Case Examples of Music Therapy for Mood Disorders [1 ed.] 9781937440305

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Case Examples of Music Therapy for Mood Disorders Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy for Mood Disorders 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: 978-1-937440-30-5 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 Guided Imagery and Music (GIM) and the Mandala: A Case Study Illustrating an Integration of Music and Art Therapies Helen Lindquist Bonny Joan Kellogg CASE TWO Music as Life and Lifeguard: Music Therapy for an Older Adult with Depression Ineke van Hest-de Witte Jack Verburgt Henk Smeijsters CASE THREE The Use of Musical Space with an Adult in Psychotherapy Carolyn Kenny CASE FOUR Group Music Therapy in Acute Psychiatric Care: The Treatment of a Depressed Woman Following Neurological Trauma Marcia Murphy CASE FIVE Group Improvisation Therapy for a Resistant Woman with Bipolar Disorder - Manic Paul Nolan CASE SIX Through Music to Therapeutic Attachment: Psychodynamic Music Psychotherapy With a Musician with Dysthymic Disorder Paul Nolan CASE SEVEN Case Study: Couple Therapy Mary Priestley CASE EIGHT Case Study of a Depressed Patient Mary Priestley CASE NINE The Song-Writing Process: A Woman’s Struggle against Depression and Suicide Georgia Hudson Smith

CASE TEN The Doors and Windows of the Dressing Room: Culture-Centered Music Therapy in a Mental Health Setting Brynjulf Stige CASE ELEVEN Music Therapy and Depression: Uncovering Resources in Music and Imagery Lisa Summer

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 with mood disorders. 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 mood disorders about the potential benefits of music therapy. About Mood Disorders The diagnosis of mood disorders according to guidelines of the American Psychiatric Association (APA, 2000) is a complicated process that relies heavily on the presence, absence, or persistence of different “episodes” of elevated or depressed affect. Major depressive episodes are characterized by a combination of symptoms, such as feelings of sadness or emptiness, diminished interest or pleasure in life, significant change in weight, sleeping problems, psychomotor disturbances, fatigue, feelings of worthlessness, diminished ability to think, and recurrent thoughts of death. Manic episodes are extended periods of persistently elevated, expansive or irritable mood, which may include feelings of grandiosity, decreased need for sleep, excessive talking, flight of ideas, distractibility, increase in goal-directed activity, and/or excessive involvement in pleasurable activities (APA, 2000). Mixed episodes are periods that include both major depressive and manic episodes. Hypomanic episodes are noticeable changes in mood from a nondepressed state, wherein the person has persistently elevated, expansive or irritably mood for at least 4 days (APA, 2000). Based upon the occurrence of these episodes, the individual is diagnosed as having a depressive disorder (i.e., major depressive disorder or dysthymic disorder), or a bipolar disorder, of which there are several types. The case examples in this book provide myriad perspectives not only of how depressive and manic symptoms are manifested differently by each individual, both within and outside of a musical context, but also how these problems can be addressed through carefully designed music experiences that capitalize on the individual’s strengths and resources. About Music Therapy (Based on Bruscia, 1993) Definition and Applications In music therapy, the therapist and client use music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help the client improve or maintain his or her health. In some instances, the client’s needs are addressed directly through music and its

