Case Examples of Music Therapy for Event Trauma [1 ed.] 9781937440213

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Case Examples of Music Therapy for Event Trauma Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy for Event Trauma 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: 978-1-937440-21-3 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 Improvisation and Guided Imagery and Music (GIM) With a Physically Disabled Woman: A Gestalt Approach Elizabeth Moffitt CASE TWO Out of the Ashes: Transforming Despair into Hope with Music and Imagery Cecilia Herzfeld Schulberg CASE THREE To Be Afraid of Your Own Shadow: A Case Analysis Chava Sekeles CASE FOUR Life Under Terror—Israeli Songs in Music Therapy: A Case Analysis Chava Sekeles CASE FIVE From the Highest Height to the Lowest Depth: Music Therapy with a Paraplegic Soldier Chava Sekeles CASE SIX A Flash of the Obvious: Music Therapy and Trauma Julie Sutton

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 individuals who have survived event trauma. 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 even trauma 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 trauma To do this, it provides basic information on event trauma, music therapy, and case examples. About Event Trauma Survivors of event trauma include all those individuals who have witnessed or experienced an event that seriously threatened their life or safety, and who responded with intense fear, helplessness, or terror (American Psychiatric Association. The event may have involved only one person, a few persons, or large groups or segments of society (e.g., collective trauma). A diagnosis of posttraumatic stress disorder (PTSD) is given when the survivor: 1) persistently relives the trauma; 2) persistently avoids or responds with numbness to anything that is likely to recall the trauma; 3) and tends to have various forms of increased arousal. These symptoms typically last more than one month, and lead to significant disturbances in the person’s occupational and social functioning. Given the wide variety of traumatic events that commonly occur in today’s world, and the wide variety of reactions that they are likely to elicit, survivors of event trauma can present with myriad symptoms and problems. The case examples in this book show the enormous struggles experienced by survivors, and the many resources and strengths that can they bring to bear in their healing, and especially through carefully designed music experiences. 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, freeassociation, 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 survivors of event trauma, 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 event trauma, 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 event trauma are as interested in this question as scientists and researchers. Their interest is in whether individuals who experience event trauma or PTSD 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 Music Therapy For Event Trauma 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 event trauma. Additional case examples have been written, which further elaborate how survivors can derive therapeutic benefits from music. Here is a list of other published case examples along with other writings on the topic. Amir, D. (2006). Awaking the “Wild woman”: Feminist music therapy with Israeli women who suffered trauma in their lives. In S. Hadley (Ed.), Feminist perspectives in music therapy (pp. 267-290). Gilsum, NH: Barcelona Publishers. Baker, F., & Jones, C. (2005). Holding a steady beat: The effects of a music therapy program on stabilising behaviours of newly arrived refugee students. British Journal of Music Therapy, 19(2), 67-74. Bensimon, M., Amir, D., & Wolf, Y. (2008). Drumming through trauma: Music therapy with posttraumatic soldiers. The Arts in Psychotherapy, 35(1), 34-48. Bergmann, K. (2002). The sound of trauma: Music therapy in a post-war environment. Australian Journal of Music Therapy, 13, 3-16. Blake, R. L. (1994). Vietnam veterans with post-traumatic stress disorder: Findings from a music and imagery project. Journal of the Association for Music and Imagery, 3, 5-17. Burt, J. (1995). Distant thunder: Drumming with Vietnam veterans. Music Therapy Perspectives, 13(2), 110-112. Carey, Lois [Ed]. (2006). Expressive and creative arts methods for trauma survivors. Expressive and creative arts methods for trauma survivors. London, England: Jessica Kingsley Publishers. Choi, C. (2010). A pilot analysis of the psychological themes found during the CARING at Columbia--music therapy program with refugee adolescents from North Korea. Journal of Music Therapy, 47(4), 380-407. Clements-Cortes, Amy. (2008). Music to shatter the silence: A case study on music therapy, trauma, and the Holocaust. Canadian Journal of Music Therapy, 14(1), 9-21.

Green, Amy. (2011). Art and music therapy for trauma survivors. Canadian Art Therapy Association Journal, 24(2), 14-19. Heidenreich, Verena. (2005). Music therapy in war-effected areas. Intervention: International Journal of Mental Health, Psychosocial Work & Counselling in Areas of Armed Conflict, 3(2), 129-134. Hunt, M. (2005). Action research and music therapy: Group music therapy with young refugees in a school community. Voices: A World Forum for Music Therapy, 5(2). Retrieved June 28, 2011 from https://normt.uib.no/index.php/voices/article/viewArticle/223/167 Lang, L., & McInerney, U. (2002). A music therapy service in a post-war environment. In J. Sutton (Ed.), Music, music therapy and trauma: International perspectives (pp. 153-174). London, UK: Jessica Kingsley Publishers. Loewy, J. V., & Hara, A. F. (Eds.). (2002). Caring for the caregiver: The use of music and music therapy in grief and trauma. Silver Spring, MD: American Music Therapy Association. Loewy, Joanne V & Stewart, Kristen. (2004). Music Therapy to Help Traumatized Children and Caregivers. Webb, Nancy Boyd [Ed]. Mass trauma and violence: Helping families and children cope. New York, NY, US: Guilford Press, US; pp. 191-215 Ng, W. F. (2005). Music therapy, war trauma, and peace: A Singaporean perspective. Voices: A World Forum for Music Therapy, 5(3). Retrieved June 28, 2011 from https://normt.uib.no/index.php/voices/article/viewArticle/231 Orth, J. (2005). Music therapy with traumatized refugees in a clinical setting. Voices: A World Forum for Music Therapy, 5(2). Retrieved June 28, 2011 from https://normt.uib.no/index.php/voices/article/view/227/171 Robb, S. L. (1996). Techniques in song writing: Restoring emotional and physical well being in adolescents who have been traumatically injured. Music Therapy Perspectives, 14(1), 3037. Schulberg, C. (1997). An unwanted inheritance: Healing transgenerational trauma of the Nazi Holocaust through the Bonny Method of Guided Imagery and Music. The Arts in Psychotherapy, 24(4), 323-346. Sutton, J. (Ed.). (2002). Music, music therapy and trauma: International perspectives. London, UK: Jessica Kingsley Publishers. Whitehead-Pleaux, Annette M. (2005). Rhode Island Fire Music Therapy Project final report. Music Therapy Perspectives, 23(2), 129-134. Yawney, R. (1995). Music therapy in Gaza: An occupational hazard? Canadian Journal of Music Therapy, 3(1), 1-18. Zharinova-Sanderson, O. (2004). Promoting integration and socio-cultural change: Community music therapy with traumatised refugees in Berlin. In M. Pavlicevic, & G. Ansdell (Eds.), Community music therapy (pp. 233-248). London: Jessica Kingsley Publishers Ltd. References 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. See: temple.edu/musictherapy/FAQ.

Case Examples of Music Therapy for Event Trauma

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

CASE ONE

Improvisation and Guided Imagery and Music (GIM) With a Physically Disabled Woman: A Gestalt Approach Elizabeth Moffitt Abstract This case describes music psychotherapy with a woman, paralyzed from the waist down, who had been traumatized from difficult hospitalizations. Gestalt verbal therapy was combined with musical improvisation and Guided Imagery and Music to enhance self-concept and to facilitate emotional expression. BACKGROUND Jenny is a woman in her mid-twenties who has been physically handicapped from the waist down since birth, and has had repeated hospitalizations. She is intelligent, articulate, and a competent pianist. Jenny came to therapy saying that she wanted to match her internal feelings with her age. She felt she had been stunted in her emotional growth at an early age, and this was interfering with her life. She had the appearance of a sweet young girl, quiet and retiring. Jenny claimed that she was unable to speak up for herself to express her thoughts or needs, especially in a group situation. She was also clearly struggling to accept her body, as described in a poem she brought to our first session. Following are excerpts from it. IN MY HEART A DANCER She feels the people closing in on her, closer and closer, ‘til she can no longer breathe. She must leave now, for not much longer can she hold back the tears....... Sadness for what can never be, no matter how much she may wish or imagine, especially since she never knew it to be such a desire.................. You see, she watched her friend dance

tonight. But unlike all the other times when she never gave it another thought, tonight she watched from her heart’s eyes, and in her heart lies a dancer.................. But her heart’s joy is not to be found, for her body is not a vehicle. Rather it seems more a stone of unease and embarrassment. Her body ever remains for her heavy, and awkward, painful and clumsy, not at all a body for the dancer inside who wishes to be known, who yearns to be free......................... Jenny also brought a drawing which she had recently completed. Several bright colors were in one corner and all the remaining space was completely black. Jenny then described a horrible series of circumstances at the age of 8, when she was taken from her country home to a city hospital. Her doctor wished to experiment with a procedure to stimulate growth in her legs by systematically breaking the bones as they were healing, hoping to thereby increase their length. When this did not work, the surgeon placed a steel rod from one thigh up to her hip. It seems that the surgeon measured the length of the rod incorrectly however, and unknown to the staff, it caused severe damage to her internal organs. She became the bad girl on the ward, isolated and left alone, because every time the nurses came to change her dressings, she would scream and faint from the excruciating pain. An intern eventually spotted her greenish colour, and they rushed her to surgery to correct the size of the rod. That particular time she remained in hospital for nine and a half months. She felt permanently damaged by this whole event. Jenny has rarely spoken about it, and has felt no permission or acceptance to express her depth of feelings regarding this traumatic experience. All this information was told to me in a very quiet, restrained voice. I was personally moved and outraged, hearing Jenny’s account. It appeared that she might require considerable support to explore ways to express herself, and specifically, to release the powerful emotions surrounding these events. It also seemed that she needed to find increased internal resources to sustain her as she worked to integrate the reality of her physical body with her hopes and dreams for a full life. Her obvious creative abilities and her courage would hopefully help with the work ahead. Method

Based on Jenny’s needs as initially presented, I chose to combine Gestalt verbal psychotherapy with musical improvisation. Gestalt therapy was originated by Fritz Perls (Perls et al, 1951) to assist the individual to become aware of, express, and reintegrate various aspects of the self. The first step is to develop awareness of both internal and external experiences (e.g., feelings, thoughts, physical sensations, spiritual desires, surrounding environment, degree of contact with that environment and the people within it). This awareness is approached with a spirit of discovery and curiosity, without judgement or evaluation. We wish to learn “what is, rather than what should be or what might have been. Thus, the person learns to trust [him/herself]” (Simkins, 1976). The two chair-technique is one way in which the Gestalt therapist assists the client to explore, express and integrate various parts of the self. These parts are often conflicting thoughts, attitudes, and opinions, such as “shoulds” and “wants” (e.g., “I should write my paper” versus “I am exhausted and feel like sleeping”). The conflicts can also be contradictory internalized voices from parents or significant others in the past (e.g. “You have to work hard and be successful” versus “You must get enough rest”). By using the metaphor of changing positions with each side of an internal conflict by literally switching back and forth between two chairs, these internal splits are more easily brought to awareness. Once feelings and opinions are expressed from both sides, dialogue is possible. With dialogue comes the possibility of increased understanding of the functions of the opposing splits, and ultimately acceptance and integration of the self. By focusing on present awareness, the Gestalt therapist believes that what is most important for the individual to experience in the moment will come to the foreground out of his background awareness. When the situation in focus is integrated, then it will naturally sink into the background, making space for the next situation to come into the foreground. This dance between fore- and background is seen as a life-long process. Zinker (1978) describes the “Cycle of Awareness” as a creative process for dealing with any situation which may come to the foreground. Integration comes when the cycle is completed. The therapist works with any blocks or resistances which may occur anywhere within the cycle. Figure 1 THE CYCLE OF AWARENESS

As the individual works to complete more and more of these cycles, increasingly integrating healthy aspects of him/herself, energy is freed to flow more smoothly. The person is more fully alive and creative, able to make healthy contacts with self and environment. By its nature music is an expression of this moment in time. People can be immediately confronted with issues of being in contact or not, with self or others. This is especially clear in free musical improvisation. All the parameters of music, for example, harmony, rhythm or intensity, can be seen as metaphors for the individual. Music is thus a stimulus to awareness, and also provides a creative, expressive medium to process this awareness. Through musical improvisation, a person can also eloquently express strengths and creative aspects of self which may have lain hidden and out of awareness. Music therapists who have worked with adults combining Gestalt therapy with clinical improvisation include Shelley Katsh, Carol MerleFishman, and Gillian Stephens (See Bruscia, 1987). In later sessions with Jenny, I used Guided Imagery and Music (GIM) to access deeper levels of experience, to enhance further expression, and to facilitate contact with her inner psyche and the wisdom that resides therein. The sessions lasted 90 minutes, and were held weekly. Towards the end of the therapy, GIM sessions were alternated with Gestalt sessions, so as to encourage her integration of imagery on a conscious level. Treatment Process Phase One In the first session, when Jenny had finished reporting about her hospital experience, she suddenly fell silent with her head lowered. I asked her to focus her attention on her body and to report what she was experiencing internally. Jenny reported feeling a fire in her hip, warm and comfortable. When asked to focus more on it, she experienced the fire turning into burning rage within. During the rest of the sessions, Jenny was able to verbally express her anger, hatred, hurt and confusion, using the Gestalt two-chair technique, to everyone in the hospital including all of the doctors, nurses and aids. Everything was stated in a very quiet controlled voice. Jenny left this session feeling tired though peaceful. Both sessions two and three began with free improvisation on the piano. Jenny felt she wanted to express more anger for the doctors, yet as she played in session two she was flooded with images of her family home, and being alone there. This led to some two-chair work with her mother, telling her how it was for the 8-year old Jenny to be left alone in the hospital. The session continued with this regression as Jenny cuddled up with pillows and blankets and asked me to sing her a hymn from childhood, “Jesus Loves Me.” In session three, Jenny played the piano in a very quiet, tonal fashion, in ABA form, even though she reported feeling extremely agitated inside. The resulting two-chair work in this session dealt with her relationship to her mother and her feelings about always having to control herself with a smiling face. Jenny expressed her resentments regarding this, again very quietly, but with clarity. By the end of the session she was able to integrate her mother’s underlying caring without “selling herself out.” In these two sessions, music stimulated

important memories and accompanying feelings, provided emotional reassurance, and highlighted an outdated need to mask her true feelings. In session four, Jenny brought in another drawing which showed progress from the first. Now the bright colours had grown in size, and the black had been broken into eight strips. She later related the strips to her age at the time of hospitalization. That day Jenny came in with her hands bandaged due to an inflammation caused by adjusting to a new wheelchair. She was unable to play the piano again until her return to therapy in the fall. For this session and the next, Jenny worked on expressing her anger, and exploring how it had taken the form of physical pains, inflamed hands and severe headaches. Her body was always considered the enemy. She felt little attachment to living in it. Though never suicidal, she often wished to be moving on, free of her body, saying that she knew there was a pair of skates waiting for her in heaven. In the remaining three sessions in this phase of treatment, Jenny was beginning to speak out for herself. The headaches began to disappear. Phase Two When Jenny returned for therapy after the summer, she talked of feeling lonely and isolated. Given these feelings, we began with an improvisation together at the piano. Her music had a plaintive quality with bursts of loud passages from which she retreated quickly. I supported her dynamic changes and at times invited more intensity by initiating louder playing. She then moved to the upper register and briefly played a motif similar to the Child’s Tune (do, do, la, re, do, la). I imitated in the middle register of the keyboard. Jenny associated this music with memories of being teased and tormented as a child, and silently ridiculed as an adult. On the keyboard she further explored the sounds of “The Tormentor,” playing a loud rhythmic motif up and down the entire keyboard. She then improvised “The Tormented” using a soft, slow melody in the treble that had a strangely removed quality to it. We then took turns playing each role together. I then suggested that Jenny experiment musically in the role of “The Tormented” to find other ways of handling “The Tormentor” which I played. At first she responded as if aloof, with spurts of frustration that would revert to more serene music, but as I persisted in the role of tormentor, her music became louder and more emphatic until she eventually established a beat so strong that I was drawn to follow it. Although there was much laughter at times during the improvisation, when it was over, Jenny felt very upset. To stop the tormentor, she had to change her way of playing (or being)—from serene and aloof to forceful and in contact. She also did not like to think of herself as capable of being the tormentor. This was a very important session for Jenny, yet it was too revealing for her to improvise after this for several weeks to come. She said that she could not control what would be expressed in music as she could with words, and at that time, she needed some control. The remaining ten sessions in the fall were spent working with poetry, drawing, and mental imagery. Through these experiences, we worked to help Jenny become more and more aware of her inner resources. In the spring, Jenny started going for massages for the first time in her life. She came from one session feeling a tension in her abdomen as if there were sounds of grief and anger

there. I asked her to express those sounds, and Jenny chose to improvise once again on the piano. She played a theme in the bass over and over, as if working into it in a trance-like fashion, going deeper and deeper into the lowest tones on the piano. Jenny described it as a “smokey blues saxophone tune” and imagined herself in a Southern bar listening to jazz. As she continued, she imagined hearing voices saying, “Who do you think you are?” It appeared that this new earthy form of expression was to be harshly judged by her internal voices from the past. Her “sax” music had sparked an awareness of herself as a sensuous human being, and this was unknown and forbidden territory for her. As in the earlier session, I took the role of improvising the tormentor or judge on the piano, repeating the words “Who do you think you are?” This time Jenny quickly and completely responded with loud dissonant chords that silenced me. After another massage, Jenny arrived feeling very grumpy. Instead of trying to banish the mood or cover it up, she decided to improvise music to learn more about it. Strong, directed music emerged with a rich bass emphasis. This was another new way of playing for Jenny. She described her music as strong, powerful and grounded. With her particular disability, Jenny had great difficulty feeling grounded. We then proceeded to work with the Gestalt empty chair technique, where Jenny had an opportunity to express whatever she had left unsaid to significant people from her past, as she imagined each of them seated in the chair. We also used the technique to help Jenny to present herself to these people as a strong and powerful person. This was another important session in that Jenny was beginning to integrate her judge/tormentor/grumpy side, and use it to her advantage. Phase Three There was a long gap between the second and third phases of our work together due to summer holidays and a temporary move for Jenny. In this phase we saw each other less frequently and mainly dealt with issues related to a temporary job she had taken in a hospital setting. The job was a true test of her newfound ability to express herself, especially to medical personnel who represented so much pain from her past. We then began to work with Guided Imagery and Music (GIM), a method originated by Helen Bonny (1980). In this method, the client (or traveller) listens to a tape of selections of classical music while in a relaxed state. The therapist (or guide) selects the tape based on the client’s needs. The client is encouraged to give a running commentary on the images, sensations, or feelings that emerge while the music is playing. The therapist interacts with the client by witnessing, supporting, questioning for detail, and heightening significant images. Upon completion of the tape, the client discusses the experience and may draw a mandala to anchor images in a visual way. GIM was used to access images that might help Jenny to integrate her physical body into her self-concept. Images came very easily to Jenny, as was already demonstrated in her piano improvisations, and her images became even clearer when listening to taped music in the GIM way. She experienced everything from being locked in a dungeon, to leaving familiar security and going on a raft, to becoming a warrior woman, healer and spiritual leader. At first she often imaged herself flying in the air. In time she saw herself more frequently walking on the ground

