In the second session she was able to say that she really wanted to play the piano, on which she then enjoyed experimenting. In the first two sessions, Kath was sometimes a little stuck in trying to tell Olivia how to play instruments “properly.” When we discussed the session together, she agreed that it would be more useful to explore creative non-verbal exchanges rather than give Olivia instructions. When reviewing the first two sessions with me, Kath was generally very positive, saying that she felt the sessions provided Olivia with an opportunity to “let off steam” and express her frustrations. When Olivia chose to play very loudly and forcefully, Kath was able to support her and allow her to do this, even when she clearly would have preferred quieter playing. She was happy to accept my guidance to ignore Olivia’s attention seeking through taking on baby-like behaviors or becoming excessively shy and coy. After our first two sessions, I suggested to Olivia and Kath that it might be helpful to video the sessions so that we could look back at them and reflect upon what we had been doing. They both agreed to this. Olivia enjoyed watching the beginnings of a couple of sessions but quickly became bored and rejoined her peers, leaving Kath and I to spend more time looking at the sessions together. Video Review. When I commented that it appeared that Kath really enjoyed music making, she again mentioned how she was not as musical as the rest of her family. I suggested that the important thing was that she was able to be spontaneous and enjoy playing, something that Olivia had clearly picked up from her. Kath was really pleased that something she was doing was having a beneficial effect on her daughter, and this seemed to give her the confidence to allow Olivia to play freely rather than feel she had to instruct her or tell her what to do. We also talked about how Kath felt she needed to tell Olivia how to play because she was different from other children. This led to a conversation about Olivia’s psychiatric symptoms and what might be wrong with her. I suggested that I could not see any obvious

symptoms in the videos, and I asked Kath whether she had noticed anything she would like to point out to me. Kath agreed that Olivia was engaged and spontaneous in these sessions. As she felt stronger in herself, she seemed more able to see and recognise the healthy aspects of her daughter’s behaviors. We looked at Olivia’s toddler-like behaviors, and Kath said she felt that Olivia was attention seeking. On reflection, she also said that it had been easier looking after Olivia when she was little, as she had felt more confident then than now. She was able to consider whether sometimes she enjoyed treating Olivia as a younger child for this reason. I suggested that we used the spontaneous musical interactions to be equal, each taking “leading” and “following” roles, removing Olivia from situations where she was either a dependent “toddler,” or omnipotent and in control. When reviewing the fourth session, wherein Olivia had told the story about her “deviant brother,” Kath again hastened to reassure me that her son was not “like that.” I suggested to Kath that I saw it as a healthy sign that Olivia now felt safe enough with her mother that she was able to tease her in this way, obviously saying things she knew her mother would react to and be embarrassed by. I pointed out that this was normal pre-adolescent behavior, and that perhaps Olivia shared her mother’s sense of humor. In watching the videos, Kath enjoyed seeing Olivia’s creative way of conducting us in the fifth and sixth sessions. She was able to see Olivia’s leadership skills as a strength rather than being overwhelming, while at other times also realizing that Olivia needed to be able to accept direction from her. Summary In this case study, I have shown that the Music Therapy Diagnostic Assessment helped the psychiatric team to highlight Olivia’s strengths and difficulties and exclude a diagnosis of Autistic Spectrum Disorder. The six music therapy sessions with Olivia and her mother, as well as the group music therapy sessions with her peers, helped us to understand Olivia’s need for control. Kath became more confident in her ability to mother Olivia, acknowledging that her mood could affect Olivia. She also noted that her own ability to be playful had had a positive effect on her daughter. She recognized that different styles of parenting were appropriate for children of different ages and that some aspects of Olivia’s need to be in control could be seen as normal pre-adolescent behavior. With the team’s support, she was able to accept that we were not giving Olivia a psychiatric diagnosis, without feeling that this meant that she was to blame for Olivia’s difficulties. References Carter, C. & Oldfield, A. (2002). A music therapy group to assist clinical diagnoses in child and family psychiatry. In A. Davies and E. Richards (Eds.) Group Work in Music Therapy (pp. 149-163). Jessica Kingsley Publications.

Lord, C., Rutter, M., Goode, S., Heemsberger, J., Jordan, H., Manwood, L. & Schopler, E. (1989). Autistic diagnostic observation schedule: A standardised observation of communicative and social behaviour. Journal of Autism and Developmental Disorders, 19(2), 185-212. Oldfield, A. (2004). Music therapy with children on the autistic spectrum: Approaches derived from clinical practice and research. Unpublished Doctoral Thesis, Anglia Ruskin University. Oldfield, A. (2006a). Interactive Music Therapy: A Positive Approach. Music therapy at a Child Development Centre. London: Jessica Kingsley Publishers Oldfield, A. (2006b). Interactive Music Therapy in Child and Family Psychiatry: Clinical Practice, Research and Teaching. London: Jessica Kingsley Publishers. Oldfield, A. & Franke C. (2005). Improvised songs and stories in Music Therapy Diagnostic Assessments at a Unit for Child and Family Psychiatry: A music therapist’s and a psychotherapist’s perspective/ In T. Wigram and F. Baker (Eds.) Songwriting: Methods, Techniques and Clinical Applications for Music Therapy Clinicians, Educators and Students (pp. 24-44). London: Jessica Kingsley Publishers. Richer, J. (2001). The insufficient integration of self and other in autism: Evolutionary and developmental perspectives. In J. Richer and S. Coates (Eds.), Autism: The Search for Coherence. London: Jessica Kingsley Publishers. Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic Books. Stern, D. (1995) The Motherhood Constellation: A Unified View of Parent–Infant Psychotherapy. New York: Basic Books. Winnicott, D. (1960) Playing and Reality. UK: Pelican Publications. Winnicott, D. (1971) Holding and Interpretation. New York: Grove Press.

Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case Study Perspectives. Gilsum NH: Barcelona Publishers.

CASE ELEVEN Just Don’t Do It: A Group’s Micro Journey into Music and Life1 Mercédès Pavlicevic Introduction This chapter focuses on some three minutes of a musical journey that happened in group music therapy, contextualized within the session as a whole. This three-minute focus is due to the richness and complexity of this particular aspect of this group’s music therapy work. This focus is further informed by two threads, the first being that Nordoff-Robbins clinicians are trained to index their work, necessitating a focused and detailed listening to the musical recording of sessions. This level of detail, in turn, often informs their therapeutic thinking (Nordoff & Robbins, 1977). The second thread links to recent discussions on music research that consider the importance of finding the “right level” of generality to maximize meaning while being prepared to engage in detailed observation and analysis (DeNora, 2003). Like reflexive researchers, reflective music therapy practitioners need to decide how much (or how little) detail suffices for their endeavours. This is a different stance from “doing detail” for its own sake. Thus, in this chapter, the decision to limit the case study to three minutes is a decision based upon the therapeutic significance of the segment. The three minutes described here happened in South Africa, in a place called Eersterust, east of the capital city of Pretoria. Eersterust is a (so-called) “coloured” urban area, so designated in the apartheid government’s “separate development” policies. It remains today an area of lower socioeconomic status than the better resourced metropolis that is Pretoria, some twenty minutes car journey away. Eersterust is characterized by high unemployment and associated problems recognizable in any part of the world: high substance abuse, crime, and a dearth of socially engaged and responsible male role models (Springveldt, 2008). The music therapy work happened in a community based organization called YDO (Youth Development Outreach), founded in order to keep Eersterust’s young people off streets, and committed to providing skills training and social programs to young offenders. Its clientele are young people in conflict with the law, and they are referred to YDO by the juvenile courts. Carol Lotter, who developed the YDO Program, serves as music therapist in this session. The three minutes frame the journey of a song, entitled “Just Don’t Do It,” from its embryonic stage to its completion. At the end of three minutes, the song is ‘performed’ by the group, as an entity. This narrative concentrates on the musical-social micro-events that enabled this rapid and skillful transition, and describes the micro-phases of this event, focusing on the swift creating, exchanging and sharing of skills, meaning, and music (Davidson & Good, 2002; Wosch & Wigram, 2007).