intrinsic therapeutic properties; in others, they are addressed through the relationships that develop between the music, client, therapist, and other participants. Music therapy is used with individuals of all ages and with a variety of conditions, including psychiatric disorders, medical problems, physical handicaps, sensory impairments, developmental disabilities, substance abuse, communication disorders, interpersonal problems, and aging. It is also used for self-development purposes, such as improving learning, building self-esteem, reducing stress, supporting physical exercise, and facilitating a host of other health-related activities. Given its wide applications, music therapists may be found in general hospitals, psychiatric facilities, schools, prisons, community centers, training institutes, private practices, and universities. Basic Premises The thing that makes music therapy different from every other form of therapy is its reliance on music as the primary medium for promoting the client’s health. Every session involves the client in a music experience of some kind. The main ones are listening to, recreating, improvising, and composing music. These will be described in more detail in the next few paragraphs; however, it is important to explain immediately that clients do not have to be musicians to participate in or benefit from music therapy. In fact, because most clients have not had previous musical training, the music activities and experiences used in therapy sessions are always designed to take advantage of the innate tendencies of all human beings to make and appreciate music at their own developmental levels. Of course, in clinical situations, music therapists may encounter clients who have physical or mental impairments that interfere with one or more of these basic musical potentials. Therefore, care is always taken to adapt music therapy experiences to the unique musical capabilities and preferences of each client. Music therapists also screen clients who may have adverse psychological or psychophysiological reactions to participation in music. Four Basic Music Experiences Used in Therapy To understand how music therapy works, it is necessary to examine the unique nature of each of the four types of music experience—listening to, recreating, improvising, and composing. In those therapy sessions that involve listening, the client takes in and reacts to live or recorded music in the style preferred by the client. The client may respond through activities such as relaxation or meditation, structured or free movement, perceptual tasks, 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 individuals with mood disorders, and the different kinds of music experiences used to address these goals. Thus, a key to reading these cases is to pay close attention to how each type of music experience affords clients many different opportunities to not only confront their problems within the music, but also to explore healthier ways of dealing with or resolving them. This leads to the next important topic—the ways that case examples can be read or studied for greatest insight. About Case Examples For purposes of the present discussion, case examples can be divided into two main types: clinical cases, and research cases. A clinical case is a professional report written by the therapist, client, or observer to describe what transpired during and upon completion of the music therapy process with an individual client or group. The report is usually based on recordings of the session or notes and logs kept by the therapist and/or client. Efforts are made

to present an accurate and unbiased account of the therapy process to the extent possible, and theories are often used to substantiate or contextualize the therapeutic approach. Objective data may or may not be provided to verify or document the report. In contrast, a research case is a data-based report, provided by the therapist or researcher, to document or verify the specific therapeutic effects of a particular music therapy protocol on an individual client or group. As such, a research case operationally defines and measures how the independent variables (e.g., treatment methods used by the therapist) act upon the dependent variables (e.g., targeted treatment outcomes for the client), when all other relevant variables and conditions are controlled. Perhaps the best way to derive the most benefits from a clinical or research case is to read it from a particular perspective, and to interrogate the case or group of cases from that perspective. Essentially, the reader adopts a particular lens or viewpoint to study the case(s), and then asks questions that arise as a result. Three of the most helpful reading perspectives are: scientific, personal, and clinical perspectives, each of which poses very different questions for the reader to ponder. Reading from a Scientific Perspective Scientists usually look for answers to two basic questions when reading a case. First, is the case credible? That is, how accurate were the perceptions and interpretations of the writer, and how trustworthy are the findings and conclusions presented? Of course, this is not a question that only scientists pose. One’s natural propensity as a reader is to question the truth value of what is read. Certainly, if the reader is involved in some way with an individual with mood disorders, 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 mood disorders are as interested in this question as scientists and researchers. Their interest is in whether individuals 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 Mood Disorders 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 individuals with mood disorders. Additional case examples have been written, which further elaborate how individuals with mood disorders can derive therapeutic benefits from music. The list of references below includes various kinds of writing on music therapy for mood disorders, including case examples. Albornoz, Y. (2009). The Effects of Group Improvisational Music Therapy on Depression in Adolescents and Adults with Substance Abuse. Dissertation Abstracts International, 70(6-B), 3773. Ashida, S. (2000). The Effect of Reminiscence Music Therapy Sessions on Changes in Depressive Symptoms in Elderly Persons with Dementia. Journal of Music Therapy, 37(3), 170-182. Bodner, E., Iancu, I., Gilboa, A., Sarel, A., Mazor, A., & Amir, D. (2007). Finding Words for Emotions: The Reactions of Patients with Major Depressive Disorder Towards Various Musical Excerpts. The Arts in Psychotherapy, 34(2), 142-150. Brandes, V. V., Terris, D. D., Fischer, C. C., Loerbroks, A. A., Jarczok, M. N., Ottowitz, G. G., & ... Thayer, J. F. (2010). P01-14 - Efficacy of a Newly Developed Method of Receptive Music Therapy for the Treatment of Depression. European Psychiatry, 25234. Brandes, V., Terris, D. D., Fischer, C., Loerbroks, A., Jarczok, M. N., Ottowitz, G., & ... Thayer, J. F. (2010). Receptive Music Therapy for the Treatment of Depression: A Proof-Of-Concept Study and Prospective Controlled Clinical Trial of Efficacy. Psychotherapy and Psychosomatics, 79(5), 321-322. Castillo-Perez, S., Gomez-Perez, V., Velasco, M.C., Perez-Campos, E., & Mayoral, M.A. (2010). Effects of Music Therapy on Depression Compared with Psychotherapy. The Arts in Psychotherapy, 37(5), 387. Chan, M. F., Chan, E. A., Mok, E. & Tse, F. Y. K. (2009). Effect of Music on Depression Levels and Physiological Responses in Community-Based Older Adults. International Journal of Mental Health Nursing, 18(4), 285-294.