(grounded). When Jenny needed to be nourished, she relived safe, loving family scenes or was replenished by her beloved forests and streams. In one session she allowed herself to completely enter a whirlpool in which there was only exquisite beauty and peace all around. Jenny later reported this to be a profound experience of transition, putting her in touch with a greater dimension. Jenny was very upset in our last session after a confrontation with a doctor at work. She managed to clearly state her position to him, and indeed even challenge his actions. Yet it took its toll on her, and she was feeling the need to retreat to a safe place for a while—literally under a blanket with all the lights off. After this, Jenny became physically ill with a flu, and went out of town to stay with family who could care for her. A recent letter from Jenny states that she is well again, continuing to work with imaging to music on her own, and writing poetry. She reports a developing and sometimes surprising ability to make her own thoughts and feelings known, no matter what others might think! She states, “Now the feelings, previously unknown, have words and meanings from which I gain understanding.” Conclusions Jenny and I have worked together for over two years. I regret that there has not been an opportunity to find closure to our work. Perhaps this remains for the future. There are recurrent themes which run through the work with her. The little girl is becoming a woman, with strength and power, beginning to speak for herself, to comfort and advise herself, and to integrate various aspects. She is learning to access deep resources within herself giving meaning to her life. The combination of improvisation, GIM, and Gestalt verbal work has proved effective, largely due to her high level of creativity and readiness to understand herself more and thereby move forward with her life. Within these methods are the freedom and support to proceed at one’s own pace to find one’s own wisdom. Jenny needed no more external pronouncements. There is more work to be done. There always is! Jenny’s internal dancer needs to be more integrated into everyday life. Living in Jenny’s body is still a tremendous struggle. The more Jenny is aware of her emotions, and the more she can express them, especially the depth of her resentments from the past, the freer she becomes to be more fully alive in mind, spirit, and yes, even in body. References Bruscia, K. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C Thomas. Bonny, H. (1980). GIM Therapy: Past, present and future implications. Salina, KS: Bonny Foundation. Perls, F., Hefferline, R., & Goodman, R. (1951). Gestalt Therapy. New York: Dell. Simkin, J. (1976). Gestalt Therapy Mini-Lectures. Millbrae, CA: Celestial Arts. Zinker, J. (1978). Creative Process in Gestalt Therapy. New York: Brunner/Mazel.

Taken from: Hibben, J. (Ed.) (1999). Inside Music Therapy: Client Experiences. Gilsum NH: Barcelona Publishers.

CASE TWO Out of the Ashes: Transforming Despair into Hope with Music and Imagery Cecilia Herzfeld Schulberg Introduction I am a music psychotherapist, but here I write of my own experiences with music therapy as the child of Holocaust survivors. These experiences are transcribed from sessions that began during my training in the use of Guided Imagery and Music (GIM). During the sessions, I was in a deep state of consciousness listening to specially selected classical music that helped me face and work through the powerful images of the Holocaust. I am deeply indebted to the music therapists who helped me in this process. The Transforming The first time I was ever able to address this legacy was in a group GIM session. I was led into a relaxed state by the therapist who then put on a classical music program. The descending bass melody quickly pulled me into an experience I had feared my whole life. I smell the smoke and the stench of burning bodies. I hear the cries of the dying and the mournful sobbing of those who barely survived. I feel the heaviness and emptiness of death all around me. It is too real. And it seems like I am here for an eternity. A few remaining survivors are slowly, hypnotically making their way into a burned, desecrated synagogue. I find myself among them, also in a trance. The chanting, moaning of the familiar liturgy grows louder as the walking dead fill the remains of this holy place. I am surrounded by these rocking, half-dead bodies, their heads covered with prayer shawls, and I become one of them. My voice rises with theirs, crying, screaming, mourning. The sounds are filling a deep dark hole inside me. As the music ends, I felt my spirit rising from this place into my own shell of a body. I drew a mandala (a circular drawing) to capture this experience, and my body became filled with me — my heart, my life, my spirit — and I was born. I was no longer that 15-year-old who survived Auschwitz: she was my mother. It was in that music and imagery session that I was first able to look at how the Holocaust affected me directly as a child of Holocaust survivors. I experienced it with my whole being, from bodily sensations to psychic numbing. It was the ultimate death-rebirth experience: I was no longer my mother, a Holocaust survivor; I was reborn as me. The experience is as alive in me today as it was then, years ago. As a result of that session, I realized at a much deeper level how much I lived my life for and as my mother. I came in touch with loss, despair, and grief so overwhelming that I created powerful barriers of protection from the pain within

myself and in the world. That GIM session was the beginning of breaking through those barriers, the beginning of my life. My reconnection with music as a powerful source of life, healing, and spirituality enabled me for the first time to face, experience, and release some of the tremendous loss and grief I have felt since I was a child. This occurred in recurring death-rebirth GIM experiences. Although this first session highlighted the entanglement with my mother, following sessions intensified my lack of connection with her mother, after whom I am named; she was gassed at Auschwitz. The image of my grandmother during my GIM sessions embodied for me all the losses incurred during the war. These losses showed up in various images of death in my GIM sessions: being in a grave and not being able to get out; being dead for a whole session; being in a death march to the crematoriums and not being able to do anything to stop it; being surrounded by dead bodies, half-dead bodies, and mass graves without markers. I experienced death in my body as nothingness, heaviness, coldness, or emptiness in a shell. It was not the actual death that was so painful; it was the inhumanity. The image of my grandmother in my GIM sessions also provided me with the safety and protection I never felt in the world growing up, enabling me to work through and heal these traumas. In my GIM sessions, I experienced her comforting me as a child, rocking me in her lap. I felt safe in her arms while sirens were blaring and bombs were exploding outside her home. I have felt her presence with me throughout my life; but with the music, she helped to fill the endless void I had with the loss of her and everyone else. With the music and my GIM training community, I was developing resources for facing this “shadow.” Whether in individual or group sessions, I knew I was supported and I no longer felt alone. My first powerful encounter with my “Holocaust shadow” began in an individual session, with the music pulling me inward and upward this time. The image of a smokestack is emerging in my groin, and the music is drawing it up inside of me. I feel the music wrenching everything out of me — my essence, my soul— ripping me open. I feel a cord of light from the heavens latch onto me and lift me upward. I feel I am going to burst as the swells in the music are squeezing everything out of me from many lifetimes — it’s overwhelming! The violin plays on the strings of my heart from many lifetimes, everything of human experience — the joys, the sorrows, everything — it’s so wonderful it hurts, but it’s okay to feel that. The light now takes the shape of the smokestack and is so blindingly bright and powerful that I can no longer see the smokestack. The light is going through me and around me. When everything is squeezed out of me, all the heaviness, aches, and pains are gone. I become light and float up with the music. The violins are not gripping anymore. They are sweet. I am a transparent bubble, totally alone, but I do not feel alone. I am connected to the souls of the family I had lost, as we are all part of the light. However, I am starting to have feelings in my body again and float back down to earth; it is not my time to be there yet. [The music changes.] I come down to fire. It is strange. I do not feel it but I know it is hot. I can feel its heaviness and hear its deafening roar. The fire is in the belly of the smokestack, the furnace. There is no enclosure; the furnace is immense and open. It seems like I am in Hell. I have to work hard to keep myself out of the fire, to reach back up into the light. I reach beyond the flames up to the level of gas. But I can feel fingers of fire — misery, pain, sorrow — pulling me down. I have to fight hard not to let them keep me there. I become filled

with despair, feeling, “Why should I bother if I am going to lose anyway?” I am consumed by the flames and become crispy black embers. The fire wipes out everything without a trace. It pounds its chest in glory, boasting: “How dare you stand up against me? No matter how far you go (into the light), I’ll get you!” I respect its words, but I cannot let it get me. With the help of the music, I return to the light with a hole in my chest to remind me of what was lost. Death felt cold, but the light and the music fill (the hole in) my heart with warmth and life. The strings play in my body. I am back on earth with the light, without the consuming fire. The smokestack and light transformed into a powerful symbol of integration that I saw again later that year as the Jewish sanctuary in Dachau; I had never seen this structure before this GIM session. The actual integration of this shadow occurred during a group GIM experience a few weeks later. At this advanced training, we were learning how to facilitate the mind and body working together with the music. As the client, I focused on the chronic pain in my left shoulder, where stress tends to accumulate in my body. It is becoming a gray rock, which is there to store emotions. The rock spreads around my shoulders and over my head into a concrete prayer shawl to grieve, to say Kaddish (a Judaic prayer that is recited for the dead yet speaks of life). It continues to spread down over the rest of my body into a statue, as a memorial to those who were murdered in the Holocaust. And then, I become a smokestack. I can feel the flames coming up from my feet, roaring inside of me. I am horrified: I am killing all those people! It is the most painful experience. I am hysterical. All of a sudden, the smokestack and the fire are gone and there is nothing left but ashes. The pain in my shoulder is gone, too. The ashes are in a hole in my solar plexus, and I am Mother Earth. There is a new pain with this hole. It feels like a void in the universe, an emptiness; nothing is left. But then it becomes filled with dirt, which become people. I am Mother Earth and the people are my children, floating up into the light. I feel a seed planted in my pelvis, and a very powerful tree with one leaf grows out of it. The pain is gone. Out of the Ashes A flame ignited in the bowels of my groin, Fuelled with the energy and sounds of music, Spread out through my limbs, Sprouted into the wings of a white Phoenix That rose out of the ashes, ever upwards, As the music connected my many multicolored Threads around the world, Transformed into an angel, entering the heavens, Connecting with souls and the light, Tears flowing from the container of my soul. In subsequent GIM therapy, I continued to have death-rebirth experiences as I continued to mourn the losses and to let go of the damaging constructions I erected throughout my life to deal with the pain. The most significant construction, or barrier, was that of control. The myth was that (unlike those who were enslaved or murdered by the Nazis) I

could have control over my life. Unlike my parents, relatives, and family friends of that generation, I had the opportunity for education, freedom of choice, happiness, and life as I chose, so I was determined to make the most of these opportunities. I became a therapist, a social activist, and created a new family. But I also tried to control all the things I did not have control over (such as bad things happening) in an attempt to make my world safer than what my parents experienced. The music had all the elements that allowed me to break through this strongly erected barrier of control and pseudosafety. The music provided the dynamics that evoked the experiences, a structure that provided the safety to have the experiences, a container expansive enough to hold all the experiences, and the integration of all of these that supported healing and transformation. The music allowed me to experience the despair and still have hope about the outcome.

Taken from: Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum NH: Barcelona Publishers.

CASE THREE To be Afraid of Your Own Shadow: A Case Analysis Chava Sekeles “He will destroy death forever; and the Lord God will wipe away tears from off all faces; and the rebuke of His people shall He take away from off all the earth, for the Lord hath spoken it.” (Isaiah 25:8) Dedicated to Meir Harnikl Introduction Avi suffered from both neurological dysfunction and psychological traumas. He dwelt with his family in a settlement behind “The Green Line”2 and exhibited severe anxieties, which prevented him from doing many simple activities such as playing in the backyard of his home. Avi had five brothers and two sisters. He was the sixth-born. Because of his neurological dysfunction, mild retardation, and learning disabilities, his studies took place in the city, in a special education school. This necessitated a daily bus drive back and forth. During these journeys, he used to sit frozen in his seat and at times cry out in anxiety. At the age of seven, he was referred to music therapy by the school’s psychological advisor. Throughout the two and a half years that Avi was in therapy, it became obvious that a great number of his anxieties were a result of the many losses the family had suffered and the possibly dangerous experiences of his everyday reality. If I had to draw a line recounting Avi’s development in music therapy, I would do the following:

A is the first half-year of therapy, in which the child learned to use music for expression, representations, fun, and relaxation. B is the sessions during which he began to speak openly of the losses and anxieties he experienced. C is the elaboration period, in which we worked very actively on the anxiety-eliciting subjects. D is group therapy and conclusion.

Intake and Observation • Observation location—Well-equipped music therapy clinic. • Duration/date/hour— • Reported to— • Received by— • Name of patient—Avi (changed for ethical reasons) • Age—7 years old. • Address— • Educational framework—Special education school • Family—Parents and eight children • Reason for referral to music therapy—Neuropsychological condition of child: mild retardation, learning disabilities, and psychologically based anxieties • Previous and present therapeutic frameworks —None • Diagnosis—Mild retardation, learning disabilities, and psychologically based anxieties • External impression—A sweet, polite child, very cooperative, eager to be a “good boy,” has some vision problems and mild hyperactivity • Equipment employed—None • Movement (fine and gross mobility)—General hypotonia, head and torso lean forward, left side is dominant, changes posture every few minutes. He accompanies his talking with energetic movements and while listening moves in back and forth, praying movements. Avi has difficulties in finger separation and in directing his hands in an efficient way (apraxis). • Senses—Hearing seems to be normal, has some vision problems (as yet unclear) • Vocality—Avi speaks and sings very willingly. His speech is very quick, not always fluent, but understandable. His singing is clear, and he keeps tonality easily. He is able to improvise within a harmonic frame and adds words from time to time. His pronunciation of words while singing is very clear compared to his nonmelodic speech. • Rhythmicality—Both rhythmical perception and rhythmical performance are very good. His muscle tone is elevated while drumming with both hands. • Instrument playing—He moves quickly from one instrument to the other, drumming with two hands in a free, creative way. In four-hands piano playing, he tries to cooperate in spite of his fine motor difficulties. Avi enjoys conversing through the piano. While playing simple wind instruments he invests too much energy in order to produce a sound and while doing so stiffens his neck muscles. • Hearing and listening—Seem normal • Emotional aspects—Avi is an energetic, hyperactive child, verbally and musically communicative, interested in contact. He tries to be a good child and to overcome his concentration difficulties. He tells stories with tragic contents but is not ready to discuss them and abandons them as soon as possible. • Cognitive aspects —Avi has associative thinking. As he becomes excited, his sentence formation becomes chaotic and so does his pronunciation. He can only read with punctuations. His mathematical abilities are low for his age.

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Social aspects—Avi is very cooperative when interacting with an adult. Generally speaking, he is a very lonely child and has no socialization strategies. This fact contributes to his closing up at home as a result of anxiety. Summary and recommendations—Avi seems to be a very easy child to be with, but at the moment he probably needs a period of adaptation and to form a trusting relationship before he’ll be able to seriously work on his anxieties and loneliness. As he loves music and is ready to use it in different creative ways, I believe that it would be worthwhile to proceed with developmental-integrative music therapy that takes into consideration the physical, emotional, cognitive, and social aspects of development.