Foundational Concepts The music therapy programme at YDO is informed by a Community Music Therapy stance (Pavlicevic & Ansdell, 2004), which endeavours to be responsive and appropriate to “time, place and persons,” as well as engaging with (and indeed becoming a part of) sociocultural and political contexts of the site of work. In practice, the music therapist engages with YDO’s ethos and core values, as well as with its other music practices, familiarizing herself with current adolescent music genres, and music being played on the streets. This “streetwork” can be understood as the music therapist’s acknowledgement of popular music’s powerful social imperatives on the life of young people (Martin, 2006; Miell, MacDonald, & Hargreaves, 2005). In keeping with Community Music Therapy’s extended spectrum of work (Pavlicevic & Ansdell, 2004), Carol’s practice includes “private and confidential” work with individual clients and small groups, open-ended group work, where clients come and go from week to week, and public music performances for larger groups. Carol runs guitar classes and teaches skills such as songwriting and performance. In addition, Carol provides other music sessions from week to week, depending on what is happening within and around YDO. Much of the time, these music practices run in tandem with one another, with clients moving between various formats on offer. YDO mentors (i.e., staff members) at times participate in music sessions alongside their charges, and Carol also works with visiting musicians and community musicians. The music therapist engages with the entire organization and its needs, running open workshops for all members of the organization when the need arises. This can be understood as developing an organizational socio-musical identity; where relationships can be based on shared musicing rather than only on the basis of YDO or Eersterust hierarchy and status. The Community Music Therapy work is informed by Nordoff-Robbins’ music-centered stance (Aigen, 2006; Ansdell, 2004; Nordoff & Robbins, 1977). Here, musical action per se is understood to be the therapeutic locus, based on an understanding that co-improvisation in music therapy engages and repairs our neuro-psycho-biological capacities for human communication, as well as our cultural musicing experience (Pavlicevic, 2000; Pavlicevic & Ansdell, 2008; Stige, 2002; Trevarthen & Malloch, 2000). Not only does co-musicing in music therapy enable participants to regulate themselves in relation to others, but this very act enables a reframing of social identity: from youth at risk to youth in music. In the words of music psychologist Ian Cross (2003), it is music’s “floating ambiguity” (p. 27) that is advantageous in enabling what we might call a “floating identity” to be explored, improvised, and stabilized. Group music’s demands for precise shared coordination, both as individuals and as a collective, enables participants to enact and experience an investment in “present time.” This experience, according to Daniel Stern, has powerful implications for social bonding (Stern, 2004). This shared experience leads naturally to another ethos underpinning this work: that of “social and interactive” health. In contrast to a western medicine and psychology’s understanding of illness or health as situated within the delineated, individual self (with corresponding treatment and “cure”) (Billington, Hockey & Strawbridge, 1998), health and empowerment are enacted between persons, and situated in social contexts (Rolvsjord, 2004). The UN’s Millenium Report makes a compelling case for linking diseases to poverty, malnutrition, and geographical characteristics (Annan, 2000). This suggests that health, or the

lack of it, are at the very least, contextual. The experiences of health include being able to participate in society; having a sense of belonging in, and with, one’s social world; experiencing neighborliness, usefulness, social reciprocity, and support (Blaxter, 2004). In this sense, collective personal marginalization and a sense of “uselessness” (Sennett, 2006), are often refractions of socially disabling environments. At Eersterust, where the environment might be considered disabling, one of music therapy’s tasks is to enact health-giving social experiences through musicing, embedded in YDO’s ethos and values. Music therapy at YDO can be characterized as “social health musicing” (Stige, 2003) geared towards creating social bonds, enabling persons to participate in their social worlds. As such, they experience a sense of belonging, and “rehearse” skills that are socially useful. This stands in contrast to the kind of social recognition and status that come from being “good” at crime and brinkmanship. The Clients The clients portrayed in this chapter are four young men from Eersterust who participated in YDO’s Adolescent Development Program. Little else is known about them, in keeping with the social rehabilitation and empowerment ethos for YDO programs. This ethos also fits with the music therapist’s stance of engaging YDO’s clientele as well-resourced musicians, with a potential to participate in communal musicing, rather than engaging with them as “youth at risk” who need therapy. The case study happened as part of open group work. Two of the clients (Jabu and William) attended music therapy the previous week, while the other two (Benji and Michael) were new to the group. Consistent with Community Music Therapy philosophy, no formal music therapy assessment took place before the group. Instead, the music therapist contributed to, and participated in, discussions of group members and significant events within the community that might emerge as themes in sessions. Therapeutic Process The Session Unfolds This element of the session centers on the “rehearsal” and “performance” of a song, written by Jabu. In the previous week, Jabu and Carol spoke of ways to convey a message to young people in Eersterust about crime and how it ruins your life. Jabu has first-hand experience of this, and was keen that others (especially those younger than him) be alerted to the dangers of crime. Carol suggested he write a song and bring it in the following week for the group to work on together. This was when this excerpt was recorded. Jabu used newspaper headlines to put together a text, and with Carol’s help, subverted Nike’s “Just do it” into “Just don’t do it” as the song’s refrain. The words are: Please guys, drugs and crime are no solution to any problem in life Instead they lead one to end up in jail or dead ……………..Just don’t do it……………… Today’s youth have no future / Due to dangerous substances / It leads them to steal and commit a lot of crime

……………Just don’t do it ……………….. Parents, teachers, the police and the community / Must stand together to fight evil deeds ……………Just don’t do it ……………….. The words are in the form of a plea, addressing various social groups within Eersterust. Verse One warns young folk that crime doesn’t pay, while in the third verse, directly addressing elders in the community (parents, teachers, police) implies their failure to prevent evil deeds and protect their young people. The second verse is a more general narrative--possibly addressing the song’s audience, recounting the poorly resourced environment in which the future for young people is bleak. During the delineated session time, the five participants (four young men and Carol) transform the words on the page into a heartfelt, quasi rapped performance. This happens swiftly--so swiftly that had the excerpts not been subjected to micro-analysis, it would have been difficult to account for how a written text became “performed” from scratch in under three minutes. The three-minute segment was further segmented by Carol and me using straightforward criteria: “when something changed” or “when something happened.” These subjective, perceptual-temporal delineations remained stable throughout repeated viewings. The segments were indexed using Nordoff-Robbins’ (1977) descriptive listening techniques over a real time base, where each segment was subjected to thick description and temporal microanalysis. The latter focused on body movement, communicative and expressive gesture, and the musical utterances. In addition, Carol and I studied the segments together, discussing their content and possible meanings. The following section presents a summary of each segment, with a heading to characterize it. Unfolding Segments Four young men, William, Benji, Jabu and Michael, aged 17-19 years, are on chairs drawn into a semi-circle, together with Carol. All look at writing on a large flipchart sheet on the floor: the text of ‘Just Don’t Do It.’ Another scribbled version of the text is on a flipchart stand next to the group, behind William. Behind Carol is a piano, with the lid closed. She sits with her back to the piano. Segment 1--Gathering, Preparing, Attuning (9 seconds). Jabu talks to the group (which includes Carol), and conducts three beats (he says 1, 2, 3!). On his fourth beat, all begin reciting the song’s words while Jabu continues conducting. The group’s movements and voices are out of alignment at first, but soon begin coordinating and aligning with one another. There is a gradual build-up of momentum as the recitation progresses. Shortly after, however, the recitation begins to lose momentum and energy. Segment 2--Suggesting, Directing, Modifying (11 seconds). Carol suggests that the group takes the song from the beginning, and asks whether William (who’s holding a drum) would like to play it. Someone says, “No, you play the piano.” Jabu nods in agreement, looking at Carol. She asks in a surprised voice, “Me?” The group responds with “Yes!” She turns to the piano behind her with a swift decisive movement and opens the piano lid. She now has her