Chan, Moon F., Wong, Z. Y., Onishi, H. & Thayala, N. V. (2012). Effects of Music on Depression in Older People: A Randomised Controlled Trial. Journal of Clinical Nursing, 21, 776-783. Choi, A., Lee, M., & Lim, H. (2008). Effects of Group Music Intervention on Depression, Anxiety, and Relationships in Psychiatric Patients: A Pilot Study. Journal of Alternative & Complementary Medicine, 14(5), 567-570. Chou, M., & Lin, M. (2006). Exploring the Listening Experiences during Guided Imagery and Music Therapy of Outpatients with Depression. The Journal of Nursing Research, 14(2), 93-102. Clair, A. A., Lyons, K. E. & Hamburg, J. (2012). A Feasibility Study of the Effects of Music and Movement on Physical Function, Quality of Life, Depression, and Anxiety in Patients with Parkinson Disease. Cordobes, T. K. (1997). Group Songwriting as a Method for Developing Group Cohesion for HIVSeropositive Adult Patients with Depression. Journal of Music Therapy, 34(1), 46-67. Davies, A. (1995). The Acknowledgement of Loss Working through Depression. British Journal of Music Therapy, 9(1), 11-16. Erkkilä, J., Gold, C., Fachner, J., Ala-Ruona, E., Punkanen, M., & Vanhala, M. (2008). The Effect of Improvisational Music Therapy on the Treatment of Depression: Protocol for a Randomised Controlled Trial. BMC Psychiatry, 8(1). Erkkila, J., Punkanen, M., Fachner, J., Ala-Ruona, E., Pontio, I., Tervaniemi, M., et al. (2011). Individual Music Therapy for Depression: Randomised Controlled Trial. The British Journal of Psychiatry, 199, 132-139. Goldstein, S. L. (1990). A Songwriting Assessment for Hopelessness in Depressed Adolescents: A Review of the Literature and a Pilot Study. The Arts in Psychotherapy, 17(2), 117-124. Guétin, S. S., Portet, F. F., Picot, M. C., Pommié, C. C., Messaoudi, M. M., Djabelkir, L. L., & ... Touchon, J. J. (2009). Effect of Music Therapy on Anxiety and Depression in Patients with Alzheimer’s Type Dementia: Randomised, Controlled Study. Dementia & Geriatric Cognitive Disorders, 28(1), 36-46. Guetin, S, Portet, F, Picot, M.-C, Defez, C, Pose, C, Blayac, J.-P, et al. (2009). Impact of Music Therapy on Anxiety and Depression for Patients with Alzheimer’s Disease and on the Burden Felt by the Main Caregiver (Feasibility Study). L’Encephale: Revue de Psychiatrie Clinique Biologique et Therapeutique, 35, 57-65. Han, P., Kwan, M., Chen, D., Yusoff, S. Z., Chionh, H. L., Goh, J., et al. (2011). A Controlled Naturalistic Study on a Weekly Music Therapy and Activity Program on Disruptive and Depressive Behaviors in Dementia. Dementia and Geriatric Cognitive Disorders, 30, 540546 Hanser, S. B. (1990). A Music Therapy Strategy for Depressed Older Adults in the Community. Journal of Applied Gerontology, 9, 283-298. Hanser, S. (1992). Music Therapy with Depressed Older Adults. In R. Spintge, & R. Droh (Eds.), MusicMedicine (pp. 222-231). Saint Louis, MO: MMB Music, Inc. Hanser, S. B & Thompson, Larry W. (1994). Effects of a Music Therapy Strategy on Depressed Older Adults. Journals of Gerontology, 49(6), P265-P269. Hendricks, C. (2001). A Study of the Use of Music Therapy Techniques in a Group for the Treatment of Adolescent Depression (Ed.D., Texas Tech Univ., 2001). Dissertation Abstracts International Section A: Humanities & Social Sciences, 62(02), 472.