Therapeutic Considerations Avi was raised in a loving family that acted as a small community within a larger community. His parents were very intelligent and aware of their son’s need for help. At home and perhaps in their community as well, people did not discuss their emotional problems and were very busy building the country according to their own principles and beliefs. Through my work with children whose parents have strong idealistic principles concerning Israel, I have noticed that parents attempt to bequeath these principles to their children, usually with great success. There are several problems inherent in this process: 1. Not every child is strong enough to cope with the existential dangers that accompany certain ideologies. In this case, Avi, due to his developmental problems, was unable to do so. 2. The conversations surrounding idealistic issues do not include clarification of emotional content. Avi was not accustomed to talking about his difficulties and certainly not used to asking for help. Neither was he encouraged to do so by his parents. They loved him and took care of him, and in practice he was also helped by his brothers and sisters. However, when he was frightened and unable to function, the family encouraged him to overcome his feelings and to behave normally. They would request that he employ a form of detachment mechanism, but he could not do so as he was overwhelmed by anxiety. Each time the radio/television informed the public of a terror attack or shooting or wounding of civilians, he had proof that the dangers were not imagined. They were real. Yet when Avi’s situation became very difficult, they decided to bring him to music therapy, as music was his beloved art. It became clear to me that treating Avi was not enough and that I would have to find a way to change the parents’ attitude and help them understand that the child’s anxiety could be worked on only through a mutual collaboration. In order to do so, I suggested a monthly meeting to clarify the developmental progress and the general situation. The parents immediately consented. A. Music Therapy First Stage (about six months) This stage was characterized by experimenting with musical improvisations in different ways: Avi tried out the many musical instruments, learned to converse through music in interactions with the therapist, experienced activating songs from different categories (motor, sensory, emotional, cognitive, and social), sang, was stimulated by music to move and paint, listened to

short compositions, created music for his little theatrical stories, and, in spite of his difficulties, began to write little songs. Generally speaking, Avi had improved his motor skills throughout this stage and was taught to elevate his muscle tone through proper movement. He extended his concentration span and experienced much pleasure. Avi began to trust the therapist and to understand that music can express emotions. I regard this period as an introductory warming up phase for the impending developments. During this phase, we planted the roots of the music therapy process. Parent-Therapist Meetings. Throughout this stage, I met the parents approximately once a month, and we had conversations concerning Avi’s development and needs as well as some experiences with music. Avi was not present in these meetings. Though it could not be defined under the title of Family Therapy, I did use some of my acquired knowledge of the field. In their first chapter, “In Search of the Golden Mean,” Bergman and Cohen (1994) write that regarding each child in the family, the parents must ask themselves: How much pressure can be put on the child? Can I trust his ability to make decisions? Do we have to expose him to such a reality, and how much protection and help should we provide? Concerning education and growth, parents are naturally inclined to behave in accordance with their personality, beliefs and ideals. The encounter with the child’s response sometimes compels them to recheck their strategies and mobilize themselves to alter them. In our first conversation, I told them of Avi’s musical creativity and expressed hope that based on it we would be able to help him. We agreed that concern for Avi’s well-being was what should guide them as parents and me as his therapist. We also agreed that Avi was different from their other children and that he may require a special, adapted attitude. They claimed that by principle they treated him as equal to their other children, and we discussed the possibility of changing this philosophy for Avi’s sake. Generally speaking, the meetings in this first stage progressed slowly, with no dramatic developments, but they gradually proved efficient. B and C. Music Therapy Second Stage (about 12 months) From these stages, I chose four examples, which will be presented in chronological order. It should be mentioned that these examples are but a few out of many others. The Bloody Bus. Avi came to the session and told me that he had had a dream/nightmare. He requested to draw his dream, and the picture below was the result. His explanation: “I went to school on a bus full of many other children. Suddenly, I heard a very, very terrible noise like the voice of a thousand witches, and the whole bus flew in the air. Only the floor, which was covered with blood, remained. All the children were dead and flew out of the windows. I lost my hands and legs and could never move again.” He then added: “This is why I’ll never again ride on a bus.”

We worked further on the subject through verbal discussion, shifting to music and recounting the dream through musical improvisations, finding the most important scenes in the dream and so on. It was clear to me that soothing is primal and not the way to treat Avi’s severe anxiety. On the other hand, it was also unclear whether the artistic modalities (painting, music) and the verbal discussions were doing the work. Nonetheless, these were the events that took place in the described session and I decided to wait patiently for more developments. The Death March. Several weeks later, Avi entered the music therapy room, sat by the piano, and began to sing an incessant mourning song in an incantation style in which he named and told the story of all of the people his family and the community had lost in the past years. While chanting, he rhythmically hit the piano’s keys and at a certain moment asked me to accompany him. I did so by slowly playing contours, perceiving his singing as a recitative, thus supporting him. This musical occurrence was experienced as a march of dead people in a long, endless row. Later on, I obtained information from the family that supplied proof that all of the names and stories were true. Avi had stored in his memory everything that he had heard about death and tragedies in his community and family. It was as though he had collected mounds of details that contributed to his anxiety. How do we work on anxiety when real life is the main contributor to its origin? How was it possible to support Avi without changing his environment, his community, and his country? How could I make him stronger, considering the fact that he was born with neurological problems and mild retardation? An Artistic Cemetery. Throughout a long period, Avi established burial ceremonies through every artistic modality. He commenced the entire process by choosing a big cardboard box in which he asked me to store his future creations. He began with paintings of different motives that indeed are typical of Jewish cemeteries3: mainly the Star of David, the blessing hands, and a cut-off tree. He painted several variations on these topics and did not talk of their meanings. I knew that he was acquainted with the cemetery near his village. He proceeded by taking a plastic box of butter, painting it with colors, and placing something inside. He then

closed it and scattered some earth on it. He then placed it in the cardboard box and asked me to keep it in the music room, declaring that it was a cemetery. I sensed that by doing so, he was coping with his death anxiety through action. I asked Avi for permission to invite his parents to one of his music therapy sessions, with the notion that it might help them better understand what frightens him. Avi agreed. .

Drumming the Bad People to Death. Avi was a gentle child who rarely exerted strength, not even while drumming. I tried to encourage him to do so by playing together and supplying modeling or by playing along with precomposed drumming or as a reaction to a story. It worked somewhat, until Avi fully recognized the possibility of making a lot of noise and initiated a story: “There once was a bad man who killed one person every day. So he killed children, fathers and mothers, grandfathers and grandmothers, uncles and aunts, animals, and everything. Then he hid the dead people in a cave in the mountains and put a huge stone at its entrance. One day, a group of children passed by the cave and found all the dead people. They ran away and called the police and the soldiers. The man was captured and put in prison forever.” After he told this horror story, he began to beat the orchestral timpani with all of his might. It should be mentioned that at Avi’s home there was no television, so this “film” was his personal invention and the product of his imagination. Up until the hour’s end, we worked together just on beating the huge drums, chasing away the ghosts and frightening evils that filled Avi’s heart and head. Through his story, just as through the “bloody bus” painting, Avi was able to open a window into the frightening pictures in his mind that caused his unbearable anxiety. Expressing the themes fueling his anxiety through artistic modalities and explaining them with words added additional value to the entire process, compared with just talking. As a music therapist, I frequently feel that this is one of the strongest advantages our profession has to offer. Generally speaking, anxiety is defined as “...a state of uneasiness, accompanied by dysphoria and somatic signs and symptoms of tension, focused on apprehension of possible failure, misfortune, or danger” (Colman, p. 46). In Avi’s case, the threat of danger was real. The community’s philosophy of “God shall guard us and we have to be strong” was not relevant to Avi. He was not strong and he was not mature enough to understand his community’s ideology. Salvador Minuchin (1974) explains that in most societies, the family stamps self-values and individuality on its members. Experiencing human identification has two aspects: the sense of belonging and the sense of separation. The sense of belonging is developed within the family’s boundaries, and the sense of separation develops as a result of participation in subfamilial settings and in extrafamilial groups and relationships. Avi essentially had a strong, almost compelling sense of belonging without the strength that it might facilitate. He had not, however, exercised separation or parting because of his loneliness and communication difficulties. The meetings with the parents revolved around this concept, and I hoped that the parents would alter their attitude and support their son in every possible way. Indeed, due to their goodwill the changes eventually transpired, and Avi’s self-confidence improved. In therapy, we dedicated part of the hour to socialization until it became apparent that Avi needed group therapy. Group music therapy is an important branch in our profession. It has been employed from ancient times on, as in healing rituals of traditional societies such as Siberia (Sekeles, 2000). Group music therapy has become the topic of much theoretical research (Plach, 1980;

Davies & Richards, 2002; Pavlicevic, 2003; Hunt, 2005). Social Interaction. The group was composed of four children about Avi’s age (7 to 8): a blind boy, a girl who suffered from spina bifida, another girl with learning disabilities, and Avi. Virginia Satir (1989) mentions four life aspects are ever present in family dynamics: • • • •

Self-esteem (the feelings and thoughts that a person develops in connection to himself) Communication (the paths people choose in order to create interrelationships) The family structure (the rules people use to direct their feelings and actions) Social contacts (the interrelationships between family members and the outside world)

I decided to work on these four life aspects within the group. Through music, it was possible to establish clear rules that were flexible enough to leave place for the expression of individual wishes. We exercised interrelationships through different musical techniques that also helped to encourage the children to demonstrate patience and respect for one another. Self-confidence and self-esteem were developed through these approaches. The group therapy stage continued for a year, and at its end, the music therapy process was concluded. Summary Avi, a 7-year-old boy at that time, was brought to music therapy with the following problems: mild retardation, learning disabilities, hypotonia, lack of social skills, and anxiety that sabotaged his everyday life. Avi lived with his family in a community outside “the Green Line” whose members had experienced many tragedies, including death, injuries, and more. He went to school every day in an armored bus, but still feared his own shadow, a fact that did not promote his development of social strategies. Being one of eight children, Avi was educated, as all of his brothers and sisters were, in light of a specific ideology that accentuated the positive sides of being strong and which related to God’s will. Avi was too weak to exercise this direction. It should be stressed that Avi’s parents and family were caring, loving people with strong faith in their chosen path. In spite of this faith, they agreed to meet with the therapist monthly and gradually, as far as Avi was concerned, shifted their inflexible ideology to one more comforting and supporting. With Avi’s permission, the parents also joined two of their son’s sessions. The fact that music possesses all of the curing aspects of “playing” (not only the fun, but also the ability to discharge anger, aggressiveness, and anxiety, and to develop human relationships, socialization, and communication) helped all those involved and certainly illustrated to the parents their son’s world of frightening fantasies. As Winnicott (1971) formulated it: “The natural thing is playing, and the highly sophisticated 20th-century phenomenon is psychoanalysis. It must be of value to the analyst to be constantly reminded not only of what is owed to Freud but also of what we owe to the natural and universal thing called playing” (p. 48). The power of playing through music proved true in regard to Avi himself, Avi and his parents, Avi and the therapist,

and Avi and the therapeutic group. Music therapy was the modality through which Avi began to express himself, his anxieties, his horror fantasies, and his loneliness. Following 18 months of individual music therapy, in order to encourage Avi’s communication and socialization, I formed a group of four children who spent a year together exercising human relationships. At the end of this period, Avi’s process was concluded and the music therapy sessions were discontinued. Frequently, adults do their best to mold the lives of their children in accordance to their own beliefs, ideologies, and education. Children often do their best to follow their parents’ lead in order to gain their parents’ approval and acceptance and to feel part of a group or a community and share a common power. In the case of children who suffer from deficiencies, this may prove to be a dangerous tendency. It may eventually operate as an obstacle and disrupt the child’s development. Avi was lucky to have parents with goodwill and enough strength to work on and accept change, thereby saving their son from further deterioration. Among other alterations, one of them began to accompany Avi on the bus, encouraging and supporting him by remaining near to him, and gradually improving his self-confidence. The Muslim claims that we cannot change our fate, that it is fixed from birth on and that death will arrive whenever Allah (God) has appointed it. I wonder about this fatalistic saying. Even so, 11 years later, Avi was killed in a car accident and was buried in the graveyard near his village. God bless his soul. Notes (1)

(2)

(3) (4)

Meir Harnik was born in 1927 and died in a motorcycle accident in 1972. He was an excellent musician, a performing pianist, a choir director, a presenter of programs in the Israeli radio, among the initiators of the Israeli television, and a creator of songs as well as of piano compositions. He traveled all over the country with his vocal group to present Israeli songs and encouraged the careers of many young artists. I dedicate this chapter to Meir Harnik for his multifaceted, colorful personality and for his musical friendship and inspiration. “The Green Line” is the term given to the border of Israel as was established by the 1949 armistice agreement with Jordan. This transpired before the Six Days War (1967) in which Israel conquered the West Bank and Gaza. Most countries and organizations view the green line as a de facto border. Incantation is a vocal style that includes melodic speech and spells. It can be found in the healing rituals of traditional societies and in Western music of mystical content (see Sekeles, 1995). The ornamentation on Israeli-Jewish gravestones is traditionally limited. For example: the Star of David = shield of David. This six-pointed star has held meaning in Judaism since the 6th century B.C.E. and symbolizes the reconciliation of opposites. It is seen on tombstones, in synagogues, and on the Israeli flag. Hands held in benediction is the symbol of the Cohen = the priestly family of the Levi’s tribe. A crown is a symbol of the “Torah” (the first part of the Bible) or of priesthood, kings, or God. Animals: The lion is the symbol of Judah’s tribe; the deer is the symbol of Naftali’s tribe. A lamp with seven candles symbolizes wisdom and purification. A cut-off tree is the symbol of a cut-off life.

(Robertson, 2006.) Due to Avi’s traditional education, he was probably familiar with some of these symbols from his family and community. References See end of Case Four

Taken from: Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum NH: Barcelona Publishers.

CASE FOUR Life under Terror: Israeli Songs in Music Therapy: A Case Analysis Chava Sekeles “The day has gone, the night arrived, the two are taking an eternal slumber, on the well of blood, on the well of umber” (from “Ringing Chimes,”1 lyrics and music by M. Shelem, 1937) Dedicated to Amos Fink2 Introduction Miri was 4 years old when referred to music therapy. She was a tiny little girl with curly blond hair and a blank facial expression—save for her searching eyes—with sharp, quick movements, she was devoid of verbal communication. Miri did not use her voice; neither did she react to the voices of others. She gave me the immediate impression of a little animal, confused in a new cage, using nonstop mobility to survive. I was informed by Miri’s father that she could talk, that she was a very intelligent little girl, that her language was extremely advanced, and that her loss of voice was due to a traumatic event: She had been shopping with her mother and her baby brother, and as they had been standing by the window of a delicatessen, a “human bomb” had detonated, blowing up the entire floor. The mother and brother were killed on the spot. Miri was mainly wounded from the dispersion of glass. Unconscious, she was rushed to the hospital, and it later became clear that she did not remember or realize what had happened. She regained consciousness the following day when she awoke from the operation she had undergone. Miri spent several weeks in the hospital, and it soon became clear that she would not use her voice and that the trauma she had experienced would necessitate a long process of recovery. At that time, she had already been informed as to the death of her mother and baby brother. Her father told me that when the news was broken to her, she did not cry or react. Why music therapy? Mainly because Miri did not cooperate in verbal therapy, play therapy, or any another art therapy modality. We were not certain that music therapy was the answer, but we decided to give it a try. Intake and Observation Miri was brought to therapy by her father, who, in compliance with my request, remained in the room throughout the session. He sat quietly on the couch, watching his little

daughter. She would run around the room, not touching any of the musical instruments and not making any reference to her father or to me. Miri could be observed as detached, with the exception of the interest she conveyed through her eyes. I noticed her looking at the guitar, knowing that Miri’s mother had loved folk singing and sometimes used to accompany herself on the guitar. I therefore decided not to touch the guitar and to be careful not to rush into too hasty a step. Neither did I talk to her or to her father. The room was quiet and calm. Nobody interfered with Miri’s walking around. This initial meeting was the experience of three people using their eyes without uttering a sound. The music clinic, which is abundant in instruments from all over the world, cassettes, and a CD library, became a watching room. Nonetheless, I did not feel uncomfortable and neither did Miri’s father. We were under the impression that neither did Miri. According to the model I work with, Developmental-Integrative Model in Music Therapy (Sekeles, 1996), the intake/observation stage holds the potential of turning into the preliminary process of therapy. Consequently, the initial behavior of a client in the music therapy room informs us greatly of stages yet to come far beyond the historical details divulged to us. Therefore, therapeutic considerations must sometimes wait until the scene fills up with meaningful details. In this case: the child before the trauma, the family constellation (relationship with the parents, brothers, grandparents), the child in the educational setting, the community, general development (emotional, sensory-motor, cognitive, social), artistic tendencies, dislikes, and more. It most often takes a considerable amount of time to collect all the details, requiring much patience. Throughout the two weeks of observations (twice a week for a full hour), aspects that had to do with senses, motion, concentration, and tension became more apparent, and Miri was also able to remain in the clinic without her father. From my observation pages (ibid., Appendix 3, pp. 153-155), I summarized the following aspects (some points were left blank for ethical reasons and others could not yet be examined): • • • • • • • • • •