back to the semi-circle. She plays repeated accented chords in E minor, following the earlier tempo of the group recitation, entering seamlessly into the beat and tempo as well as dynamic level of the recitation (while watching the segments together, Carol told me she had no idea what to play at that moment). We noted that her role had shifted from suggesting (let’s take it from the beginning) to being guided by the group to play the piano. The group again starts reciting the words together, re-pitching their voices in relation to the piano’s E minor chords. At the second repeat of the refrain (Just Don’t Do It), the singing loses tightness and alignment. Segment 3--Checking Direction (21 seconds). Carol continues to play through the group’s loss of momentum, and attempts to re-energize the group by slightly tightening the tempo and emphasizing the accents. During this ‘bridge” passage, Jabu looks down at the sheet on the floor while still sustaining clapping/upper body movement. He seems to have withdrawn his gaze from the rest of the group. Benji follows Jabu’s gaze and also looks at the words on the floor, while William points at the flipchart stand while looking at Jabu (as though asking which words they should follow). Benji and Michael also look up and around to the flipchart. Jabu looks up from the floor to the flipchart in response to William, shakes his head as a “no,” then returns to looking intently at the words on the floor. Musically, there are various possibilities as to where the next verse can begin. Carol continues to play repeated chords. There is some indecision as to where to start, while all continue clapping and tapping their feet with the piano. Segment 4--Checking and Acknowledging Roles (9 seconds). Carol looks round at Jabu, and he returns her gaze. They watch one another intently, while her playing slightly eases in intensity to a slower rock. Carol seems to be waiting for Jabu’s cues as to how to proceed. Jabu listens to Carol’s playing and seems to tacitly encourage her to continue. The rest of the group listen and watch both Jabu and Carol. In this brief segment, there is a sense of high attentiveness between all group members. Segment 5--Checking Roles (8 seconds). With split-second accuracy and seamless alignment of intensity, Jabu cues in the group to begin at the very moment that Carol forcefully says “Let’s go!” accompanied by stronger piano playing. The young men begin nodding, clapping, tapping their feet and moving their bodies, with Carol providing a harmonic pulsed ground. The energy of the music has picked up, and this is reflected in the young men’s body movements and clapping. Michael points to the sheet as though asking Jabu, “Is it my turn?” Segment 6--Directing, Supporting and Rehearsing (85 seconds). Jabu nods emphatically to Michael and the group falls into collectively practicing the words, seamlessly entering the piano’s pulsed harmonic stream. The recitation begins to sound like singing. The song gathers momentum and intensity, supported by the piano, and Jabu signals to William to move closer into the group. In response, he draws his chair in. The circle is closed; the space between the participants is tighter and closed, refracting the tightening of the music’s pulse and phrasing. Segment 7--Towards Spontaneous Performance and Elaboration (28 seconds). The group now shifts into a different musical gear. The song is “performed” with no more interruptions or hesitation. As one unified organism, they clap, tap their feet and move their

bodies, while Jabu seamlessly signals as to who recites each verse. During the refrain, the group shifts from recitation to singing, and as the song progresses towards the end, Jabu ceases to direct or conduct. At the last reciting of the verse, Jabu spontaneously exclaims, “Please GUYS! Just don’t do it!” On the last chord Carol spins round and exclaims excitedly, “NICE!” The momentum from this session led the group members to explore the possibility of performing the song in public, using it as a way of educating their peers about the dangers of drugs. With Carol they discuss the possibility of recording the song onto a CD and sending it to a local radio station. Soon after this discussion, a spontaneous semi-public performance of “Just Don’t Do It” happened at YDO. A visiting jazz musician provided keyboard backing, and one of the YDO mentors took the role of compère/MC. Jabu, microphone in hand, performed the song powerfully while the small attentive audience sang the refrain. At the end of the song, the mentor saluted Jabu to the “audience.” The event had all the ingredients of a popular music happening. Reflections on the Session Experience This musical journey conveys the transformative power of “collaborative musicing” (Pavlicevic & Ansdell, 2008). In this brief group musicing event, people’s experiences of making music together can be seen to be as much social as musical. All participants closely monitor one another’s participation as social-musical beings, attending to fluid roles of leading, suggesting, prompting, following, reciprocating, supporting and simply finding the best and most enjoyable way of being part of this event. During this musical journey, the song’s cultural-musical imperatives invite all participants to engage in a particular way of being together. Although “Just Don’t Do It” was created “in vivo,” it draws from local musical genres familiar (more or less) to the five participants. These genre-specific characteristics place a powerful (and, one could suggest) non-negotiable attitude and commitment on the five. For the song to do its social-musical transformative work, everyone needs to collaborate. Here are five persons who find themselves in the same physical space-time, but share little in terms of language (with the exception of Carol, English is a second language), background (from Eersterust, Mamelodi and Pretoria) and social status. Despite all these differences, what they do share is a willingness to make this song work. How does this happen? And what does the music therapist have to do with this? Is her presence necessary? Indeed, watching the session video, it would appear that Jabu could have managed this event as the musical director. The music therapist appears to play second fiddle. Close study of this and other excerpts reveal that it is not so much what the music therapist “does” that matters, but her stance. Her stance is anchored in an unshakeable belief in musicing’s transformative powers; a belief anchored in her direct experiencing of music therapy over the years. The music therapist’s skill, I propose, does not come from “book knowledge:“ It is grown through her stance, grown from the ongoing experiencing and honing of the subtle skills needed for the crafting and evoking of trans-formative musicing. Her stance, then, is one of acute alertness and still listening, constantly attentive to what needs to happen: when, and how. She navigates with a light touch, appearing to do very little. However, when she “acts,” it is with musical decisiveness and impeccable timing. Her skill is in creating an optimally alive,

liminal musicing experience. This is about creating the best possible musical product (a song that grooves, swings, and rocks), the best social product (that conveys clearly and powerfully that crime doesn’t pay) and the best possible collaborative musicing. The “magic” of this liminal experience transforms the experiencing of “life;” crystallising in each participant an optimal quality of bonding, collaborating and enjoyment. In this time-space, rather than folk with identities of “young folk in conflict with the law,” “middle aged woman,” “music therapist,” or “gang members,” a shared identity as musicians is enacted. Such musicians choreograph a social space with elegance, nuance, and skill; knowing when to lead, who needs to lead, how to listen, to respond, to contradict, to ensure that music does its work. Their skills resemble those of skilled amateur and professional musical groups rehearsing, improvising, and performing (Davidson & Good, 2002; Sawyer, 2005). Summary This three-minute music therapy journey reveals rich and complex aspects of music therapy work. These include the music therapist’s expertise in being acutely still and engaged so as to invite expertise from all; all participants’ social elegance enables this collaborative experience; and the music therapist’s stance, which is to do as little as necessary to ensure that all do as much as possible. Close analysis of the brief musical journey of “Just Don’t Do It” reveals the micro patterns and networks of optimal collaborative musicing: Ways of being together that are charged with musicing’s transformative power; transformative power that may propel the song onto a journey culminating in a radio station broadcast. References Aigen, K. (2006). Music Centered Music Therapy. Gilsum, NH: Barcelona Publishers. Annan, K. A. (2000) We the Peoples. United Nations Millennium Report. Retrieved from http://www.un.org/millennium/sg/report/summ.htm Ansdell, G. (2004). Rethinking music and community: Theoretical perspectives in support of community music therapy. In M. Pavlicevic & G. Ansdell (Eds.), Community Music Therapy (pp. 65-90). London: Jessica Kingsley Publishers. Billington, R., Hockey, J. & Strawbridge, S. (1998). Exploring Self and Society. Houndmills: Palgrave. Blaxter, M. (2004). Health. Cambridge: Polity Press. Cross, I. (2003). Music and Biocultural Evolution. In M. Clayton, T. Herbert and R. Middleton (Eds.), The Cultural Study of Music - A Critical Introduction (pp. 19-30). New York and London: Routledge. Davidson, J. & Good, J. (2002). Social and musical co-ordination between members of a sting quartet: An exploratory study. Psychology of Music, 30, 186-201. DeNora, T. (2003). After Adorno. Rethinking Music Sociology. Cambridge: Cambridge University Press. Martin, P. J. (2006). Music and the Sociological Gaze. Art Worlds and Cultural Production. Manchester: Manchester University Press.