Hendricks, C., & Bradley, L. J. (2005). Interpersonal Theory and Music Techniques: A Case Study for a Family with a Depressed Adolescent. Family Journal, 13(4), 400-405. Hendricks, C., Robinson, B., Bradley, L. J., & Davis, K. (1999). Using Music Techniques to Treat Adolescent Depression. Journal of Humanistic Counseling, Education & Development, 38(1), 39. Herman, E. P. (1954). Music Therapy in Depression. In E. Podolsky (Ed.), Music therapy (pp. 112115). New York, NY: Philosophical Library. Hsu, W., & Lai, H. (2004). Effects of Music on Major Depression in Psychiatric Inpatients. Archives of Psychiatric Nursing, 18(5), 193-199. Jochims, S. (1992). Depression in Old Age: The Benefit of Music-Therapy to Work of Mourning. Zeitschrift fur Gerontologie, 25(6), 391-396. Jones, N. A. & Field, T. (1999). Massage and Music Therapies Attenuate Frontal EEG Asymmetry in Depressed Adolescents. Adolescence, 34(135), 529-534 Kim, K., Lee, M., & Sok, S. (2006). [The Effect of Music Therapy on Anxiety and Depression in Patients Undergoing Hemodialysis]. Taehan Kanho Hakhoe Chi, 36(2), 321-329. Lane, D. (1989). The Implications of Measuring Speech Pause Time in Determining the Efficacy of Music Therapy with Depressed Patients. In J. A. Martin (Ed.), the Next Step Forward: Music Therapy with the Terminally Ill (pp. 61-68). Bronx, NY: Calvary Hospital. Levinge, A. (2011). ‘The First Time Ever I Saw Your Face...’: Music Therapy for Depressed Mothers and Their Infants. Edwards, Jane [Ed]. Music Therapy and Parent-Infant Bonding. New York, NY, US: Oxford University Press, US; pp. 42-57. Lin, M., Hsu, M., Chang, H., Hsu, Y., Chou, M., & Crawford, P. (2010). Pivotal Moments and Hanges in the Bonny Method of Guided Imagery and Music for Patients with Depression. Journal of Clinical Nursing, 19(7/8), 1139-1148. Maratos, A., Gold, C., Wang, X., & Crawford, M. (2008). Music Therapy for Depression. Cochrane Database of Systematic Reviews (Online), (1), CD004517. Maratos, A., Crawford, M. J. & Procter, S. (2011). Music Therapy for Depression: It Seems to Work, But How?. The British Journal of Psychiatry, 199, 92-93. Mays, R. (1979). The Use of Music as a Counseling Aid in the Treatment of Depression. Dissertation Abstracts International, 40(4-A), 1878-1879. McKinney, C., Antoni, M., & Kumar, M. (1995). The Effects of Guided Imagery and Music on Depression and Beta-Endorphin Levels. Journal of the Association for Music and Imagery, 4, 67-78. Mei-Hsien, C., & Mei-Feng, L. (2006). Exploring the Listening Experiences during Guided Imagery and Music Therapy of Outpatients with Depression. Journal of Nursing Research (Taiwan Nurses Association), 14(2), 93-102. Migliore, M. J. (1991). The Hamilton Rating Scale for Depression and Rhythmic Competency: A Correlational Study. Journal of Music Therapy, 28(4), 211-221. Mohammadi, A. Z., Shahabi, T. & Panah, F. M. (2011). An Evaluation of the Effect of Group Music Therapy on Stress, Anxiety, and Depression Levels in Nursing Home Residents. Canadian Journal of Music Therapy, 17(1), 55-68. Murphy, M. (1991). Group Music Therapy in Acute Psychiatric Care: The Treatment of a Depressed Woman Following Neurological Trauma. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 465-478). Phoenixville, PA: Barcelona Publishers.