• •

Observation location—Well-equipped music therapy clinic. Duration/date/hour— Reported to— Received by— Name of patient—Miri (changed for ethical reasons). Age—~ years old. Address— Educational framework—Non-obligatory kindergarten in a city community. Family—Father and 10-year-old brother. Mother and baby brother were killed two months ago in a terror attack. Reason for referral to music therapy—Psychological condition of child and muteness after surviving (with comparatively mild physical injuries) the explosion in which her mother and brother were killed; her difficulty to cooperate in verbal therapy and in other tried modalities. Previous and present therapeutic frameworks—During her hospitalization, the child received psychological aid and occupational therapy. Miri was not able to cooperate. Diagnosis—Physical injuries were appropriately treated. Her psychological condition remained severe. She does not speak, does not play with the children in

kindergarten, barely eats, sleeps about three hours a night, prefers to stay at home in bed, and does not show interest in anything. She moves quietly in the room, does not cry, and scarcely relates to her father and older brother. Miri fits the clinical picture of PTSD.3 • External impression—Thin little girl, curly blond hair, neatly dressed, cute face, big dark eyes, very sad facial expression, moves nonstop in the room, does not touch anything, and stares around. • Equipment employed—None. • Movement (fine and gross mobility)—Walking and balance looks normal and adequate for her age. Specific motor abilities could not yet be examined. • Senses—What could be examined so far seems normal. • Vocality—Specific vocality could not be examined. The child does not use her voice at all. • Rhythmicality—The present tempo of her walking is pretty fast. Other aspects could not yet be checked. • Instrument playing—She does not touch any musical instrument. • Hearing and listening—Though she does not speak, she seems to listen and understand general directives such as “Please come inside” or “We have finished today, hope to see you next week.” I have been told that she has a high level of language comprehension. • Emotional aspects—Miri does not yet initiate contact, but also she does not run away from the music room. She does not express any strong feeling such as anger, fear, aggression, or even passive-aggressiveness. She is mainly passive and receptive only through her eyes and probably her ears. There is no question about the severe psychological damage and the patience required in therapy to hopefully overcome the horrible trauma. • Cognitive aspects—These could not be examined but have been reported to be very good. There is no brain damage. • Social aspects—Cooperation could hardly be examined. • Summary and recommendations—Though Miri shows signs of depression and avoidance of people and almost all everyday functions, she seems to be accepting the music therapy clinic and perhaps the calm atmosphere I try to keep in it. The fact that she gazes at the guitar might help at a proper moment. Patience is always an extremely important aspect in therapy and this is surely so in Miri’s case. In the two weeks of observation, she was not pushed to do anything, and we have the impression that it helped her to get used to the room, its physical content, its atmosphere, and probably to the therapist. It also occurs to me that my age may cause Miri to associate me with more of a grandmotherly figure than a (her) mother. This might assist in developing trust. Therapeutic Considerations: Based on Intake, Practice, and Theory In the meantime, I had learned that Miri was raised in a warm, loving family. Her father’s profession was related to agriculture, her mother’s had been in education, and folk

singing was a hobby that she took seriously. Grandparents on both sides were still alive and involved in their children’s lives. Miri and her brothers had had a good, healthy relationship. Though her father, brother, and grandparents had undergone a horrible experience, they knew that they ought to direct all the efforts toward Miri and were very willing to accept her as she was, not to push her, and to support her with love and care. During this period, her father and brother were supported by a social worker. As for the kindergarten teacher, she was a nice lady who had lost her husband in one of our wars. She therefore treated Miri with patience and took proper caution and care. Being well aware of the practical and theoretical importance of the preloss human relationship, this background gave me hope. When young children lose a parent before their personality is fully developed and before they fully internalize their parents’ image, it is especially necessary to examine the preloss emotional environment and the postloss ability of their surroundings to contain the bereaved child as she is. There is no way to comprehend the change that occurred in the child’s behavior without being aware of how she remembers and has internalized the deceased parent. In cases where the parent-child relationship was healthy and facilitating and the surviving parent maintained suitable functioning, though he experienced the loss as well, there is a better chance for the child to adjust and to rebuild her life. Bowlby taught us that it is essential for animals and young children to be close to their mothers in order to physically exist and to mentally construct the representation of the mother’s image. In his attachment theory, Bowlby claims that grief indicates the effort of the grieving person to sustain a connection to the dead person. The mandatory departure and the irreversibility of death elicit anxiety and protest. Bowlby (1969, 1973, 1980) wrote three volumes on the subject of loss from the perspective of object relations and the essential role of attachment in development and functioning from infancy to old age. He accentuated the importance of the different stages of mourning: shock and nonacceptance, searching for everything related to the deceased, disintegration of the existing psychological organization, and reorganization. The final stage has to do with the releasing of the bond to the dead person. Kubler-Ross’s (1969) stages are as follows: denial and isolation, anger, bargaining, depression, acceptance (pp. 34- 122). Though Kubler-Ross discusses work with terminal patients in this book, the stages she formulated are also valid in cases of bereavement. Miri had gone shopping with her mother and brother and then found herself wounded and in pain in the strange surroundings of a hospital. With her mother suddenly gone, a huge black hole of missing memories enveloped her, but the catastrophic experience was certainly buried somewhere in her brain and heart. This situation struck her with numbness as a radical defense mechanism. We must remember that Miri was merely 4 years old. It took time until her father could tell her about the explosion and loss of her mother and brother. Miri did not actually witness what had happened, but she probably heard it and perhaps some quick flash ran in her mind. The defense mechanism of denial served to hinder the realization of the horrifying events and prevent any possible pain. Smilansky (1981) claims that only at the age of 4 to 5 does the child begin to understand the concept of death. At this stage in life, children conceptualize death as a different form of life, similar to sleep in a way, and thus reversible. The full understanding of what it means to die is delayed to a further stage, which takes place at age 9, 10, or even 11, according to some researchers (pp. 36-37). Smilansky claims that many children in a loss situation are afraid that they may fall asleep and never wake. Perhaps this was

partially contributing to Miri’s sleeplessness in addition to a more general anxiety as the result of the Post-Traumatic Stress Disorder (PTSD). Miri’s father, with whom I regularly met, impressed me with his ability to mobilize his energy for Miri and his 10-year-old son, while still tending to his own mourning process. Though he shared the typical characteristics of Israeli men who served in a selected military group and mostly kept his emotions to himself, in this particular situation he was committed to doing anything for his children. He also amazed me with his understanding that it would be a long process and that he had to trust me to calculate the proper timing to intervene. Intervention, as Bruscia (1998) defines it, is “a purposeful attempt to mitigate an existing condition in order to affect some kind of change” (p. 44). In Miri’s case, the intervention began by bringing her to the music therapy clinic where she could soon be left with the therapist. Breznitz (1983), in discussing “the denial of stress,” claims that denial works as a barrier between life and death. From this point of view, it denies the psychobiological continuation of life. Not to know and not to touch actually exempt the child from coping with pain and loss and the irreversibility of death. First Stage Following an additional week similar in content to the four observational meetings, I had the feeling that a more active intervention could take place: Miri arrived at the clinic, where soft music, lullaby style, welcomed her. In the middle of the room there were some handmade animal puppets and symbolic figures (grandfather, angel, witch, baby, etc.). I sat on the carpet activating the puppets, joining the music, inventing lullaby words, and putting the puppets to sleep on a cushion. Miri watched, stopped moving, suddenly sat near the cushion, and began to slowly move back and forth to the rhythm of the music. I continued to address her, describing what she was doing with new words. At a certain moment, Miri put her head on the carpet near the puppets, closed her eyes, and fell asleep until the end of our meeting. When Miri’s father arrived, she was still asleep. He told me that she was accustomed to going to bed with her mother singing to her. Since her death, when he tried to do the same or to tell her a story, she would pull the blanket over her head, signaling her unwillingness to listen. We both considered her response to the improvised “bedtime story” positive, specifically since calm sleeping was one of the treatment’s objectives and it happened in a manner more similar to her normal past. On this occasion, her father told me that Miri loved many Israeli songs and that she even knew very complicated texts and melodies by heart. In the subsequent meeting, I sat on the carpet holding a soft teddy bear in my arms, singing a Hebrew bear song to him. Again, Miri sat near me and looked at the bear. I handed him to her softly. She took the bear while I continued the song. After half an hour, she placed the bear on the sofa, approached the shelves of recordings, and looked at them intensively. I have about a thousand cassettes as well as CDs, records, and more. The cassettes are organized in different colors. Light blue is the color of the Israeli song cassettes. I pointed at this shelf and told her that she could choose one. Miri hesitated, then randomly removed a cassette and placed it in my hand. I understood this as a request to listen to it and inserted it in the tape recorder. It was the music of Yoni Rechter, one of our talented composers, whose music and harmonization have original features. The first song was titled “The Most Beautiful Girl in the

Kindergarten.” She could certainly have chosen a different cassette, and it could have been a different song. However, what had happened left me with an elated feeling of “something good is happening with Miri. There is hope.” The following session, Miri brought a CD of Israeli songs, which she was fond of, according to her father. These songs were not meant for children, and the lyrics were not simple. They consisted of a collection of a variety of songs sung by Mati Caspi in his semiapathic poker voice. I could not avoid comparing his expression to hers, which in a way was very similar. Miri stopped walking around and sat near to me on the carpet, leaning against the sofa and listening quietly to the singing. At the end, I decided to softly join in the performer’s singing. Miri did not react clearly but stayed in her place. In this session, we further established the phase of mutual listening, which in music therapy represents the dynamics of being. This stage persisted for three months and enabled me to gradually introduce tiny changes: to join in singing to different performers she brought, sometimes adding a small musical instrument, then an autoharp, an alto recorder, and a piano. Following these three months, Miri entered the clinic, went straight to the string instruments (hanging on the wall), and pointed at the guitar. A heart-warming moment resulted: I took the guitar and handed it to her, and she placed it on the carpet. Therapeutic Considerations. Virtually all of the professional literature dealing with children’s conditions resulting from PTSD discusses the importance of gradual intervention; patience; using clear, simple words; emotional reassurance; and behavioral consistency. Specifically, when there is an inhibition of feelings, meaning: no way out, no sharing, no ventilation. Tatelbaum (1984), in her book The Courage to Grieve, emphasizes that “the manner of death affects our grief. Sudden death (war, accidents) causes shock, anxiety, distress ...” (p. 14). As Miri had been fixated on this stage, the only way to help her out was to be there with her, encourage tiny variations, and allow her to gradually raise her head above the water. This is a summary of what happened during the first stage of therapy. Following a lengthy period of mutism and detachment, Miri brought her own familiar, reassuring material (Israeli songs) and used it to connect to the music therapy clinic, to the therapist, to her dead mother, and, above all, to herself. She chose adult and not typical children’s songs, most with complicated lyrics and melodies, but they were hers. The Israeli songs, according to my interpretation, were like golden threads connecting her to the beauty and warmth of her mother and enabled her to be aided and comforted by good memories at this stage. So far, selecting the music and bringing it to the clinic was the active part of the music therapy, and the mutual listening was the receptive music therapy. I considered the initiation of the active part an additional step toward normal life. Second Stage The guitar was lying on the carpet where Miri had placed it. I softly touched the strings and stopped. Miri then took my hand and pushed it toward the strings. Each time a new variation transpired, I felt as though it was part of a process of rebirth. The first variation was Miri sitting on the carpet (attention and concentration), the second was Miri sitting on the carpet and moving to the rhythm of the music played (turning the external

stimulation into a self-action), the third was choosing a cassette (demonstrating initiation and interest in the music therapy room), the fourth was listening to it (dynamics of “being”), and the fifth was bringing her own cassettes for mutual listening (connecting her home life to the clinic by bringing material of her own). The final variation emerged after three months through a request she made (though had not yet verbally expressed): Play the guitar for me. I quickly screened a proper song and decided in favor of a Mati Kaspi melody with lyrics by Jehonathan Geffen, “A Place for Concern”: At the end of the sky and at the end of the desert, there is a remote place covered with wildflowers. God sits there, observes, and thinks about his creation. It is forbidden to pick the flowers of the garden. And he is worried, he is enormously worried. (1st verse) My choice was made in Miri’s footsteps: She loved the composer (probably because of his voice and calm expression) and was familiar with his songs. I sang it accompanying myself on the guitar. Miri listened with her gaze directed at the wall. I thought that it may have been too intimate for her, but still, she listened attentively. Following that moment, there transpired a few weeks during which Miri would listen to Israeli songs, which I sang, accompanied by the guitar or piano. From a psychological point of view, listening to live music is certainly different from listening to a recording. The patienttherapist-sound/music relationship elicits closeness or even intimacy. The position among these three elements might be very influential. At this stage, the therapist and the music were in an active position and the patient was in a receptive position, but we were gradually approaching a change in this balance: Miri began to say “Yes” and “No” and took an active role in selecting music. The same process was transpiring at home, where she showed more initiative. The situation concerning eating and sleeping had improved, and there were small signs of positive changes, even in her kindergarten. Regarding the everyday therapeutic considerations, I examined the dynamical line and concluded that although progress was slow, there had been no regression and the tempo suited the depth of Miri’s psychological damage. Third Stage After Miri had already been in music therapy for several months, the following occurred: I considered that she was ready for a more direct step and thus chose a children’s song about a family where mother and father are mentioned and sang it accompanying myself on the piano. Miri listened and after one verse joined in singing the song. She knew the words perfectly. I stopped singing while she continued on till its end. The sound of her voice was an utter surprise, as though a tiny little ray of light had peered through the darkness and modestly brightened the clinic. Miri had a pure voice, very beautiful though not yet daring. Her rhythm was perfect, and she knew all the words. My general impression was that her voice was imprisoned in a spiritual cage waiting for salvation and liberation. This incidence indicated the beginning of a new phase: Miri became active, sang

gently, not yet in her full voice, chose Israeli songs, was willing to record her singing and relisten to it, spoke very little, but spontaneously uttered few sentences. Positive development appeared when Miri at times began to object to my suggestions and insisted on her own. I accepted these oppositions as the development of ego strength and trust in the therapist. At a certain point, I considered expanding the improvisational component by instrumental interaction. As common with many children suffering from deep anxiety and disability, Miri feared to show anger, and thus was willing to play on different musical instruments but excluded the big drums. An additional two months transpired before she gradually began to touch the drums and, encouraged by my piano playing, broadened the range of dynamics and tempo. At that time, her verbal communication had improved, though she still did not mention her mother, brother, or explosion. Compared to the initial static stage, therapy was now steadily progressing, albeit at a very slow tempo. Therapeutically speaking, this is the stage at which we have to be careful not to be tempted to rush the process along. I was aware of this danger and thus proceeded handin-hand with Miri. As soon as the instrumental improvisation became a part of our meetings, I demonstrated to Miri, by way of modeling, a few examples of vocal improvisations. My goal was to eventually advance to representation, both instrumentally and vocally. Representations in music therapy are done in different ways and can contribute to the revelation of frightening issues by presenting them in a symbolic way. For example: representation of key figures (such as family members), of a situation (for example trauma), of a conflict (interpersonal, intrapersonal), and more (Sekeles, 1996, pp. 53-56). Miri was ready to take a new step: She invented a story about a bird’s family: female, male, and a little daughter. Miri used various instruments, choosing a different wind instrument for each bird and using the cymbal to represent a black, evil cat, which she added to the scene. She “played” the family and asked me to play the cat on the “flageolet oboe.” Within a short period of time, she began to add words to the story and transformed it into a murder scene in which the cat killed the bird’s entire family. By choosing animals, Miri was able to approach her own family in a circumventing, symbolic way while still maintaining close contact to reality. After relistening to the recording, she commented very softly: “Like my mother and Ben. Both killed by a dangerous man.” Fourth Stage Following the utterance of these words and the opening of the shelter in which the horrors were hiding, Miri gained the courage for more and more expression through music, words, role playing, and more. The sessions had their own architecture, meaning that they became structured from within: Miri always brought a CD of Israeli songs or chose one from my collection, usually joining the music with her own voice, adding musical instruments. After this opening, which served as a holding frame, she would invent a story on varying subjects, mainly horrifying, including a variety of emotions: anger, sadness, hatred, and aggressiveness. These were mainly directed at “the bad people” or the “bad man” and at times toward her mother. Gradually, she could clearly state that mother left her and took her baby brother with her. For this, she was very angry. Moreover, she told a story in which people were killed by a bomb, disintegrated into tiny pieces, and disappeared forever in the sea. Fifteen years later, I heard of