Miell, D., MacDonald, R. & Hargreaves, D. (2005). Musical Communication. Oxford: Oxford University Press. Nordoff, P. & Robbins, C. (1977). Creative Music Therapy. New York: John Day. Pavlicevic, M. (2000). Improvisation in music therapy: Human communication in sound. Journal of Music Therapy 37(4), 269-285. Pavlicevic, M. & Ansdell, G. (2008). Collaborative musicing. In S. Malloch & C. Trevarthen (Eds.), Communicative Musicality. Oxford: Oxford University Press. Pavlicevic, M. & Ansdell, G. (2004). Community Music Therapy. London: Jessica Kingsley Publishers. Rolvsjord, R. (2004). Therapy as empowerment: Clinical and political implications of empowerment philosophy in mental health practices of music therapy. Nordic Journal of Music Therapy, 13(2), 99-111. Sawyer, R. K. (2005). Music and conversation. In D. Miell, R. MacDonald, & D. Hargreaves (Eds.), Musical Communication (pp. 45-60). Oxford: University Press. Sennett, R. (2006). The Culture of the New Capitalism. New Haven & London: Yale University Press. Springveldt, I. C. (2008). The relationship between local government and welfare organisations in Eersterust. (Unpublished Master’s Thesis) Pretoria: University of South Africa. Stern, D. (2004). The Present Moment in Psychotherapy and Everyday Life. New York: Norton. Stige, B. (2002). Culture-Centered Music Therapy. Gilsum, NH: Barcelona Publishers. Stige, B. (2003). Elaborations Towards a Notion of Community Music Therapy. (Doctoral Dissertation) University of Oslo, Norway. Published by Unipub. Trevarthen, C. & Malloch, S. N. (2000). The dance of wellbeing: Defining the musical therapeutic effect. Nordic Journal of Music Therapy, 9, 3-17. Wosch, T. & Wigram, T. (2007). Microanalysis in Music Therapy. London: Jessica Kingsley Publishers. ____________________________________ 1 I am grateful to Carol Lotter for permission to draw from her work, for the purposes of this chapter.

Taken from: Hadley, S. (Ed.) (2003). Psychodynamic Music Therapy: Case Studies. Gilsum NH: Barcelona Publishers.

CASE TWELVE Being Beverley: Music Therapy with a Troubled Eight-Year-Old Girl Helen M. Tyler Abstract This case study follows the music therapy process of Beverley, an eight-year-old girl diagnosed with moderate learning difficulties. She had been referred to music therapy because of her aggressive and disturbed behavior at school which was preventing her from learning and fulfilling her potential. The weekly music therapy session became a place where Beverley could explore her feelings in a safe, nonjudgmental environment through fantasy play and musical improvisation. Understanding Beverley’s outward play as a representation of her inner world enabled the therapist to survive her potentially overwhelming attacks and to find the real child behind the “acting out” behavior. This in turn helped Beverley develop some insight into her difficulties and enabled her to lead a more fulfilled life, emotionally, socially, and intellectually. Introduction It is a well-established fact that children’s development and learning are affected by pressures such as family conflict, financial strains, illness, or the loss of a parent through separation, divorce, death, or imprisonment. In the final pages of “Good Wives,” written in the 1860s, Louisa M. Alcott’s character, Jo March, expresses her dream of opening a school in the large family home, Plumfield, for “poor little forlorn lads who hadn’t any mothers.” When challenged by her family that a school for poor children would not be profitable, she replies: Rich people’s children often need care and comfort, as well as poor. I’ve seen unfortunate little creatures left to servants, or backward ones pushed forward, when it’s real cruelty. Some are naughty through mismanagement or neglect, and some lose their mothers. Besides, the best have to get through the hobbledehoy age, and that’s the very time they need most kindness and patience (Alcott, 1994, p. 338). The issues which Alcott tackles through the pupils of Plumfield are astonishingly wideranging, including overeating, running away, bullying, theft, fighting, murder, and imprisonment, but each episode comes back to the overriding need for a child to have someone reliable to “feed, nurse, pet, and scold them” (1994, p. 337). Today, we might translate this in terms of the need for emotional and physical nurturing, unconditional acceptance, containment, and boundaries. Dickens, too, expressed his concern for society’s neglected children through literature, in the stories of Oliver Twist, Nicholas Nickleby, and David Copperfield. The Victorian philanthropist, Thomas Barnardo, put all his missionary zeal into the

rescue, care, and education of destitute children through the founding of his “Dr. Barnardo’s Homes.” Although moral and spiritual teaching was a priority, Barnardo’s vision went beyond this: Little cottages should arise; each of them presided over by its own “Mother”.... The girls should be of all ages, from the baby of a few months or weeks to the growing girls, some of whom would be nearly out of their teens. There, family life and family love might be reproduced and gentle modest ways would be made possible... under the influences of godly women (Wagner, 1979, p.80). There are echoes of Alcott and Barnardo in Docker-Drysdale’s account of the setting up of the Mulberry Bush School for emotionally disturbed children in 1948. She writes: Therapy in child care is concerned with the content of the total life situation in the place, including waking and sleeping, eating and drinking, working and playing, and so on (Docker-Drysdale, 1993, p. 57). In the same post-war period Axline was drawing up her principles of nondirective play therapy to address the emotional needs of difficult children and so free their minds to work and develop to their full potential. A teacher whose mind is beset with anxieties, fears and frustrations cannot do a satisfactory teaching job. A child whose emotional life is in conflict and turmoil is not a satisfactory pupil (Axline, 1989, p. 133). The link between emotional difficulties and learning was also acknowledged by Nordoff and Robbins, who recognized that music therapy addressed more than simply musical needs. In a rationale for their pioneering work in the special education department of Philadelphia they wrote: It is the music therapists’ role to supplement the educational and classroom activities of the teacher with a programme aimed at providing special experiences that have central psychological significance for the children, and which can be therapeutic for their whole development. The strengthening of ego-function, the liberation from emotional restrictions and the alleviation of behavioural problems all make for happier, more fulfilled children who can participate more fully in their school life and derive greater benefit from it (Nordoff & Robbins, 1992, p. 139). Winnicott, in his dual role of pediatrician and psychoanalyst, saw the child as part of its family and society. His case studies of work with children reveal his concern for the child within the context of home, family, and the wider world while his theory of play expresses many of the principles that he drew from his analytic work with both children and adults. It is play that is the universal and that belongs to health: playing facilitates growth and therefore health; playing leads into group relationships; playing can be a