Myskja, A., & Nord, P. G. (2008). “The Day the Music Died”: A Pilot Study on Music and Depression in a Nursing Home. Nordic Journal of Music Therapy, 17(1), 30-40. Naranjo, C. C., Kornreich, C. C., Campanella, S. S., Noël, X. X., Vandriette, Y. Y., Gillain, B. B., et al. (2011). Major Depression Is Associated with Impaired Processing of Emotion in Music as Well as in Facial and Vocal Stimuli. Journal of Affective Disorders, 128(3), 243-251. Oh, J. S. (2010). Music Therapy in Breast Cancer Patients with Depression: Functional Magnetic Resonance Imaging Results on the Influence of Music Therapy on the Perception of Music. Musik-, Tanz- und Kunsttherapie, 21, 53-70. Pignatiello, M., Camp, C. J., Elder, S. T., & Rasar, L. A. (1989). A Psychophysiological Comparison of the Velten and Musical Mood Induction Techniques. Journal of Music Therapy, 26(3), 140-154. Rajewski, A., Paterka, I., Fellman, B. & Nalewajko, B. (1982). Active Forms of Music Therapy in the Treatment of Depressed Patients. Psychiatria Polska, 16(5-6), 377-382. Redinbaugh, E. M. (1988). The Use of Music Therapy in Developing a Communication System in a Withdrawn, Depressed Older Adult Resident: A Case Study. Music Therapy Perspectives, 5, 82-85. Reinhardt, A., Rohrborn, H. & Schwabe, C. (1986). Regulative Music Therapy (Rmt) in Depressive Disorders: A Contribution to the Development of Psychotherapy in Psychiatry. Psychiatrie, Neurologie und Medizinische Psychologie, 38(9), 547-553. Reinhardt, U. & Lange, E. (1982). Effects of Music on Depressive Persons. Psychiatrie, Neurologie und Medizinische Psychologie, 34(7), 414-421 Siedliecki, S. L., & Good, M. (2006). Effect of Music on Power, Pain, Depression and Disability. Journal of Advanced Nursing, 54(5), 553-562. Silverman, Michael J. (2011). Effects of Music Therapy on Change and Depression on Clients in Detoxification. Journal of Addictions Nursing, 22, 185-192. Smeijsters, H., Wijzenbeek, G., & van Nieuwenhuijzen, N. (1995). The Effect of Musical Excerpts on the Evocation of Values for Depressed Patients. Journal of Music Therapy, 32(3), 167188. Smith, G. H. (1991). The Song-Writing Process: A Woman’s Struggle against Depression and Suicide. In K. E. Bruscia (Ed.), Case Studies in Music Therapy (pp. 479-496). Phoenixville, PA: Barcelona Publishers. Suzuki, A. I. (1998). The Effects of Music Therapy on Mood and Congruent Memory of Elderly Adults with Depressive Symptoms. Music Therapy Perspectives, 16(2), 75-80. Tonn, C. (2003). Giving Standstill a Sound: Depression-Specific Themes and Their Treatment in a Music Therapy Group of Female Patients. Musiktherapeutische Umschau, 24(2), 120-133 Tornek, A., Field, T., Hernandez-Reif, M., Diego, M., & Jones, N. (2003). Music Effects on EEG in Intrusive and Withdrawn Mothers in Depressive Symptoms. Psychiatry: Interpersonal & Biological Processes, 66(3), 234-243. Werner, P. (2009). Ethnicity, Music Experience, and Depression. Journal of Music Therapy, 46(4), 339-358. Williams, G., & Dorow, L. G. (1983). Changes in Complaints and Non-Complaints of a Chronically Depressed Psychiatric Patient as a Function of an Interrupted Music/Verbal Feedback Package. Journal of Music Therapy, 20(3), 143-155.