the same image from another little girl whose mother was killed by the collapsing of a floor, and though her father had told her exactly what had happened, she still had the notion that it was just like the explosion of the space shuttle Columbia. It taught me that the burden of a horrible blocked image (which, though repressed, does not lose vitality, threatens to surface, and requires much energy to be kept repressed) can be very dangerous and that artistic expression is not always enough. It certainly requires, if possible, a verbal elaboration as well. Indeed, her stories gave us the opportunity to openly discuss the death of her mother and baby brother, ventilate the nightmares, and gradually understand the irreversibility of death. Fifth Stage After the ninth month, Miri was able to visit the kindergarten on a regular basis, communicated with her friends there, became manageable at home, joined the family on weekend journeys, could sit with her father and older brother and look at a family album, and slept and ate normally. I remained concerned due to the fact that she cried very little, as if some parts in her being had not really healed. She continued to come to music therapy for an additional year, until at the age of 6 we were certain that she was prepared to proceed to elementary school. That final year, Miri composed about 20 songs, complete with lyrics, through which meaningful and threatening material emerged. She improvised the lyrics and the melody, we recorded them, and I wrote them down in her book. When we terminated therapy, she did not request permission to obtain the book. On the contrary, she said: “This belongs to this room and I want to leave it here.” In the last month of therapy, with permission from the family, we visited the mother’s and brother’s graves. Miri’s father accompanied her, and I brought the guitar along with me. At that time, the graves were covered with plants and flowers. As we sat by the grave, Miri’s father uttered a few calming words to her, and Miri said, “Ima [Mother] and Ben live in a nice field with flowers. I want to sing a song for them.” Miri sang a well-known Israeli lullaby-style song accompanied by the guitar, and she then burst into an ocean of tears. It was the heaviest cry of her mourning process. We allowed her to cry for a long time, cradled in father’s arms. Heeding my recommendation, her father again visited the grave with his two children a week later, after which Miri began participating in all the yearly memorial days.4 It is important to remember that Miri began the process as a 4-year-old girl and completed music therapy at the age of nearly 6. During this time, she grew up and her understanding of the concept of death changed, and she became better prepared for life. In his article “Children in Stress Situations,” Noah Milgram (2000), while writing on principles of treatment, warns adults to be careful of forcing their own anxieties and concerns on the children. He recommends surrounding the traumatized child with warm support and confident guidance to help gradually change the fantasies into reality, which is less frightening. I again wish to remind the reader that when the parent or parents support the therapy and cooperate with the therapist, the healing prospect of their child increases. Among other reasons, I included this chapter due to the fact that this was a healthy family constellation, which proved to bear a most positive influence on the process Miri underwent. Summary

In this chapter, I described and analyzed the process that Miri, a little 4- year-old girl, underwent in 21 months of music therapy. She came to therapy two months after being wounded in a terror attack, in which her mother and baby brother were killed. She suffered from PTSD, stopped talking, became very passive, did not cooperate in kindergarten, ate very little, and had sleeping difficulties. In spite of the extreme grief and mourning, Miri’s family was very cooperative, a fact that contributed tremendously to the therapeutic process. This was especially important since the situation required us to be very patient and not hasten progress before time allowed it. Miri’s mother’s hobby was singing Israeli songs while accompanying herself on the guitar. Indeed, at the observation stage, the only musical instrument she gazed at was the guitar. Later on, when she progressed and passed the passive stage, the first two actions she took were related to Israeli songs and to the guitar. Miri passed through five stages of slow, gradual development. Each opened a new, meaningful window to an improved horizon and to the discovery of another hidden layer. After nine months, Miri was able to function at home, in kindergarten, and in the clinic without the anxiety that had stunted her normal development. She could face the facts of loss, reintegrated within the family framework and kindergarten, and expressed herself verbally and musically. She remained in music therapy an additional year to make certain that she went through all the bereavement stages and would be able to cope with elementary school. Miri had a very good background, which, in spite of the horrible trauma, assisted her in returning to life. The role of the therapist was to walk with her slowly, at her own tempo and ability, along the thorny path of blocked emotions and help her rediscover her voice. The role of the Israeli songs was to connect her to her deceased mother even before she would utter the word “mother” and to support her through well-known and beloved musical material. The role of instrumental and later of vocal improvisations was to facilitate her with the ability to represent figures and situations in a symbolic way, as a circumventing stage, before linking them to reality (concerning improvisation, see Wigram, 2004). The songs Miri created in the fifth stage of music therapy expressed issues from the entire therapeutic period and operated as assurance as to her ego strength. In his article “Models of Understanding the Reaction to Trauma in Supporting and Defining the Principles of Treating Trauma and Post-trauma,” Shabtai Noy (2000) claims that dissociation is important in preventing pain and is therefore important for adjustment. Without the ability to detach from the trauma, the survivor might be overwhelmed with endless anxiety. The treatment teaches the patient to use the dissociation to gradually gain mastery over his life and cope with reality (chapter 2). In Miri’s case, she had needed to dissociate herself from the very blurred reality of the explosion in order to eventually be able to emotionally and cognitively reconnect. The DIMT model with which I work considers what may be called pathological symptoms to actually be coping mechanisms. Their eradication is therefore not sufficient. Another challenge is that of the therapist to remain tolerant of these symptoms as much as is necessary and to assist the family to do the same. Further, the therapist must keep the surviving family member, in this case the father, involved as a protector of the child and as a strong, supporting figure, and take care that the child doesn’t develop a dependency on the

therapist. Some psychological theories concerning intervention in a situation of uni-occurrence trauma recommend a short therapeutic process that relays a message of health to the parent and to the child (Peterson, Prout, & Schwartz, 1991). In Miri’s case, it was not possible to rush the dynamics of the events, but the fact that the music therapy clinic looked like a magic room with many interesting objects and sounds helped to turn it (as far as Miri and her father were concerned) into a nonthreatening space and through this enabled a degree of much needed relaxation. The closure of the process was the visit to the cemetery in which I took care to be involved as the music therapist and not as a mother figure. The role of the father was very clear, and he acted as the main figure, strong and facilitating. Many years have passed since Miri’s music therapy sessions have ceased, and thanks to her family and to her, I was granted the opportunity to follow up on her development. After finishing high school, she insisted on joining the Israeli army (though she could have obtained an exemption). She coped very well with her duties, completed her service, and began her academic studies at one of our universities. Noy (2000) said: “Grief is boundless, but a person learns to distance it, as he does with some other feelings, thus preventing them from overwhelming him” (p. 72). Notes (1)

(2)

(3)

(4)

The song was written by M. Shelem, a shepherd and musician, after two of his fellow shepherd friends were ambushed and murdered in 1937 by Arab terrorists. In 1936, the opposition of the Arabs began to take the form of armed insurrection, and the Israelis responded with retaliation. This was one of the more horrific periods of violence in the country. Amos Fink was killed by a sniper in July 1948 during a period of ceasefire. Amos was a lover of nature and a soldier in the Jewish Brigade during World War II, after which he volunteered to help survivors immigrate to Israel. He served as a lieutenant during the Israeli Independence War. Amos left behind a two-month-old baby, Tamar, and a young widow, my eldest sister. Post-Traumatic Stress Disorder (PTSD) “is an anxiety disorder arising as a delayed and protracted response after experiencing or witnessing a traumatic event involving actual or threatened death or serious injury to self or others.” (Colman, 2001, p. 572). The symptoms include a numbing of responsiveness and eating and sleeping problems, which typified Miri’s condition. In the Jewish tradition, every moment is detailed and ritualized, beginning with the prayer of confession (Vidui), continuing with the laws concerning the body, and concluding with the burial procedures and mourning practices (seven consecutive days, then the 30th day following the burial and each Memorial Day). This ritualization provides everyone involved with a firm structure that enables the mourners to focus on their grief and places the burden of the organizational details on the community (cooking, cleaning, participating, and paying last respects, which is perceived in Judaism as the “truest act of charity”). The burial customs are rooted in the biblical era. From an emotional point of view, these customs and the gradual process through which they are

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U5T

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

CASE FIVE From the Highest Height to the Lowest Depth: Music Therapy with a Paraplegic Soldier Chava Sekeles “me’igra rama le’bira amikta”1 Introduction I met Dor2 at the suggestion of his nursing team at the institute where he was undergoing rehabilitation therapy. Dor had suffered serious injuries to his lower spine after having a military accident that left him a paraplegic.3 Another soldier was slightly wounded, and a third was killed instantly. Since Dor refused to comply with his proposed treatments, the nursing team suggested bringing in a music therapist from outside the institute. At that time, Dor was about twenty. He was a soldier in routine service in the army and his parent’s only child. Before the accident he had been an excellent sportsman, had played electric guitar in an amateur band, had enjoyed nature and hiking and had been considered intelligent, joyful and sociable. Dor’s music therapy process was based on the Developmental-Integrative Model in Music Therapy4 (DIMT) (Sekeles, 2006) which integrates neurological as well as psychological facets. The overall goal was to enable Dor to return, as much as possible, to his music and hobbies, and to facilitate his psychological rehabilitation. In our first meeting, these goals seemed to be overly ambitious and impossible to reach. The changes were slow and gradual and required significant patience. In this chapter, I will de scribe and analyze the obstacle course the patient and therapist passed through together, the necessity for flexibility on one hand, and of a clear and supportive framework on the other, the meaning of mutual trust, and the struggles gaining and maintaining that trust. Foundational Concepts A Basic Foundation of Beliefs and Principles As music therapists, and trainers of music therapists, we frequently examine our own psycho-musical sources, the profound influence music has on our spiritual and physical life and the place music holds in our personal life. As far as I have observed and investigated, models of music therapy were established and assembled by professionals based on and influenced by their personal history and culture, as well as by practical and theoretical thinking that

connected music to relevant subjects and developed into one body. Moreover, over the course of years I learned that therapists who strongly believe in the healing power of music began their relationship with music at an early stage in their lives, and music became metaphorically intertwined with their physical and spiritual organism, like fine threads of silk. Throughout the many years in which I gradually defined my own model (DIMT), I underwent the same process by carefully examining my musical history, and by performing a kind of musical psychoanalysis. This analysis brought me to the clear conclusion that the basic principles of the DIMT model were rooted in my personal developmental path and in the integration of my multi-faceted studies: music, occupational therapy, psychology, ethno-psychology and musicology. Another factor is my belief that music is like food, faith and love: natural ingredients necessary for a healthy, meaningful life. Music may be the language of therapy, but can we conduct therapy without words? Furthermore, can we utilize words and movement without knowledge of psychological and medical processes? In music therapy, there are approaches and models which claim that psychological thinking and medical knowledge are almost irrelevant vis-à-vis the knowledge and therapeutic potential of the music. Others claim that medical knowledge is secondary and stress the importance of psychological considerations for any kind of patient problems. I happen to believe in a therapy of integration and balance, and cannot accept either view stated. It is true that we are supposed to make therapeutic use of music and its components, but we cannot separate the process from medical knowledge and psychological thinking, just as we cannot ignore the patient’s stage of development and cultural background, and apply the same material/approach/technique to everyone. As such, I developed a model of music therapy that seeks to integrate my personal and professional experiences in a way that acknowledges psychological and medical processes. The central components are outlined below, wherein I articulate their developmental and integrative elements. The Developmental-Integrative Model in Music Therapy: DIMT Developmental implies a basic concept of Man as a being who passes through various stages of development during his lifetime, including certain vital functions of his senses and sensations, vocality, motion, emotion and cognition. Developmental psychology and physiology maintain that growth is characterized by supra-cultural or universal processes. Science seeks to describe, investigate and measure these, as well as to study deviations from their norms. Such research into deviationary patterns has indeed advanced our potential of understanding and treating future pathologies. Despite the apparent differences between various current psychological approaches, it would seem that rather than contradicting each other, their different accentuations tend to support the overall accepted view of infant development. As a result of long-term observation of infants, children, adolescents, adults and the elderly (employing music), DIMT arrived at the following conclusions regarding its definitions: Developmental:

•

•

• • •

Part of human health is determined by the degree of maturity and integration that exists within and between the vital systems that contribute to development. Observation by means of music can pinpoint deficits, gaps, regression and fixation. This is because music itself influences these very same life systems. Should there be any health malfunction, this must be examined according to its developmental significance. Identifying the developmental stage is an essential part of the intake and observation phase of music therapy. Without such data, the therapist is unable to evaluate and consider any form of treatment. There exists a certain parallel between the development of the persona in general and its development in music therapy. By observing musical activity, we can identify stages of physical, psychological, cognitive and social development. DIMT sees each hour of therapy as a developmental microcosm and follows the patient’s development as though it were parallel to the life continuum. DIMT stresses the need to stimulate and develop the surviving and healthy functions of the patient, without ignoring deficits and gaps, in order to bring about positive changes and to improve the quality of life. (for additional discussion of these dimensions see Sekeles, 1996 pp. 147–155).

Integrative: • • • • •

The integrative treatment of deficits and gaps. A holistic treatment of the complete individual (sensory-motor integration, motion-emotion integration, etc.). The integration of the physiological and the psychological persona, and the treatment of the whole person as far as music permits, whether or not the handicaps are defined as either physical or emotional. Integration of the problems as diagnosed and the therapeutic approach, techniques, and the musical and verbal means at the disposal of the therapist. Integration of methods and techniques in music therapy with knowledge acquired from relevant fields (music, musicology and ethno-musicology; psychology, psychiatry, neurology and other basic subjects in psychology and medicine), in order to render as effective a treatment as possible.

This model can be either active or receptive, depending on the needs of the individual patient. However, the most desirable aim is to achieve a balance between a receptive (being) and active (doing) approach. Since development is perceived in terms of human relationships, even a receptive approach finds its fullest expression in the contact established between therapist and patient. In order to use the model efficiently, the following standards are mandatory for the music therapist: •

To be a professional and flexible musician.

• • • •

To be educated on all the relevant subjects mentioned before (music, medicine, psychology, etc.). To be educated on different psychological approaches. To undergo his/her own psychotherapy. To continue with complementary studies in music, music therapy and required therapeutic education and to be equipped to meet the needs and requirements of each patient (for additional reading, see Sekeles, 1996 pp. 25–63). The Client

At our first meeting I found Dor lying in bed, his face turned toward the wall, eyes open. I introduced myself. Dor did not respond. After twenty minutes of mutual silence, he turned his head toward me and asked: What do you want from me? I answered: I came to find out with you if you are interested, and if you could be helped by music therapy in order to improve your situation. Dor reacted: I never heard of such nonsense. I don’t believe in any help. I replied: What do you think it is? Dor, showing lack of interest and apathy: What? Listen to music? I can’t play anymore, and what do you know about my music anyway? You must be my mother’s age, and you sure don’t know a thing about rock and all…5 This was the first spontaneous welcome by Dor, but despite his de-pressed-angry mood, I detected in his resistance some aspects of strength. I said: Every therapy means embarking together on a journey of quest and discovery. I know that you play electric guitar, and that you took part in a rock band in high school. If you’d like, we could start on this subject of “your music.” You could share with me and teach me the music you know and love. We could begin with records and then continue with playing the guitar together and other instruments that I could bring you. Dor replied: Leave me alone, I don’t believe you, or any therapy, nobody can give me back my legs. I am not ready to live as half a man. I prefer to die. I decided to refrain from an answer, and asked if I could return a few days later. Dor’s reaction was not positive, but neither negative. In my heart I pondered his feelings of frustration and guilt over the death of a comrade, the injury suffered by another, the sense of the terrible burden of the “punishment” inflicted on him, the loss of freedom, his bruised manhood, the sudden dependence on others — mostly strangers — and, probably, his anxiety concerning the future. It should also be mentioned that in Israel, with its multitude of war-injured people, sports for the handicapped are high on the list and considered important beyond their physical aspects, because they restore some of the self-confidence and self-respect that are usually lost.