form of communication in psychotherapy; and, lastly, psycho-analysis has been developed as a highly specialised form of playing in the service of communication with oneself and others (Winnicott, 1999, p. 41). Like psychoanalysis, the music therapy session provides a place for a child to play, in every sense of the word, and a safe, accepting environment in which to explore “communication with oneself and others.” The framework of the therapy gives the security and consistency of time and place, while the shared language of musical improvisation offers a medium for expressing unsounded feelings and thoughts. In this chapter I hope to show how the “highly specialised form of playing” which takes place in the music therapy room can make a significant difference even to children like Beverley, facing the most intractable of life situations. Background Information Beverley was referred to the Nordoff-Robbins Music Therapy Centre in London by her school--an inner-city primary school for children with moderate learning difficulties and behavioral problems. The school was in an area of social deprivation with poor housing and a high crime rate. All the background information that I had about her came from her class teacher, Peter. I did not ever meet Beverley’s mother, but Peter visited her to explain about the music therapy program and to obtain consent for Beverley to attend. This was necessary as her mother also had learning difficulties and could not complete the usual consent form without help. As a child, she too had been a pupil at the school Beverley now attended, but was described by Peter as being “not as bright” as her daughter. Beverley’s father did not live with the family, and at the time of the therapy was, in fact, in prison. There were two other children in the family and the mother had recently had two pregnancies, which ended in miscarriages. Home life was said to be chaotic, with various boyfriends coming and going. Because of the instability of the family there were concerns for the children’s safety, and social services were monitoring their well-being. Beverley’s grandmother lived nearby and was able to help out when things were difficult by having Beverley to stay. This provided a safety net. The unpredictability of Beverley’s life showed in her appearance when she arrived for her Monday morning music therapy session. Sometimes she looked unkempt, grubby, and neglected while on other occasions she was smartly dressed with new clothes. Treatment Peter had referred Beverley initially because of poor peer relationships and aggressive outbursts in school. He felt that she had ability, but was not achieving as well as she could in class because of her emotional difficulties. She came with three other girls from her class for group music therapy where the aim was to encourage positive relationships, cooperation, and sharing through musical activities. However, although she was obviously motivated to take part in the music-making, Beverley found it impossible to share the instruments or the attention of the therapists with the other children. She would become distressed, claiming that the others were “picking on her” and would rush out of the room. As her presence became increasingly disruptive and detrimental to the progress of the rest of the group, her group therapists

suggested that she should transfer to individual therapy. This was agreed, and after a planned ending with the group, Beverley began therapy with me on a one-to-one basis, work which was to last two years. Early Sessions — Preacher and Pop Singer Beverley made the change from group to individual therapy willingly and seemed delighted to have all the instruments to herself. The room contained a piano, side drum, bongos, a cymbal, a metallophone, wind chimes, and a selection of small percussion instruments. My first impression of Beverley was of a graceful, well-coordinated girl with a great deal of physical energy. She was rarely quiet or still, restlessly moving around the room, often dancing and singing into an imaginary microphone. Her speech was muddled and unclear, with a lack of grammatical structure, and her tendency to change from one topic to another added to the sense of confusion. In the early sessions, she played the percussion and I accompanied her on the piano. Her musical tendency was to “run away” from me, so that if I matched her playing precisely, she would invariably change tempo or meter. She also sang, revealing a flexible and wide ranging voice, which was generally so loud that it drowned out my accompaniment. She often interrupted the music suddenly, saying it was time to go, or rushing out to the toilet, finding it hard to stay in the room for the full half-hour. Her lack of containment was apparent, as was her need to control our interactions and the environment. Each week she would rearrange the instruments and the furniture in the room, often putting them behind the piano so that I could not look at her directly when she was playing. As Beverley settled into the new relationship, she began to use the sessions to act out a variety of scenes which mixed fantasy with reality. They were usually highly dramatic with a sense of energy and excitement. I would accompany her singing, acting, and dancing wherever possible, but she was quite controlling of my participation, shouting at me to “cut the music,” “you be quiet,” or “shut the piano!” I would generally comply with Beverley’s musical demands to meet her omnipotence in the way that Winnicott identifies as vital to a child’s emotional development. The good-enough mother meets the omnipotence of the infant and to some extent makes sense of it. She does this repeatedly. A True Self begins to have life, through the strength given to the infant’s weak ego by the mother’s implementation of the infant’s omnipotent expressions (Winnicott, 1984, p. 145). Clear boundaries, however, were necessary in other areas. For example, Beverley would want to take my shoes off or braid my hair. I felt that this kind of closeness would not be helpful to the therapy, so I would state clearly, “I’m keeping my shoes on” or “My hair’s fine like it is.” I would also monitor my countertransference response to her frequent commands for me to “stand up,” “sit down,” or “go in the corner.” If I began to feel despised or abused by Beverley I would reply firmly that I would stay on my chair and allow her to experience the frustration of not being able to control me. I wanted to demonstrate that it was possible to have a relationship which was based on respect, not on domination or bullying.

Beverley would generally take on another persona in the sessions, imitating well-known pop stars or a boxer or wrestler, famous from a television show. Another figure who often dominated the sessions was a hell-fire religious preacher. When she took this role her excitement could turn to near hysteria, with her singing transforming to shrieking or screaming. There was often a feeling of disassociation, bordering on the psychotic, when she became deeply involved in her fantasy. I would match her emotional intensity with strong playing, and found that the music could organize her responses and keep her in touch with external reality. Her innate musicality would draw her to complete a phrase at a cadence or to wait for me to give her a musical cue. Although her words were hard to understand I would catch short phrases which seemed significant and sing them back to her. I would also frequently introduce a refrain, such as, “We’re singing together on Monday” or “This is Beverley’s song” to try to keep a connection. Here is a transcription of part of a session in the fourth month of therapy. Beverley begins by telling me that “we’re making a little bit of music, a little bit of sound, we’re making a show.” She instructs me to sit and watch her while she sings into a drum beater “microphone.” She sings unaccompanied. B: This is my song, this is my friend, this is my friend, this is my friend. I played the drum in music, I played the drum and drumpet [sic]. And the rain is falling down. I then sing back to her, unaccompanied, the essence of what she had sung. H: That was your song, a song about a friend, You played the drum in music And the rain was falling down. This structure is repeated for a second verse, both of us listening attentively to the other, but when I extend the words and sing “Beverley and Helen are singing together” the connection between us is suddenly lost, and she begins to scream and gyrate like a pop singer. She moves to the back of the room and flings herself at the wall, still singing/screaming. At this point I go to the piano, feeling that she needs some containment and grounding. I sing and play with strength. H: This is Beverley’s song, she’s singing in music today, Beverley’s song, she’s singing in music today. Beverley waits till I’ve finished my phrase then joins in, with the same tune, extending it. I can only make out a few of the words: B: My name is Beverley, take me, and see. You can sing, you can cry. Again I reflect back to her the words which seem important, “crying and singing.” Her singing becomes more intense and passionate, with the phrases lengthening, Beverley allowing me to support her musically. Just as it feels as if we will come to a satisfying ending together Beverley suddenly switches to her “preacher” persona. B (shouting): Alleluia! Amen! Cut the music!

God is Bible, My name is Bethlehem Jesus. Remember me for the discipleship. Young woman! (to me) You better rise up. Beverley then prowls round the room like a boxer, punching the air and muttering “the death of Jesus” and “the blood of Jesus.” She throws herself at the wall dramatically and falls down groaning. I sing “Poor Beverley, she’s hurt,” at which she jumps up and commands me: B: Stand up! Close your Bible, turn to chapter 3. (Then more softly and prayerfully) The God is my shepherd; she made me lie down in green pastures. Thou anoint my head with oil and my cup runs over. They threw me in the path of the shadow of death — no evil. You want to listen to my prayer. Just close your eyes. Father, we bless you tonight, I want to go away, Shepherds, just leave me alone. Thank you for your old mum and your school, Thank you for your music therapy. Amen. This session illustrates Beverley’s sudden changes of mood and subject and the muddling together of home, school, and music therapy with images from the Bible and a church service. It also shows how structure, both in the music and in the poetry of the 23rd Psalm, which she was quoting in the above extract, could help her become more coherent and expressive. In her dramas Beverley generally took the role of a powerful male adult, often threatening me and attacking me verbally. Her characters were unpredictable, suddenly becoming angry and losing control. In this way she made me experience her own unarticulated feelings of vulnerability and powerlessness. An example of this comes from a session in the sixth month of therapy. In this part of the session we are speaking, with no music. B: Shut the music! (Threatening gesture) H: You want me to shut the piano. (I shut it) B: What you doing to my wife? (Throws beater at me) H: Somebody’s very angry. (Beverley hangs her head) Somebody’s sad? (Beverley pushes me) B: You told me what to do, I don’t even tell you, Helen. You keep on picking on me. H: I keep on picking on you so you’re getting angry with me? B: I didn’t tell you what nothing. H: I kept telling you what to do... B: Yes, man. H: And you got angry... B: Yes! If you do it one more time... (threatening gesture) H: And now you really want to hit me.

B: Yes! If you do it one more time I’ll GET THE WOLF PACK! H: And now you’re shouting at me because you feel really cross. B: If you do it one more time, YOU’LL FEEL THE BANG! At this point Beverley rushes out of the room but I call her back, saying that I want to listen to her. She then goes on to say that the “Wolf Pack” will whack me and throw me through the window. I continue to reflect verbally how I think she is feeling and despite her agitation, she at last seems to recognize that I am hearing her. She then comes very close to me, wanting to take a hairclip out of her hair to put in mine and saying, “Shall we get married?” Her mood has changed from aggression to intimacy and then, just as quickly, as though discounting what has gone before, she shouts exuberantly, “Let’s have a party!” and starts dancing. At this point I begin to play music for her dancing, and this then leads into a shared “good-bye” song. There was a sense of relief in having survived the confrontation and all the feelings it stirred up, while being able to make music together at the end of a stormy session was an affirmation of the reality of our developing relationship. Winnicott says that children’s play is “inherently exciting and precarious” and can lead to a high degree of anxiety. He suggests that the precariousness derives from “the interplay in the child’s mind of that which is subjective (near hallucination) and that which is objectively perceived (actual or shared reality)” (Winnicott, 1999, p. 52). The “near-hallucination” refers to the dreamlike state of children playing which can conflict with the reality of the situation. This seems to describe Beverley when she became deeply engrossed in her fantasy play. Her anxiety was apparent, and she needed constant grounding by the reflections which I offered her, whether musical or verbal. Another feature of Beverley’s fantasy play was its punitive nature. The preacher, in particular, threatened blood and death, and most of her characters were aggressive and violent. Kalsched (1996, p. 118) writing about the archetypal figures who appear in dreams, refers to “gigantic, fantasised beings” which are “of two types, malevolent and destructive on the one hand, benevolent and protective on the other.” The man who promises salvation but also threatens punishment and death is surely an example of this, expressed in play, not in a dream. It was important that I could withstand these attacks and not retaliate, nor make myself into a victim. As our relationship developed, Beverley began to show a strong emotional reaction to breaks in the therapy, either planned holidays or sessions which were missed through illness or problems with school transport. After six months of therapy there was to be a four-week holiday break. Beverley comes into the room saying “I missed you.” I take that to be a confusion of tenses (meaning “I’m going to miss you”). I begin to talk about the break, but she immediately drowns me out with loud drum and cymbal playing. She finds it too close for me to reflect her feelings so directly. She then begins to proclaim in a deep voice, half-singing, halfchanting: B: My name is Sunkanan. The Bible says you ought to believe in the drum. I want to bring up my mum, my’wife, my sister, and Helen, all my family. You’re gonna miss her tonight, I’ll miss you tomorrow. H: (singing) I’ll miss you next week...

B: Bye, see you Helen, I’ll miss you tomorrow. (leaves the room) She goes out of the door and sings “pop style” outside. Again, it seems that she cannot tolerate me expressing her feelings for her. H: (calling to her) Beverley, where are you? B: (marches back in) I’m doing my exercises. Alleluya! (exercises vigorously to marching music) Then, another mood change as picking up the drumbeater “microphone” she begins to sing. I accompany at the piano. B: You’re my wife. I’m gonna sing a song for Mother’s Day. [This had been the previous day] You can touch me, you don’t touch me. Your mum is dead, your Nan is crying for yourself, And I am pregnant, I am pregnant. H: Your mum is dead, your Nan is crying and you are pregnant. B: My mum is dead, you’re gonna miss me tonight, You pray for me tonight, say good-bye to me. H: A sad song, for Mother’s day, you’re gonna miss me. No music next Monday. At this point Beverley cuts across the mood of shared sadness, screaming and running around. I stay very still, and, when she is quieter, ask her if she would like to come and sit at the piano by me. Unusually, she agrees, and we have a brief turn-taking exchange before leading into a familiar good-bye song, which we sing calmly. As Beverley leaves she asks me three questions, “Are you my friend? What’s your name? Let me see your teeth.” These questions seem to reflect her growing awareness that she can trust this relationship, I am a real person, and I can, like her, be strong and show my teeth. However, I am also behaving like an unreliable or absent mother, in leaving her abandoned for the holiday. Middle Period—The School Game After this break, Beverley introduced a new scenario in which she was a teacher, and the instruments were pupils. She gave them the names of children in her class, so it felt as though they had come to join us, almost as though going back to group music therapy. The “children” were invariably badly behaved, and therefore Beverley could vent all her anger on them. Typical phrases were: “Don’t you swear at me or you’ll get a whack on the head,” “Don’t even hit anybody,” and “I HATE it!” After the long summer holiday at the end of the first year of therapy Beverley came back to sessions concentrating on the school game. In the first session after the break she allows me to join in, telling me to play “relaxing” music and ordering the children to “just relax and listen to the music while your feet grows.” Here, despite her restlessness and constant criticism of the children, she accepts that I had something to give her through the music even though she cannot stay with a quiet mood for long. When characterizing the instruments, the drum was usually “the winner,” the “best behaved,” while the wind chime, erratic and hard to control, was the naughty one. The cymbal

too was frequently sent out of the room for being noisy and indeed, the session sometimes ended with no instruments left in the room. This made explicit Beverley’s need to be the only one. It also seemed that she could now symbolize her feelings, rather than needing to act them out by leaving the room herself. The instruments represented the parts of herself which she found difficult to manage, and in bringing their conflicts into our session, she was enabling us to work on the issues together. Klein, in describing her psychoanalytic play technique sessions says: The variety of emotional situations which can be expressed by play activities is unlimited: for instance, feelings of frustration and of being rejected; jealousy of both father and mother, or of brothers and sisters; aggressiveness accompanying such jealousy; pleasure in having a playmate and an ally against the parents; feelings of love and hatred towards a newborn baby or one who is expected, as well as the ensuing anxiety, guilt and the urge to make reparation. We also find in the child’s play the repetition of actual experiences and details of everyday life, often interwoven with his phantasies (Klein, 1991, p. 43). The symbolic use of the instruments was part of Beverley’s exploration of relationships. All her issues--low self-esteem, rivalry with her peers, lack of self-control, and aggressive outbursts--could be contained and worked on during the sessions. For example, I developed a song about “trying to be good--it’s really difficult,” reflecting on the struggle of “the other children.” At about this time I discovered that Beverley’s mother was pregnant, although it was not known when the baby was due. This made sense of some of Beverley’s play, in which she would throw herself to the floor, writhing and groaning as though giving birth. I also wondered whether she had been present during her mother’s previous miscarriages. It seemed even more significant that she frequently brought material relating to jealousy and the need to be special. Ending—Becoming Beverley Gradually, the school game developed and there was generally a calmer, more constructive atmosphere, Beverley decided that each person, including me, could choose a song to sing. Those that were good would get a prize (a drum beater or a shaker). For the first time, she actively wanted me to play with her, accompanying the songs, rather than controlling me or just tolerating my participation. The songs ranged from nursery rhymes such as “Old MacDonald had a Farm” and “Three Blind Mice” to “When I’m 64” and “Waltzing Matilda,” songs enjoyed by any nine-year-old. Beverley allowed herself to become one of the children in the class, and let go of the punishing super-ego figure of the teacher. At the same time she was able to accept me as a benevolent figure. She also began to take pleasure in dancing to my accompaniment on piano or drums, no longer avoiding my gaze but experiencing my full attention. She was now able to accept my praise and value her own worth, wanting me to give her “a prize.” A more childlike quality came into her voice in contrast to the forced and strident sound of earlier sessions. Beverley was developing her musical skills and, what was more important, the selfcontrol to use them. I brought a xylophone into the session, and she immediately picked out