Indeed, the emotional aspect of loss of motility, of bowel control, and of autonomy, may trigger a severely depressed reaction. In the case of young people like soldiers, the difficult task of accepting a new image, the loss of masculinity, the uncertainty of their further development as men, and the loss of control over their lives, are extremely detrimental. Dor expressed this at a later stage of therapy: Hands are not sufficient, pain accumulates in the heart, and the mind enhances it. I know that it could be worse if my hands and my upper body were paralyzed, too, but right now this is of no comfort to me. I feel like a marionette that must be moved by others, because it has no living drive of its own. In the meantime, I found out that during the first month after the accident, he had harshly driven away the girl who had been his companion for two years, and had thrown her out of the hospital. After a series of rejections, the girl, a joyous person full of life, gave up and severed her relations with him. His parents took turns at his bedside, but he rejected them too, and they had a hard time coping with the tragedy and with their son’s state of mind. Dor seemed to cooperate with the physiotherapist, grudgingly tolerated passive exercises, but was not yet ready to activate his healthy limbs and to practice movements that were meant to allow him to develop some form of autonomy. Dor refused to talk with a social worker, and he did not believe in psychotherapy. His resistance, which was strong and unbending, actually served as an ineffective defense mechanism against seriously coping with his situation. It was a period in which things were not yet clear, and perhaps Dor still had some hope that a miracle would occur, and that the paralysis would go away. The Therapeutic Process Stage One: Resistance as a Defence Mechanism In principle, the term resistance refers to any action of the body, or the spirit, that opposes a force or stands against it, undermines that force, or is immune to it. Sometimes resistance is a personal trait and indicates unwillingness to carry out orders, to respond to social pressure, and so on (Reber, 1982). In psychoanalysis, resistance is seen as the refusal to allow unconscious contents (thoughts, feelings, repressed desires) to become conscious. Even in cases of conscious resistance, the assumption is that the unwillingness to disclose information originates from unconscious motives (Rosenheim, 1990). In the technique of psychoanalytic treatment, the interpretation of resistance is considered extremely valuable. The term appeared at an early stage in Freud’s writings, and was an important aspect of psychoanalytic theory. At first, resistance was defined as an obstacle to the elucidation of the symptoms and to the progress of the treatment. Freud tried a persuasive approach, but he came to the conclusion that resistance itself could bring about an unveiling of repressed material and of the secrets of the neurosis. And indeed, the interpretation of resistance and transference are the central bases of psychoanalytic treatment:

“Resistance during treatment arises from the same higher strata and systems of the mind which originally carried repression” (Laplanche & Pontalis, 1985 p. 395). According to Hadley (2002), resistance arises when the patient rejects treatment in various ways, and prevents the possibility of beneficial change. In Priestley’s Analytical Music Therapy (1994), resistance can be expressed in words, and also in music. In music, we may find that the patient refrains from making use of voice, or instrument, or remains compulsively stuck on the same musical theme. Resistance can also be expressed through musical activity without sequence of verbal elaboration, or, on the other hand, verbal activity that occupies most of the therapeutic hour, and leaves very little space for music (Hadley, 2002). In severely disabled individuals suffering from neuro-psychological problems, and in particular during the first “mourning” phase, resistance could originate from various factors: a. It is difficult to immediately muster the energy necessary to cope with hardship while you are in a state of mourning that depletes all your strength (Parks, 1972). We should not forget that in addition to Dor’s injury, he was feeling responsible for the death of a comrade, and the wounding of another soldier. Such facts can lower the drive to live, and direct the focus to feelings of mourning, guilt and frustration. b. Sometimes it is easier to relinquish difficult rehabilitation steps and to indulge in idleness and disability rather than to cope with the necessity of taking the long and painful path of rehabilitation. c. From an objective point of view, Dor lost his legs, losing the ability to change his position (sitting, walking, lying and exercising) easily. He was compelled to adapt himself to a new flawed body image, his voiding system (urine, feces) became defective, he lost normal sexual function, his status and his self-esteem. All this severely impaired his ability to function in body and in mind. In his resistance I detected, as indicated before, an expression of energy, which could be perceived as a positive force. I wish to point out that we must also consider another aspect: Dor did not yet know what kind of future was in store for him. Would some functions be restored? What studies and occupation could he acquire? What might he do? Would he have to face a court trial? What would happen if he would start exercising his upper body in order to compensate for the paralyzed parts? In fact, strengthening the upper body, which usually does not function to carry weight, might cause pain and problems in the shoulders, wrist joints and more (Trieschmann, 1987; Greenstein, 1999). Stage Two: Cautious Progress The next meeting took place a week later. Dor was lying on the bed, and the physiotherapist exercised him passively. Dor, sour-faced, was silent, and he suddenly uttered to the therapist: You are only wasting time on me. This will not help. My legs are not coming back, I am just a nothing.

In Dor’s case, I carried in my bag a few recordings from different musical categories, some composed by myself. In anticipation of the session, I had prepared and recorded with a friend a composition of my own for viola and piano. This was a short piece, with moderate tempo and limited octave range. It was meant for listening (receptive activity) and relaxing movement. I said to Dor and to the physiotherapist: I see you have a tape-recorder here. Would you mind continuing with your work while being accompanied by some background music? The physiotherapist accepted immediately. Dor kept silent, but did not object. I played the recording and the therapy session went on as before. Dor continued to be quiet, and finally commented: It was bearable, but this is not my music. This is the music of Methuselah’s generation. During the next two weeks I continued to attend the physiotherapist’s sessions. At first I brought recordings of instrumental music.6 Later, I also brought a guitar, and I accompanied the exercises with instrumental as well as vocal improvisations. About six weeks elapsed before I instigated a conversation about Dor’s feelings during the physiotherapy exercises accompanied by recorded or live music. I was very careful not to hurry with any kind of verbal investigation and processing of his thoughts, feelings and experiences. My observation had been that Dor was in a very sensitive, somewhat adolescent mood, and that verbalization might be experienced by him as intrusive and inappropriate. I waited for clear cues from him, and refrained from accelerating the process for the sole reason that we, the therapists, are short on time or have run out of patience (Sekeles, 2008). In general, the Israeli dynamic favors the kind of heroic, macho soldiers, who are not inclined to share feelings. Throughout the course of years of activity, and in particular after the Yom Kippur war (October 1973), though one could notice changes in this regard, my assumption was that I should wait patiently. During the following two weeks, I saw Dor every day for only half an hour. The physiotherapist began to sense that Dor was a little more serene, peaceful and accepting. Sometimes he even peeled away a thin layer of bitterness and rigidity, and revealed a bit of a smile, almost hidden. After two weeks I asked him if he could take over the role of the guitarist, thereby allowing me to play another instrument and extend musical activity beyond physiotherapy exercise. Dor responded: How come? I haven’t played classical guitar for years. I can’t play in a wheelchair, and I am not in a mood for that. I replied: When you feel that you can do it, we’ll try to improvise together, perhaps in the style of blues? This proposition surprised Dor:

What do you know about blues?7 I replied: I like the blues, and sometimes improvise for my own enjoyment or when needed in therapy. Dor: Okay, bring something and we’ll try. I tried to refrain from appearing over-excited, and the next day I brought a well-known piece of blues with its lyrics. Dor appeared very anxious. He asked for the guitar, I helped him to stabilize his sitting position with a temporary support around his back and chest, and he played the piece by himself. At a certain point he asked: Will you sing or won’t you? I sang, and from that moment a window of musical communication opened, which did not yet touch directly on his problems, nor bring about verbal expression of feelings. We often speak of subjects like empathy, establishing trust with the patient, containing, supporting, setting boundaries and so on, and I keep asking myself how these terms can be expressed in our therapeutic language and communication through music. What can we do if we are not familiar with the culture of the patient in general, and in particular with his or her musical preferences and rejections? With age-related culture? With the cultural background from which he, or she, came to Israel (if they were not born here), and occasionally also the culture of the disease (as with drug-addicts)? We ought to remember that music is not an international language, but rather a multi-faceted medium, and that we, as therapists, must make an effort in order to learn, understand, and be able to perform and collaborate with the patient, even if his or her music is painful and bothersome to our ears. This is one of the reasons why we, as therapists, must constantly listen to music of various categories, to different radio stations, and also continue to perform and improvise freely. Empathy is different from the identification of the therapist with the patient, where the distinction between the two becomes blurred and the therapist cannot help any more (Sekeles, 2008). In music therapy, empathy is not only expressed in the form described in psychology: Empathy is based on controlled and cautious use of transference. The therapist imagines that under certain conditions, the patient experiences something similar to what the therapist would have experienced in the same conditions (Rosenheim, 1990 p. 9). In addition to this, in music therapy we can express empathy through our specific therapeutic medium, that is to say music, which stresses its importance as a common language connecting the patient and therapist. Other themes abovementioned are also expressed in musical activity itself: we establish relations of trust, refraining from intrusion into the musical universe of the patient, lending support, and containing the music produced and performed by the patient. Support and containing can be created by “being and/or doing together.” For example, by listening to music with the patient, providing harmonic accompaniment to the patient’s music, joining the musical style of the patient, and showing respect for his creations, etc.

Indeed, according to my model (DIMT), music serves as our main therapeutic language, thus the different techniques and approaches used in psychology can be applied and worked through sound. This brings us to the next stage of therapy: Stage Three: “Music Can Speak”. During this stage, I began working with Dor with the consent of the physician in charge of rehabilitation, on mobility, beyond the aspects covered by the physiotherapist, without interfering in the therapy provided by her. Dor started practicing movements to a piece of jazz music I gave him upon his request, and in accordance with his taste. At the same time, we began to work with free improvisation: Dor began to respond to improvisations representing key themes in his life. For example, he played an improvisation on the synthesizer that he called “feet versus hands.” In this piece, the feet are represented by a long note (organ point), like the long line that shows up on the electrocardiogram screen in hospitals and indicates that life has come to an end. At the same time, he represented the hands by a series of hard rhythmical strokes. In the subsequent conversation, Dor said that by the long note he wanted to express the fact that his legs were not functioning anymore, and that his hands were strong and capable of expressing anger and rage. Another example came when he began to speak of the sorrow he felt for the soldier who was killed, and for this he chose not to play, but to listen to an Israeli song “Every Man” that spoke to his somber mood, and enabled him to later talk about the pain, and of his wish to forget and to escape. Every Man8 Don’t say: see, a man is marching straight, secure He wanders happily on his path The burden of his sorrow blown away And nothing left from yesterday. Don’t say that, for I know too well Can’t get away from the past… Every man wants to find a quiet beach In the endless night of cold Every man runs away from something Tries to reach the dawn, the light. Appears marching happily on his path, A day of spring fading away A bunch of hopes withered A grave – a lonely pit, forgotten And a friend lying there. In every man’s heart there is A gloomy secret, pitiful An echo from battle, not the last Will rise again, again to burn. But do not wonder, do not ask the flying man And do not plow his field.

He goes on, in silence like the moon Leaving his garden forever. Thirsty as a desert he walks away, tries to forget, To flee from the fangs of secret. But his secret like thistles will rise and flourish, And the man will go on wandering. The music David Zahavi chose to compose for this poem sounds like a tale, generating a very peaceful atmosphere. This peacefulness is also a desire of the heart, a kind of shield against the tragic secret one carries within, the secret the poet describes as thistles that rise and flourish, which prevents the man from escaping its fangs. I was much surprised when Dor requested to listen to this song, which he had just heard on the radio, and was very distant from his musical taste. His choice gave me a glance at a layer I hadn’t realized existed before, and showed me once again the power music possesses when it is linked with words to symbolically summarize our innermost longings. At this stage, music became more and more meaningful to Dor, and he began collaborating in full, except for when he was depressed. At such moments, I would usually sit quietly at his side, without attempting to suggest anything to play or listen to. By maintaining the silence, my intention was to show respect for Dor’s grief – his grief for others and for himself. But there was also an additional aspect, which entered my mind only later: through this I could provide his parents with the model they needed. A model saying “one must not constantly try to cure Dor.” Dor had a wide universe of suffering and sorrow, and one should not intrude without his permission and consent. Dor’s parents were what we call “the salt of the earth” of our country, and they had a strong desire to be helpful. This desire was sometimes counteracting because it irritated Dor and triggered aggression and rejection toward them (Rubin, 1990). His parents did not attend our sessions, which took place in a small adjacent room, but they saw me sitting quietly at Dor’s side during situations in which he did not cooperate. Perhaps this silence surreptitiously reached their hearts, and created some space of calmness. In this matter, I wish to mention a book by the Israeli Dan Ben-Amoz “I Don’t Give a Damn” in which he writes of a paraplegic soldier in the process of rehabilitation, and of the conflicts between him and his parents. Among other things, his father says of his wife: “He is the one paralyzed, but she is the wounded one” (Ben-Amoz, 1973 p.97). I found this to be a typical picture. Families often cannot accept the situation they find themselves in, and react with denial and false hopes. Instead of showing empathy, they project their own problems on the disabled, and in their agony they neglect the fact that the patient needs their strength. The fact that the injured person is dependent on his family intensifies his anger and leads to situations in which he simultaneously rejects his parents while still retaining his dependence on them. He assumes that their smiles are fake and that they are concentrating on their own pain. In such situations, the team in charge of the therapy must contact the family and teach them the very words to use in conversations with their son and the right moments to employ nonverbal communication. This kind of procedure is followed only rarely. In most cases, the workload on the medical-nursing team is so intense that they are unable to find much time to deal with the accompanying family.

Stage Four: New Therapeutic Space. Four months passed by. At a certain point in time, I considered the possibility of holding our two weekly sessions alternatively in my clinic and at the rehabilitation facility. At the latter we would focus on physical aspects of movements accompanied by music. The transfer to the music therapy clinic involved transportation and complicated arrangements, but Dor’s excitement and the good will of his parents and nursing team made it possible. The music therapy clinic is set up as follows: in a corner, there is a table and armchairs for conversations. The floor is carpeted, and musical instruments hang on the walls all around in such a way that most of the room is still an open space. In this space, one is at liberty to play various instruments (regular-classic, ethnic, self-made), to sing with the accompaniment of various instruments, to move around inspired by the music, to make a recording of the therapeutic session, to videotape, and so on Dor liked to be in this room. He said that in his view, therapy already began with the journey along the wooded mountain road leading to the clinic. Indeed, we should remember that we offer the patient not only meaning of internal content, but also — since we deal with arts — aesthetics and beauty. In this space, unlike the one at the rehabilitation facility where he lived at that time, Dor could get away from the atmosphere of malady and from everything related to it, like the equipment, sounds, smells, and interferences of treatments; or for other reasons. At that time, he had the electric guitar brought to the hospital, and began to play it whenever he had a chance. I wish to point out that he never requested to bring his guitar to my clinic, and that the atmosphere created there was quite different from the one he was familiar with. We practiced relaxation, exercised specific movements I invented for his sore hands, and created improvisations and composition from the material he discovered when he played on different instruments, including music and poetry. The lyrics of his songs were impressive (man and nature, falling leaves, me the child in the moon…) revealing the level of tenderness I detected when he chose to listen to “Every Man.” At this stage, playing music with Dor allowed me to discover that besides his favored rock music, he also liked jazz music, and had even experimented with it with his band. The band itself had existed a few years before. It dissolved when the members were enlisted for army service, and Dor did not tell any of them of his accident. Since I had a collection of a variety of jazz music, we were able to play it, to listen and to sometimes discuss certain issues while listening to it as a soothing background. In addition, I practiced with him the Chinese movement exercises known as “Chi Gong,” in which I have many years of training and which can be done with music and just the upper body. The Chi Gong presented to his body and soul a combination of soft movement and stable grounding. Stage Five: An End That is Not an End. Dor made progress in all facets of his rehabilitation. He collaborated in physiotherapy, participated in occupational therapy, and joined group conversations. He played music, and twice a week had music therapy sessions. His emotional state was much more stable, but he still became depressed from time to time, which worried the nursing team very much. Eventually, the time would come for Dor to leave the rehabilitation facility, move to his parents’

home, and eventually find a suitable apartment while continuing with his rehabilitation, his studies and with life. At this time he knew for certain of the seriousness of his injury, the paralysis of his legs, the problems related with sex and exertion, and so on. Despite the progress he made, I felt he was quite worried about his fate, and I was not certain that his future would be bright, as in the song: Leaving his garden forever. Thirsty as a desert he walks away, tries to forget, to flee from the fangs of secret. But his secret like thistles will rise and flourish, and the man will go on wandering. After seven months of hospitalization, Dor was released from the facility. He had to move, reluctantly, to his parent’s home, which they tried very much to adapt to his needs, in order to enable him to perform everyday activities as easily as possible. Dor temporarily discontinued music therapy until he could reorganize transportation, and for a few weeks we were out of touch. After these arrangements were made, he called me asking to re-start sessions again. We set a date and agreed that he would take care of the technicalities of transportation and arrival. Two days prior to our meeting, while Dor was sitting in his wheelchair in front of his house waiting for transportation to a medical checkup, a truck passing on the street lost control, hit the sidewalk, ran over Dor and killed him. Dor stopped “wandering.” I still remember the thought that crossed my mind after his death: In fact, he had wanted to die…he worked and overcame resistance, but something inside him could not accept disability, and the misery around him…that truck realized his fantasy that something would come and help him get away from his problems and from the whole world…as he said: Hands are not sufficient…I feel like a marionette that must be moved by others, because it has no living drive of its own. Therapeutic Closure It took me a few months to reach the possibility for emotional and cognitive closure — to cope with the process that Dor passed, the personal feeling of failure and loss that accompanied me as a therapist, and the summary of the therapeutic stages until the time of death. From a music therapy point of view, Dor had first passed through resistance with no use of music and rather short conversations. The second stage involved pre-composed recorded or live music that accompanied the work of the physiotherapist and could be defined as a receptive process. In the third stage, Dor actually began to use the guitar in an interaction with a second instrument played by me. The next step involved mobility. Dor moved in his wheelchair to the sound of jazz music, and by doing that, freed his souring body. From there developed clinical improvisation with which Dor represented key issues in a symbolic way and turned hurt feelings into art. The last stage was moving the therapy in part to my clinic and opening his eyes to the multi-possibilities of music therapy in a calm environment.

The general feeling of working in developmental stages and achieving integration became clear to both patient and therapist, as well as Dor’s ability and will to continue music therapy. From this short summary, it is obvious that the Developmental-Integrative-Model directed us physically and emotionally toward a better acceptance of the situation, and contributed more energy to coping with the future. Dor’s father said at his son’s funeral that at the end of his life, music therapy gave Dor “drops of faith and for that we have to be thankful.” With this thought I dedicate the paper to Dor, who after his death compelled his family and his therapists to dive into the world of mourning and find these drops of faith. References Ben Amotz, D. (1973). I Don’t Give a Damn. Tel Aviv: Bitan Publishers (Hebrew). Colman, A. M. (2001). Oxford Dictionary of Psychology. Oxford: Oxford University Press. Greenstein, I. (1999). Late Complications of Over-use of Upper Extremities in Paraplegia. Be’er Sheva: Medical Center, The Faculty of Health Science, Ben Gurion University of the Negev (Hebrew). Hadley, S. (2002). Theoretical bases of Analytical Music Therapy. In J. Eschen (Ed.), Analytical Music Therapy. London: Jessica Kingsley Publishers. Laplanche, J. & Pontalis, J. B. (1985). The Language of Psycho-Analysis. London: Hogarth Press. Parks, C. M. (1972). Bereavement – Studies of Grief in Adult Life. New York: International University Press, Inc. Priestley, M. (1994). Essays on Analytical Music Therapy. Phoenixville, PA: Barcelona Publishers. Reber, A. S. (1992). Dictionary of Psychology (Hebrew Edition). Jerusalem: Keter. Rosenheim, E. (1990). A Man Meets Himself. Psychotherapy: Experience and Process. Tel Aviv: Schocken Publishing House (Hebrew). Rubin, S. (1990). Death of the future. An outcome study of bereaved parents in Israel. Omega, 20: 323–339. Sekeles, C. (1996). Music Therapy: Motion and Emotion. St. Louis: MMB Music, Inc. Sekeles, C. (2006). The Developmental-Integrative Model in Music Therapy. Nordic Journal of Music Therapy, 15 (1), 58–82. Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum, N.H: Barcelona Publishers. Sekeles, C. (2008). Revised Version of Diagnostic Charts in Music Therapy. Jerusalem: David Yellin Academic College (1st Hebrew version 1990). Trieschmann, R. (1987). Spinal Cord Injuries: Psychological, Social, and Vocational Rehabilitation. New York: Demos. Trombly, C. A. (Ed.) (1983). Occupational Therapy for Physical Dysfunction. London: Williams & Wilkins. Appendix A Paraplegia As indicated in the abstract, paraplegia is characterized by motor and/or sensory loss in the lower limbs and trunk. Some of the people affected also exhibit paralysis of internal organs

below the waist. Paralysis is the consequence of a sudden or gradual lesion of the spine and affects the body below the point of impact. The condition could be caused by a variety of agents: a disease of the spine, cancer, fractures, partial or transversal slashes due to injuries from war or by accident, and so on. In some cases, the damage is limited, but it is usually extensive and irreversible. Treatment and rehabilitation include physiotherapy, adaptation of mechanical devices for the improvement of everyday functions (activities of daily living), occupational therapy, psychotherapy and arts therapies. Some of these therapies are administered on an individual basis and some in support groups. Full invalidity (as in Dor’s case) means the inability to walk and the need for a wheelchair, urinating and defecating problems, lack of sexual function, and additional problems caused by reduced motility (decubitus ulcers, thrombosis, pneumonia and so on). Therapy encourages movement, standing up (with supporting frame), compensative strengthening of the upper body and extremities and as much meaningful activity as possible, despite the severe handicap (Further information in Trombley, 1983 chapter 21). Appendix B

____________________________________ 1 This locution is in the Aramaic language, and the meaning is a sudden fall from a good situation to a bad one. Igra = roof; rama = high; bira = pit; amikta = deep: A Rabbi was reading from the Book of Lamentations. As he reached the verse “Its heavenly splendor he has turned into ruins” (Lamentations, 2, 1) the book fell from his hands. He said: “me’igra rama le’bira amikta.” From the highest height to the lowest depth (Hagiga 5, page 2). 2 Dor: A pseudonym used, in order to abide by professional ethics, with permission. All the names, and some details have been changed to protect the privacy of the patient. 3 Paraplegia: full paralysis of lower part of the body, including legs, below the location of spinal injury (see Appendix A) 4 I chose this model, not only because I myself defined it and assessed its effectiveness over the course of many years of activity, but mainly because of the necessities I faced dealing

5 6

7

8

with a young man whose injuries required care of physical as well as of emotional aspects. Indeed, the DIMT touches on basic aspects of life: movement, senses, vocality, emotion, cognition and socialization, and as such facilitates integrative treatment and strives to achieve balance and compensation. Throughout the chapter, I quote from the reports I wrote immediately following the therapy session, or from the recordings routinely made with the consent of the patient. I chose instrumental music in order to avoid inflicting on Dor the increased intimacy related to vocal music, and the immediate connotations to feelings. In this regard, the guitar is also quite intimate, specifically as it is often played while the therapist sits facing the patient. I recall my first experience in a psychiatric institution abroad, where I was working with a psychotic 17-year-old, who had a job on a freight ship. His music was indeed very far from me — heavy rock - and he rejected me immediately. I asked him offhand if he knew the latest hit that was raging and exciting at that time in the Netherlands. While asking, I played the tune on the piano, and he started, without even realizing, to join in, drumming and singing. This was a decisive, swift turning point, which resulted in four solid years of therapy, until his last day of hospitalization. I stress this subject because one of the principles in music therapy is to learn and know as many different musical cultures and styles as possible, in order to establish a positive inter-relationship with the patient. Lyrics by Abraham Ben Ze’ev. Music by David Zahavi. (Translated into English by permission of the poet Avraham Ben Zeev). Sheet music: Appendix B.

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

CASE SIX A Flash of the Obvious: Music Therapy and Trauma Julie Sutton Introduction

This chapter is an exploration of work with a female psychiatric patient1 attending a National Health Service primary care outpatient unit in the United Kingdom. The unit is staffed with psychotherapists, psychiatrists, a cognitive behavioral therapist, an art psychotherapist and a music psychotherapist. The team’s stance is psychoanalytic. I will describe what emerges from the work with the patient at different points in the therapy. This includes what appears out of her music (sounded and silent), her words and her silences. I place this alongside my experiences of listening and sitting with her, and from further reflection within the supervision context. I aim to show how staying with thoughts about music can offer a particular way of being attentive to the patient. I believe that this can open up spaces for unexpected ways of coming to an understanding of the therapeutic work that both goes beyond, but is also simultaneously and fundamentally grounded in, the music itself. Our attitude to the music made in music therapy sessions defines us as therapists. While almost all the literature is focused on sounds produced in the clinic room, I believe that silences are an essential part of our work (Sutton, 2001; 2002; 2006; 2007; Sutton & De Backer, 2009). In this chapter, I concentrate on what was not sounded in the sessions. Some may ask, ‘is this music therapy?’ I will argue that it is indeed music therapy, and as this chapter unfolds, I will demonstrate how focusing on the silent music in the sessions allows us the space to think about what lies before, during and after each musical sound. Foundational Concepts Clinical Stance: An Unseen Hand My clinical focus is on the music in music therapy. This way of thinking owes much to a concept of musical listening, which is a way of putting one’s attention fundamentally in music, in what is produced musically, and in how it is produced in relation to the self and the other. The ways in which the therapist experiences and thinks about listening is core to this. I think of listening as potentially a way of sensing the present moment in the clinical room as openly as possible. In this context, music is not a noun, but a verb — music is something created in time, within and between people. Music is not something that happens in isolation. It exists in an ongoing process that takes place and requires people to be part of it, whether actively

producing sounds or not. The great pianist Alfred Brendel (2001) described this process as “an unseen hand that keeps its hold over player and listeners alike for the duration of these timeless moments” (p. 360). Part of music’s unique potential as an art form is that it is always in a state of becoming. This concept incorporates awareness of time being something that not only goes on, but is also fluid and in flux. More than any other art form, music works through a flexible relationship between actual and perceived time, where present and past might meet and move towards an as yet unknown future (Sabbadini, 1996; Sutton, 2006; 2007). This is both a reality of the individual’s experience of the world and others in the world (Winnicott, 1971; Bion, 1984), as well as something that directly links with the infant’s experiences of his/her first relationship (Stern, 1977; Trevarthen & Aitken, 2001). Related to this, musical listening describes not only what the therapist does when she allows her attention to be caught by the patient and by the quality of this process, but also how a kind of musical preoccupation in the therapist enables us to think in detailed ways about the patient. This thinking is undertaken in the context of a kind of curiosity about the inner and outer worlds of the patient, of what takes place within the therapist while he/she is with the patient, and of how this is thought about both inside and outside sessions. Over many years of clinical work, I have become increasingly convinced of the value of a particular kind of waiting that I link to a type of listening that is inherently musical. It is musical because of the qualities of music that are both going-on-in-time and stretching time. This is something that can be experienced and simultaneously heard via musical production in improvisations in the clinic room, but is often held silently in the analytic situation, either behind words spoken, or in what is not spoken. In music therapy sessions, this occurs in verbal or musical silences, as well as what is heard in the content of the music played. We can note, in addition, the work of sitting with the desire to seek out neat explanations for what occurs in the therapy room, particularly when one part of a therapist’s role is to help the patient to come to forms of understanding about his/her life. This idea is present in Bion’s (1974) observation that one “is usually so busy looking for something out of the ordinary that one ignores the obvious as if it were of no importance” (p. 103). Bion’s (1974) recommendation to approach each session without memory or desire goes further than proposing that the therapist remain in an open receptive state, because within his statement is an implication that when one is expecting to discover more about the patient, or for therapy to move forward in any particular way, one is no longer available to the patient. Therefore, the therapist’s memory, desire, and sense of anticipation of the content of a session works directly against his/her ability to stay in the present moment and to feel the present unfolding in the patient while he/she sits with the therapist, and the therapist sits with the patient. Ogden (1997) developed this idea using the term the intersubjective analytic third, which he describes as “not…a static entity; rather, I understand it as an evolving experience that is continually in a state of flux as the intersubjectivity of the analytic process is transformed by the understandings generated by the analytic pair” (p. 30). This experience is not identical for both, but meanings are negotiated between both. In musical terms, we might think of a form of free-improvised duet, where one, or both, or neither might play, but where there can be a listening to the duet that is not being sounded, is nonetheless silently present (or potentially so). This jointly negotiated potential way of ‘being’ musically places the emphasis on

the therapeutic relationship. The therapist pays attention to nuances and changes from moment to moment, to how patterns emerge over time, and how a shift or hiatus can bring new ways of thinking about what happens between patient and therapist while in the clinic room. Therefore, meanings may be musical experiences that are shared or not shared, and may be transformed further into words that can be thought about and linked with feelings and sensations. While many of these ideas are connected to psychoanalytic theory, and while my work includes a psychoanalytic stance, I also place an emphasis on music and music therapy research. In particular, I am interested in the ways that a patient’s music enables us to hear his/her inner state as it unfolds in ongoing time (movement toward a future), and also backward and forward across time (the past emerging in the present). Compared with the main body of music therapy research, there is relatively little published material dealing in any depth with traumatic material presented musically, a notable exception being De Backer’s concept of sensorial play (a description of the musical and psychic phenomena of the patient’s inner traumatized state) and the identification of a musical-personal process moving toward the appearance of musical form. Both concepts represent significant contributions to our understanding of the unique place that music therapy has in the treatment of the traumatized patient (De Backer, 2008, Sutton & De Backer, 2009). I believe that ideas about the development of a personality can be thought about musically, making it possible to identify a process that traces a parallel developmental pathway from the infant’s first experience of being at one with mother, to experiencing relationship (oneself in the context of two people), but which process is found in altered form in the pathological presentation of the traumatized patient (from sensorial play to musical form). More specifically, I am concerned with the unexpected emergence of what De Backer (2008) terms moments of synchronicity, which he defines as spaces that open up in the repetitive, endless, meaningless sensorial play through which emerge brief moments of potential for intersubjectivity. De Backer described these moments as when: the music already anticipates something, which is not yet there, a type of structure, within which the patient possibly can enter [into] (De Backer & Wigram, 2007 p. 132). De Backer (2007) links this with the ways in which “structures originate [in music] to which we escape” (p. 132) and with an experience described by Lacan (1966) as mirroring, where, to simplify a complex process, one perceives oneself one step removed, and where one senses oneself as no longer quite alone. In sensorial play, one could say that the therapist takes on the task of an echo in order to be nearby the traumatic, and it is the space in which the music itself comes into existence, as it lives in the therapist, that makes this possible. In order for this to happen, the therapist is making use of the way of being that Bion and Odgen have described as reverie and the emergence of an analytic third, as cited previously. While there is a personal experience of what takes place between and within the patient and therapist, it is the music itself and its presence inside the therapist (and then potentially inside the patient, and between patient and therapist) that makes this possible. A Few Words About Trauma

In the case study that follows, much of the musical listening was to the traumatic material presented musically by the patient. This material had no meaning other than being a sounded statement of the patient’s inner world, where time had ceased to exist and where there was repetition but no development. When a patient plays in this way, trauma is presented as a form of enactment, heard in the endless musical material, trapped and destined to repeat over and over, but not to move forward or onward, nor to have reference to the past. The theoretical thinking about trauma and music therapy outlined in this chapter is relevant to all types of traumatic experiences, and speaks particularly to the complex interplay between earliest and later traumatic events, and between developmental and single event trauma. The case presented here is of someone whose life spanned the 30 years of the Northern Ireland conflict, and like everyone else living in N. Ireland, they experienced life in a part of the world where paramilitary and military activity was taking place. While this patient was not referred to psychological services specifically because of conflict trauma, her experience of what was taking place in the community was part of a complexity of influences on her mental state, and would have had an impact on her sense of feeling safe in the world. The case material explored here is not the full story of the therapy with this patient. It was a deliberate decision to focus only on the earlier part of the therapeutic process. The theme running through this chapter is that of the therapist’s sitting with the unknown in the therapy room, and of suspending expectation of any particular outcome for the work. As emphasized earlier, this stance encourages the therapist to aim to be as open and receptive as possible in his/her listening attitude to the patient. In this chapter, I make use of the theme in a way that will leave the reader similarly ‘suspended’ regarding full details of the entire therapy process. There is no neat ending provided, the purpose of which enables the reader to fully focus on the theme of sitting with (or the experience of) ‘not knowing.’ It is acknowledged that experienced clinicians will be familiar with this idea and will recognize the kind of inner space this requires in the therapist, while trainee therapists will come to connect with this through their experiences during and after reading this text, and from further reading and clinical experience. The Client Vicky was a woman in her thirties with a history of self-harm and acting out dramatically as a teenager. Vicky’s notes show that she had cut herself and had made a number of suicide attempts, none as serious as the recent attempt, from which she had to be resuscitated. Her early history indicated that she had been with one foster family before arriving with a second foster family who eventually adopted her at the age of six months. The circumstances of the first six months of her life are sketchy, but suggest a rather confusing and unboundaried immediate environment. Vicky was referred initially to the Centre during the aftermath of a suicide attempt. At this point, it had not been possible to obtain a clear picture of her psycho-emotional state, due to brain damage from the suicide attempt. Therefore, it was decided to offer a music therapy assessment, where Vicky would have both words and music available. Vicky attended her first meeting with me eight months after her suicide attempt, at which point her physical condition had stabilized, and she was out of hospital and resident in a nursing home. Initially, the primary