the children’s song “Twinkle, Twinkle, Little Star,” correcting herself when she miss hit a note, and looking very pleased with her achievement. Having worked at an unconscious level for the first eighteen months with the music as a supportive accompaniment, it seemed that she was now able to experience it in the here and now. Free association and the dreamlike state had been replaced by a purposeful and intentional involvement in the music therapy sessions. Beverley’s baby brother was born sixteen months into her therapy, an event which she seemed to take in her stride. Shortly after this she announced that the instruments were too small and gave several other indications that she was moving into a new stage of maturity. I began to consider finishing the therapy and in speaking with Peter, her teacher, I learned that she was showing improvement in all areas, with an increase in her concentration span and a leap forward in her reading and writing. Peter and I both felt it was time to draw her therapy to an end, at least for the time being, with a planned ending. Beverley was well aware of the forthcoming ending and was able to join me in counting down the weeks to finishing. The final sessions were, in Beverley’s typical style, acted out in the context of a school leavers’ ceremony. In it, she announced that she was leaving and going to another school; that it was sad but she would have to say good-bye. She told all the children to “be good for Helen” when she had gone and everyone would get a prize. Then she improvised a “leaving song” and allowed me to watch her, support her, and sing with her, as we both expressed sadness at the parting. Nevertheless, there was a celebratory feel to her final song and dance, as though she knew this had been an important achievement. Discussion An interesting aspect of Beverley’s treatment is that the point at which she began to use her musical ability in a more intentional and focused way, in the playing and singing of known songs, was the time when I began to think of terminating the therapy. I felt that the further development of her creative abilities through singing, dancing, or acting was not my primary task. My hope was that the insight she had gained through the therapy would facilitate her in experiencing these activities in other settings. This was a situation I had experienced with other children in therapy, for example, Joe, a twelve-year-old boy with Asperger’s syndrome about whom I have written elsewhere. Our stormy and often chaotic music therapy sessions eventually became more ordered and productive and we mutually felt an ending was appropriate. With Joe, leaving therapy coincided with him giving away his toys to his younger brother and starting to have “proper” piano lessons rather than the free musical play of the therapy sessions. It was as though he recognized that music therapy had addressed the angry, fearful, and omnipotent infant part of himself, and that it had helped him to contain and manage it. This was made explicit in our final session when he told me that his dog was getting out of control so perhaps he could send it to live with me (Tyler, 1997, p. 231). This might lead the reader to the conclusion that the psychotherapeutic function of the sessions with Joe and Beverley outweighed the musical therapeutic dimension, but this could be as a result of what Ansdell has termed “the music therapist’s dilemma.” He says “Whilst musicians have a limited vocabulary for musical ‘objects’ and techniques they have almost none for musical experience — arguably the starting point for music therapy” (Ansdell, 2001, p. 2). In describing Beverley’s music therapy I am aware that it is more straightforward to transcribe

words and actions than to convey the essence of the musical interaction. However, moment-tomoment in the therapy I was making musical decisions and monitoring my responses with my “internal supervisor” (Casement, 1985, p. 49). There were endless choices to be made, such as to play or not to play, to sing or speak, to match Beverley’s music or be separate musically, to build up or draw back, to increase the musical tension or relax it. The choice of instrument, the key, mode, meter, tempo, and dynamics all had to be decided at every moment of each session. As Pavlicevic (2001) writes, “the powerful flexibility and shifting nuances of improvised clinical music can resonate with, and sound, the child’s totality” (p.20). In order for this to happen, the therapist must be finely attuned to the child on all levels. Aiding this process for me was the discipline of recording every session on either audio or video and listening back to the tape, making detailed notes or an “index” of the session using the method devised and advocated by Nordoff and Robbins (1977, p. 92). This careful study of the weekly session tape helped me to grasp the complex musical self-portrait that Beverley presented to me, with its many forms and facets and this, combined with regular supervision, enabled me to recognize and nurture Beverley’s authentic voice. I began this chapter with thoughts about the care and treatment of disturbed and distressed children. The poignant image of the motherless child was evoked by Victorian authors and philanthropists wishing to raise awareness of the plight of such children to improve their lot. Throughout Beverley’s therapy I did not meet her mother or have any more than the minimum of information about her, but the maternal figures she presented to me were generally weak, ill, pregnant, or abused, and in need of prayer. All the power was situated in the male figures who dominated the sessions with their physical or verbal bullying. Beverley’s recognition of me as a person who could be strong but not persecuting and who could withstand her assaults without retaliation gave her the strength to find her authentic self. In her role-play as a teacher she explored issues of control and power, and through the school game, eventually allowed herself to be the child, Beverley, for the first time. Being Beverley, a child who could sing, dance, laugh, cry, love, and hate, without the need for concealment behind another persona, was the achievement of the therapy. References Alcott, L. M. (1994). Good Wives. (First published 1869.) London: Penguin. Ansdell, G. (2001). Music Therapist’s Dilemma, British Journal of Music Therapy, 15 (1), 2-4. Axline, V. M. (1989). Play Therapy. Edinburgh: Churchill Livingstone. Casement, P. (1985). On Learning from the Patient. London and New York: Routledge. Docker-Drysdale, B. (1993). Consultation in Child Care. In Therapy and Consultation in Child Care. London: Free Association Books. Kalsched, D. (1996). The Inner World of Trauma. London and New York: Routledge. Klein, M. (1991). The Psychoanalytic Play Technique. In J. Mitchell (ed.) Klein: Selected Letters. Harmondsworth, UK: Penguin Books. Nordoff, P., & Robbins, C. (1977). Creative Music Therapy. New York: John Day. (Out of print. New edition forthcoming: Gilsum, NH: Barcelona.)

Nordoff, P., & Robbins, C. (1992). Therapy in Music for Handicapped Children. (First published 1971.) London: Victor Gollancz Ltd. Pavlicevic, M. (2001). A Child in Time and Health, British Journal of Music Therapy, 15 (1), 14-21. Tyler, H. (1997). Music Therapy for Children with Learning Difficulties. In M. Fawcus (ed.), Children with Learning Difficulties — A Collaborative Approach to Their Education and Management. London: Whurr Publishers Ltd. Wagner, G. (1979). Barnardo. London: Weidenfeld and Nicholson. Winnicott, D. W. (1984). Ego Distortion in Terms of True and False Self. In The Maturational Processes and the Facilitating Environment. London: Karnac Books. Winnicott, D. W. (1999). Playing and Reality. (First published 1971, London: Tavistock Publications.) London: Pelican Books.