concern and medical input had related to her brain injury. The assessment was Vicky’s first post-hospital contact with psychological services, at this time she was using a wheelchair, was unable to bear weight, and showed high muscle tone in her legs and lower arms. She spoke with some difficulty, but managed to form words that could be understood. Vicky was brought to her session by her adoptive mother. Assessment Vicky was referred by her neuropsychiatrist to the consultant psychiatrist for the team within which I worked. The consultant psychiatrist saw Vicky six months after her suicide attempt, when she was out of hospital and residing in a nursing home. Her chart showed that Vicky had a complex psychiatric history from adolescence onward. Vicky’s neuropsychiatrist requested a psychological assessment. This was because up to this point it had been difficult to ascertain if Vicky’s responses were influenced by physical, cognitive and/or memory issues related to her brain injury, or underlying psycho-emotional factors related to her past. There was a sense that she was not always able to be engaged sufficiently to give coherent answers to questions, but the cause of this was unclear. However there was a feeling that a multi-disciplinary approach to Vicky’s treatment was important, and that this should include both physical and psychological therapies. This referral was more unusual for our out-patient psychiatric facility because of the extent of the brain injury. In view of this, the assessment process was carefully undertaken. For example, it had not been possible for Vicky to complete the detailed questionnaire that was an important part of team discussion between the initial referral and any assessment appointment. This was due to Vicky’s presenting cognitive impairment and the not-fully-known impact on her mind of the situation before and after such a traumatic incident. Neither was it possible for Vicky to attend the new patient clinic, meet with a psychotherapist in order for a detailed history to be taken, and then wait for the discussion between the therapist and consultant to be completed before discussing and deciding the way forward with them. The consultant psychiatrist visited Vicky and undertook an interview, reporting afterward that Vicky showed a significant degree of hypoxic brain injury. It was clear that she made unreliable responses to questions, but it was not possible to identify how far the disturbance in her thinking was as a result of brain injury or psychological defense mechanisms. It was felt by the team that verbal engagement would be too difficult for Vicky at this stage, and a further referral was made for music therapy. Vicky attended an initial music therapy session, with a view to a 4–6 session assessment. However, I believe that a therapeutic process began in our initial meeting, and have therefore detailed the first session within the main body of this chapter. It is important to note that while also observing that Vicky’s responses to me seemed to be influenced by a mixture of functional and emotional factors (that in themselves were as yet unclear), I found myself caught up in wondering what had happened to her that might have caused the current situation she found herself in. I think that this was linked to a sense that while Vicky had an acquired brain injury, there was an intact psychological factor underlying this. In many ways, the main purpose and value of this process of assessment was that it was largely completed before the referral to music therapy, by the two consultants involved. The

main purpose of our first meeting was to see how Vicky would respond to the setting and to me. Once she had agreed to continue meeting with me, my role was to suspend a belief that there was a single cause for what Vicky was presenting, or that therapy would progress in any pre-ordained fashion; I kept an open mind and acknowledged the unknown complexity of this patient’s presentation. I do not think that the music therapy assessment can be separated from the therapeutic process as a whole. This is an important point because of the meanings that may be present during any first meeting with a patient: one can think of the first session with a patient as containing everything about the therapy to come, with the therapeutic process the space in which this unfolds and is processed. This was true of Vicky’s first meeting with me. The Therapeutic Process Three aspects of the sessions demonstrate how I came to understand the ways that Vicky could have experienced her sessions, and how these have linked what happened in the room to Vicky’s past and present, and her inner and outer worlds. I have chosen to take these examples from the first six months of her therapy. While her therapy continued after this, I feel that these earlier meetings have value because they reveal much of what emerges from working with a disturbed patient such as Vicky, and the detailed musical listening and thinking that takes place in the therapist. As noted earlier, this also allows the reader the opportunity to connect with the processes relating to this. I begin with the first meeting, within which there was a sense that a therapeutic process might have begun. Meeting for the First Time and an Intense Musical Contact Vicky arrived in a wheelchair and, as observed prior, her physical state showed clear signs of hypoxic brain injury. Her speech was labored but largely clear and understandable. She looked around the room and told me that she had played a few instruments, but that she could not play anymore. Her face was mask-like. After the session, I found myself thinking about what might be behind the mask, and while the mask invited me to have these thoughts; it did not seem that Vicky wanted me to be curious about this. In the third session, we sat together at the piano, at Vicky’s suggestion. For a few minutes we played single black notes in turn. The mood was very quiet and serious, and I found myself concentrating intensely on how one note sounded, then another, and another. I realize that I must have been joining the sounds together in my mind, and hearing the music as a whole, rather than as several disconnected sounds. It was a way of keeping a sense of the nature of the space in the room, into which the notes emerged. But Vicky’s notes did not seem to exist for very long, they seemed to be like echoes of sounds, and barely there at all. On the other hand, she sometimes attached a note to the previous one I had played. Somewhere hidden in the intense concentration inside me was also a sense of something not quite working, and a painful after-effect. Vicky had no reflections after this music. She returned for her next session in a distressed state. She told me about a previous music teacher who had had a terrible accident, and although she had no way of contacting her, she wanted her to know that she thought about her a great deal. There was a very sad and anxious feeling in the air, but at the same time

I was confused about when this had happened, and about what was past and present. In supervision I thought about the potential meanings of this communication from Vicky, and particularly the way her experiences of the previous session may have manifested a figure of the teacher who seemed to be both her and me; though perhaps the lack of clarity about what belonged to which of us was created in my confusion. Sleeping Away the Session and Silenced Music After the experience of this intense musical contact, Vicky told me that she was very worried about playing again. I took her seriously about this because patients with Vicky’s kind of early history can have a fundamental terror of emotional connection with another. This ‘other’ is felt to be a terrible, threatening invader who must be kept at bay at all costs. Without protection, there would be an experience of unbearable emotional pain, for to be connected with another is to be destroyed in the most awful way (Rosenfeld, 1987). In addition, once connected, one would ultimately have to lose the connectedness and experience of being alone in a state of loss. One must remain in an impregnable place, protected against all attempts others might make to intrude. In order to achieve this, one remains vigilant to the extent that a state of nothingness is preferable to the terrible anxiety experienced when someone comes near. Contact is not only shunned, it is actively repelled. In Vicky’s case, she broke any attempt at linking by her therapist. Vicky initially closed her eyes, then apparently fell asleep. She seemed to put herself into an altered state where she was completely protected from the therapist and from anything in the therapy room that might get in. At this time, I felt intuitively that this psychotic withdrawal should not be broken. To try to make a link would be experienced as a terrible intrusion so early in the therapy. Therefore, I waited quietly with Vicky, until the session came to an end, at which point I spoke her name and informed her that we had completed the session. Vicky showed a hint of interest in this but otherwise remained quite blank. In subsequent sessions, it was also possible to make the neutral observation that I had seen Vicky close her eyes and go to sleep. My statements had a musical quality, placed in the mid-low vocal range, paced slowly and carefully, and were quiet, calm and serious. Vicky’s reaction to these words was ambivalent — she both welcomed the fact that I had sat quietly with her, but hated me for being there at all, whether silent, or making sounds. Later, I was able to wonder aloud whether or not Vicky had been dreaming when she slept, again saying this with a similar musical vocal quality. Vicky simply said, “no, I don’t dream. I am nowhere.” This had the effect of shutting a door on any further contact, giving me the message that there could be no hope of anything living, or anything coming to life in the space within which Vicky sat. Additionally, when Vicky sat with her eyes shut, I found my attention was drawn to thoughts about her suicide attempt. On one occasion, I found it difficult to catch my breath, and I had to concentrate on my breathing in order to remain in the room. This body sensation helped me to understand something of the quality of Vicky’s terrible anxiety about a connection with a woman that could link her directly with her earliest experiences of her mother. Later in the same session, I found myself imagining a lullaby, accompanied by feelings of tenderness toward Vicky. Such a maternal transference, and the nature of the music imagined, also linked me with a completely vulnerable infant who needed delicate and gentle

holding. We can wonder what an infant does to survive when he/she has experienced such a devastating threat to his/her sense of safety and where, as Rosenfeld (1987/2005) puts it, “something which should have been pleasurable and satisfying, and could have been the basis of security and love, created terror and misery” (p. 152). How could such an infant ever trust anyone, when the source of comfort is also the source of overwhelming, terrible anxiety? How fundamentally these early experiences would color attitudes and responses to future relationships. I wondered about Vicky’s experience of being with me, while I was in the sessions, during the time that I wrote my notes, during post-session musical reverie2 and in supervision. There was a sense of a terrible dilemma between us: at times we seemed to move a little closer to each other, but this mood immediately frayed at the edges and fell away into a kind of colorless nothingness. I had no sense of any music that could exist there, and the quality of silence in the room was thin, shapeless and timeless. There was not enough of anything present that could be called a silence. In these moments, I found that something in me disappeared. My mind wandered to a place outside the room, and it took considerable effort to bring myself back into the space and exist as a living being. However, once or twice a gentle lullaby began to appear in my mind, and I was overcome with feelings of tenderness along with a deep sadness. I think this is where there was something in Vicky’s music therapy that came alive and I will expand on this point in the next section of the text. A Flash of the Obvious and Music That Cannot Yet Become After weeks of quietly sitting with Vicky, I found myself increasingly being able to observe nuances in her state. It is important to note that this indicated something happening between us, found in my growing awareness, attunement to and discovery of different kinds of qualities in Vicky. These were indistinct but nonetheless present, and here one might find it helpful to think of the image of shapes appearing briefly in the formless mist of a session, existing for the briefest of moments before returning to an overall shapeless fog. In musical terms, this comprises a process in the therapist that involves listening to the echo of a refrain, of a song yet to be sung, as suggested by Williams (2010). While an active process in the therapist, it requires an overall internal stillness and a different kind of refrain — a refraining from acting on one’s responses and a ‘staying with’ the overall mood of a session until something begins to emerge more clearly from the patient’s material. This is part of a stayingwith the unknown, as recommended by Bion, and paraphrased as being without memory, desire or the need to understand (Bion, 1967; 1984; Symington & Symington, 1966). Working in this way, I also noticed a clearer sense of tension in Vicky, and it became quite possible to sense when she was about to cut off any connection with me. At the beginning of one session, when this seemed to be happening, I said, “Vicky, I am sitting here with you, and I am thinking how hard all this is. How something goes on that cannot work and is always doomed to fail.” Vicky stared hard at me, looked very serious and said, “yes, you understand.” At this point, and for a short while, something lived between us. I experienced this as moving towards a moment of synchronicity, and something that I think is meant by Paul Williams’ (2010) description of a particular kind of potential space. In another form, this was almost the beginning of a silence before music could be sounded.

This also reminds me of Williams’ (2010) comments when sitting with very disturbed patients, of his definition of love as being able to make time for another. I think this includes making time for an ‘other’ when the other does reciprocate, as with Vicky, who was not able to allow a space for me to exist in the room, and therefore could not make time for me. However, when I discovered time and space be came alive in me, as described earlier, there existed a potential that was otherwise deadened. This would not have been possible without attention paid to the process described previously, of listening to ‘the refrain that was from a song yet to be sung.’ This, while undertaken silently, is part of music therapy, and of the therapist’s own internal work, via personal psychotherapy and regular clinical supervision. I noted that Vicky’s apparently impermeable state nullified any attempt to be present with her, or to sit with her. There was no music that could be sounded, although as her therapist, I could begin to imagine a gentle lullaby that linked me to tender and deeply sad feelings about her early experiences, without knowing what these were. This imagined lullaby provided something alive in the deadened silence created by Vicky, who would sometimes become aware of my efforts to be present with her without despising me for it. Much later in her therapy, she described how she could feel the therapy was pointless (because nothing could be allowed to enter her dreamless sanctuary), but sometimes felt something different via my presence in the room. I wondered if this indicated a potential for Vicky to also become aware of the song yet to be sung, in a way that was fleetingly manageable. This was the most delicate thread between us and one that was always broken or smashed. Remaining open to remember the moments where this ‘thread’ was managed and could also be imagined, was one of the most important aspects of the work with Vicky, who actively forgot in order to protect herself. Along with Rosenfeld (1987/2005), we can only continue to wonder about what was at stake for Vicky and what unbearable terrors could emerge if such a song was allowed to be sung, be listened to, or be heard. Conclusion Final Thoughts: A Flash of the Obvious Vicky came into therapy as a result of unanswered questions about her rehabilitation following a suicide attempt that had resulted in significant hypoxic brain injury. Answers that had been unavailable through the usual psychological assessment procedures emerged in the music therapy room through using musical perspectives (via musical listening and thinking), to experience and think about Vicky. Attention to the detail of the sessions during lengthy periods of silence was fundamental to this, with the therapist allowing moments to pass without acting upon them, remaining open to how this resonated in her, and how impressions, sensations and thoughts appeared as if musical motifs in the silence. Without searching for answers, this left the therapist open to experience the patient as fully as she could. As Bion (1973) noted, this stance enabled freedom for the unexpected to emerge: I found that I could experience a flash of the obvious. One is usually so busy looking for something out of the ordinary that one ignores the obvious as if it were of no importance. Indeed, one of the reasons for thinking it is time to give an interpretation is that nobody has seen something that is obvious (p. 67).

As Bion also seemed to imply, when we do experience the present in its intensity, then the past and the future are powerfully brought together to produce a ‘timeless’ state. In Bion’s (1973) words “A present experience is past, is present, and is future; it is timeless” (p. 88). This kind of timelessness is alive to what might pop up, and should be placed alongside Vicky’s deadened timelessness that destroys any possibility for this. Awareness of the distinction between these two forms of timelessness provides a clue about how to understand the meaninglessness of traumatic material. This awareness can only be developed via the therapist’s willingness to open up thinking and feeling spaces both inside and outside the therapy room, and why personal psychotherapy and supervision are essential when working with those traumatized. In work with severely disturbed patients, our task is about discovering ways of remaining musically present in the clinic room, and therefore, also open to what is not sounded. Vicky taught me more about this essential task, and I hope her story also opens up a thinking space for the reader that will lead to potential new discoveries. As we leave Vicky’s story poised here, I hope that within this musical pause, the unknown future comes alive in the reader, waiting to be found in a flash of the obvious. References De Backer, J. (2006). Music and psychosis. Unpublished doctoral dissertation, University of Aalborg. De Backer, J., Wigram, T. (2007). Analysis of notated music examples selected from improvisations of psychotic patients (pp. 120– 133). In: T. Wosch and T. Wigram (Eds), Microanalysis in Music Therapy. London: Jessica Kingsley Books. De Backer, J. (2008). Music and psychosis: A research report detailing the transition from sensorial play to musical form by psychotic patients. Nordic Journal of Music Therapy, 17(2), 89–104. Bion, W. R. (1984). Attention and Interpretation. London: Karnac Books Ltd. Bion, W. R. (1973/1990). Brazilian Lectures. London: Karnac Books Ltd. Bion, W. R. (1967). Notes on memory and desire. Psychoanalytic Forum, 2, 271–280. Brendel, A. (2001) On Music. London: Robson Books. Freud, S. (2003) An Outline of Psychoanalysis. London: Penguin Books (The New Penguin Freud Series). Lacan, J. (1966). Le stade du miroir comme formateur de la function de Je. Ecrits. Paris: Seuil. Ogden, T. (1997/ 1999). Reverie and Interpretation: Sensing Something Human. London: Karnac Books. Ogden, T. (2002). Conversations at the Frontier of Dreaming. London: Karnac Books. Rosenfeld, H. (1987/2005). Impasse and Interpretation: Therapeutic and Anti-therapeutic Factors in the Psychoanalytic Treatment of Psychotic, Borderline, and Neurotic Patients. London: Tavistock. Sabbadini, A. (1996). On sounds, children, identity and a ‘quite unmusical man’. Paper presented at a Study Day on Psychoanalysis and Music at the Centre for Psychoanalytic Studies, University of Kent, Canterbury. Retrieved April 24, 2008, from http://www.ukc.ac.uk/sdfva/sound-journal/sabbadini981.html.

Stern, D. (1977). The First Relationship. Infant and Mother. Cambridge Massachusetts, Harvard University Press. Sutton, J. P. (2001). The pause that follows… Silence, improvised music and music therapy. Nordic Journal of Music Therapy, 11(1), 27–38. Sutton, J. (2002). Music, Music Therapy and Trauma: International Perspectives. London, Jessica Kingsley. Sutton, J. P. (2006). Hidden music: An exploration of silence in music and music therapy. In I. Deliège and G. Wiggins (Eds.), Musical Creativity: Multidisciplinary Research in Theory and Practice (pp. 252–271). East Sussex: Psychology Press. Sutton, J. P. (2007). The air between two hands: Silence, music and communication. In N. Losseff and J. Doctor (Eds.), Silence, Music, Silent Music (pp. 169–186). Hampshire: Ashgate Publishing Ltd. Sutton, J. & De Backer, J. (2009). Music, trauma and silence: The state of the art. The Arts in Psychotherapy 36 pp. 75–83. Symington, J. & Symington, N. (1966). Without memory or desire. In J. Symington and N. Symington (Eds.), The Clinical Thinking of Wilfred Bion. London: Routledge. Trevarthen, C. & Aitken K. (2001). Infant intersubjectivity: Research, theory, and clinical applications. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 42(1), 3– 48. Williams, P. (2010). Invasive Objects: Minds Under Siege. London: Karnac Books. Williams, P. (2007.) The worm that flies in the night. British Journal of Psychotherapy, 23(3), 343–364. Winnicott, D. W. (1971). Playing and Reality. London: Routledge.

____________________________________ As the work takes place within a health service setting, I use the term ‘patient’ rather than client. 2 Musical reverie is a way of further processing material from sessions, via improvising, with the patient in mind. I also find it useful to improvise when a patient is unable to attend a session, with my mind preoccupied with them as I play. 1

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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

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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)

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