Other E-books in this Series Available from: www.barcelonapublishers.com

Case Examples of Music Therapy— For Alzheimer’s Disease For Autism and Rett Syndrome In Bereavement For Children and Adolescents with Emotional or Behavioral Problems For Developmental Problems in Learning and Communication At the End of Life For Event Trauma For Medical Conditions For Mood Disorders For Multiple Disabilities For Musicians For Personality Disorders For Schizophrenia and Other Psychoses For Self-Development For Substance Use Disorders For Survivors of Abuse

Barcelona Titles by Topic Available at www.barcelonapublishers.com Analytical Music Therapy • Essays on Analytical Music Therapy (Priestley) • Music Therapy in Action (Priestley) • The Dynamics of Music Psychotherapy (Bruscia) • Group Analytic Music Therapy (Ahonen-Eerikäinen) Case Studies • Case Studies in Music Therapy (Bruscia) • Inside Music Therapy: Client Experiences (Hibben) • Psychodynamic Music Therapy: Case Studies (Hadley) • Developments in Music Therapy Practice: Case Study Perspectives • Case Examples of Music Therapy: A Series of 16 e-books Children with Special Needs • Alike and Different: The Clinical and Educational Uses of Orff-Schulwerk – Second Edition (Bitcon) • The Miracle of Music Therapy (Boxill) • Music for Fun, Music for Learning (Birkenshaw-Fleming) • Music: Motion and Emotion: The Developmental-Integrative Model in Music Therapy (Sekeles) • Music, Therapy, and Early Childhood (Schwartz) • Music Therapy in Special Education (Nordoff & Robbins) • Therapy in Music for Handicapped Children (Nordoff & Robbins) Infancy and Early Childhood • Music, Therapy, and Early Childhood (Schwartz) • Music Therapy for Premature and Newborn Infants (Nöcker-Ribaupierre) End of Life • Music Therapy: Death and Grief (Sekeles) Feminism • Feminist Perspectives in Music Therapy (Hadley) Fieldwork and Internship Training • Clinical Training Guide for the Student Music Therapist (Wheeler, Shultis & Polen) • Music Therapy: A Fieldwork Primer (Borczon) • Music Therapy Supervision (Forinash) Group Work • Music Therapy: Group Vignettes (Borczon) • Music Therapy Improvisation for Groups: Essential Leadership Competencies (Gardstrom) Guided Imagery and Music (Bonny Method) • Guided Imagery and Music: The Bonny Method and Beyond (Bruscia & Grocke) • Music and Consciousness: The Evolution of Guided Imagery and Music (Bonny) • Music and Your Mind: Listening with a New Consciousness (Bonny & Savary) • Music for the Imagination (Bruscia) Guitar Skills

• Guitar Skills for Music Therapists and Music Educators (Meyer, De Villers, Ebnet) Improvisational Music Therapy • The Architecture of Aesthetic Music Therapy (Lee) • Essays on Analytical Music Therapy (Priestley) • Creative Music Therapy: A Guide to Fostering Clinical Musicianship – Second Edition with Four CDs (Nordoff & Robbins) • Group Analytic Music Therapy (Ahonen-Eerikäinen) • Healing Heritage: Paul Nordoff Exploring the Tonal Language of Music (Robbins & Robbins) • Improvising in Styles: A Workbook for Music Therapists, Educators, and Musicians (Lee & Houde) • Music as Therapy: A Dialogal Perspective (Garred) • Music-Centered Music Therapy (Aigen) • Music Therapy: Improvisation, Communication, and Culture (Ruud) • Music Therapy Improvisation for Groups: Essential Leadership Competencies (Gardstrom) • Paths of Development in Nordoff-Robbins Music Therapy (Aigen) • Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Sounding the Self: Analogy in Improvisational Music Therapy (Smeijsters) Music for Children to Sing and Play • Distant Bells (Levin & Levin) • Learning Songs (Levin & Levin) • Learning Through Music (Levin & Levin) • Learning Through Songs (Levin & Levin) • Let’s Make Music (Levin & Levin) • Music for Fun, Music for Learning (Birkenshaw-Fleming) • Snow White: A Guide to Child-Centered Musical Theatre (Lauri, Groeschel, Robbins, Ritholz & Turry) • Symphonics R Us (Levin & Levin) Nordoff-Robbins Music Therapy (Creative Music Therapy) • The Architecture of Aesthetic Music Therapy (Lee) • Being in Music: Foundations of Nordoff-Robbins Music Therapy (Aigen) • Conversations on Nordoff-Robbins Music Therapy (Verney & Ansdell) • Creative Music Therapy: A Guide to Fostering Clinical Musicianship – Second Edition with Four CDs (Nordoff & Robbins) • Healing Heritage: Paul Nordoff Exploring the Tonal Language of Music (Robbins & Robbins) • Here We Are in Music: One Year with an Adolescent Creative Music Therapy Group (Aigen) • A Journey into Creative Music Therapy (Robbins) • Music Therapy in Special Education (Nordoff & Robbins) • Paths of Development in Nordoff-Robbins Music Therapy (Aigen) • Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Therapy in Music for Handicapped Children (Nordoff & Robbins) Music Psychotherapy • The Dynamics of Music Psychotherapy (Bruscia) • Essays on Analytical Music Therapy (Priestley) • Emotional Processes in Music Therapy (Pellitteri)

• Group Analytic Music Therapy (Ahonen-Eerikäinen) • Guided Imagery and Music: The Bonny Method and Beyond (Bruscia & Grocke) • Music and Consciousness: The Evolution of Guided Imagery and Music (Bonny) • Music and Your Mind: Listening with a New Consciousness (Bonny & Savary) • Music Therapy: Group Vignettes (Borczon) • Psychodynamic Music Therapy: Case Studies (Hadley) Orff-Schulwerk • Alike and Different: The Clinical and Educational Uses of Orff-Schulwerk – Second Edition (Bitcon) Periodicals (Free Downloads Available) • International Journal of Arts Medicine • Qualitative Inquiries in Music Therapy: A Monograph Series Profound Mental Retardation • Age-Appropriate Activities for Adults with Profound Mental Retardation – Second Edition (Galerstein, Martin & Powe) Psychodrama • Acting Your Inner Music (Moreno) Psychiatry – Mental Health • Music Therapy in the Treatment of Adults with Mental Disorders: Theoretical Bases and Clinical Interventions (Unkefer & Thaut) • Psychiatric Music Therapy in the Community: The Legacy of Florence Tyson (McGuire) • Psychodynamic Music Therapy: Case Studies (Hadley) • Resource-Oriented Music Therapy in Mental Health Care (Rolvsjord) Research • A Guide to Writing and Presenting in Music Therapy (Aigen) • Multiple Perspectives: A Guide to Qualitative Research in Music Therapy (Smeijsters) • Music Therapy Research: Quantitative and Qualitative Perspectives – First Edition (1995) (Wheeler) • Music Therapy Research – Second Edition (2005) (Wheeler) • Playin’ in the Band: A Qualitative study of Popular Music Styles as Clinical Improvisation (Aigen) • Qualitative Inquiries in Music Therapy: A Monograph Series (Free Downloads Available Here) • Qualitative Music Therapy Research: Beginning Dialogues (Langenberg, Frömmer & Aigen) Supervision • Music Therapy Supervision (Forinash) Theory • Culture-Centered Music Therapy (Stige) • Defining Music Therapy – Second Edition (Bruscia) • Emotional Processes in Music Therapy (Pellitteri) • Music and Life in the Field of Play: An Anthology (Kenny) • Music as Therapy: A Dialogal Perspective (Garred) • Music-Centered Music Therapy (Aigen) • Music Therapy and its Relationship to Current Treatment Theories (Ruud) • Music Therapy: A Perspective from the Humanities (Ruud) • Music Therapy: Improvisation, Communication, and Culture (Ruud) • Music—The Therapeutic Edge: Readings from William W. Sears (Sears)

Voice

• • • •

The Music Within You (Katsh & Fishman) Resource-Oriented Music Therapy in Mental Health Care (Rolvsjord) The Rhythmic Language of Health and Disease (Rider) Sounding the Self: Analogy in Improvisational Music Therapy (Smeijsters)

• •

Authentic Voices, Authentic Singing (Uhlig) Psychiatric Music Therapy in the Community: The Legacy of Florence Tyson (McGuire)