Wu, S. (2002). Effects of Music Therapy on Anxiety, Depression and Self-Esteem of Undergraduates. Psychologia: An International Journal of Psychology in the Orient, 45(2), 104114. References for Introduction American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, Text Revision. Washington DC: American Psychiatric Association. Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ.

Case Examples of Music Therapy for Mood Disorders

Taken from: Bonny, H. (2002). Music and Consciousness: The Evolution of Guided Imagery and Music. Edited by Lisa Summer. Gilsum NH: Barcelona Publishers.

CASE ONE Guided Imagery and Music (GIM) and the Mandala: A Case Study Illustrating an Integration of Music and Art Therapies Helen Lindquist Bonny Joan Kellogg Based on: Bonny, H.L. & Kellogg, J., (1977). Guided Imagery and Music and the Mandala: A case study illustrating the integration of music and art therapies. Creativity and the Art Therapist’s Identity: The Proceedings of the Seventh Annual Conference of the American Art Therapy Association (AATA), pp. 71–76. Originally a case study (pseudonym: John) presented by Kellogg and Bonny at the October 1976 AATA Conference in Baltimore, MD. “My mandalas were cryptograms concerning the state of the self which were presented to me anew each day. In them I saw the self—that is, my whole being—actively at work. To be sure at first I could only dimly understand them; but they seemed to me highly significant, and I guarded them like precious pearls” (Jung, 1961, p. 195). Introduction The positive integration of music therapy, using the Guided Imagery and Music (GIM) technique for psychotherapy sessions developed by Helen Bonny, RMT, and then ending of the session by the drawing of a mandala, that was monitored according to the approach of art therapist, Joan Kellogg, ATR, has proved to be an innovative combination of these two expressive therapies. At the Maryland Psychiatric Research Center the authors collaborated in using music sessions followed by the drawing of the mandala in the context of short term, intensive psychotherapy. The music technique, called Guided Imagery and Music (GIM) is composed of relaxation exercises followed by continued therapist support during the playing of musical selections. GIM has been defined elsewhere, by Helen Bonny, RMT (1975), as listening to selected music, a programmed tape or live music, in a relaxed state to make use of the imagery, symbols, and/or feelings that arise from the deeper self for the purpose of encouraging creativity, therapeutic intervention, self-understanding, aesthetic imprinting, religious, and/or transpersonal experience (p. 121-135). The GIM sessions were given on a weekly basis, each lasting from one and a half to two hours, and followed by the drawing of a mandala. The music therapist does not provide client

information or test scores to the art therapist. After each session the mandala was mailed to the art therapist who wrote out and returned a diagnostic interpretation. In this psychiatric research, the mandala, a circular art form, is used as a projective device for the purpose of visually monitoring the ongoing therapy process of patients by Joan Kellogg, ATR. The procedure consists of having subjects use colored oil pastels to fill a penciloutlined circular area of about ten inches in diameter in the center of a sheet of drawing paper 12×18 inches. The subject is asked to focus on the center of the circle first, make a shape there, color it, and to keep working it in the round. Whether he goes beyond the circle outline is up to him, it is not a fence but a guide. On completion, the top of the mandala is identified, and date/initials/sex is added. Paper or plastic dinner plates are used for outlining the circle in pencil, lightly. Pastels with a minimum of 36 shades are used. Case Study We are going to present a case study in which this approach was used in an attempt to enhance the therapeutic movement toward health and wholeness. From the point of view of the music therapist, the drawing of the mandala seemed (1) to allow the client an opportunity to make a concrete representation of certain non-verbal elements of his music experience, (2) and to allow him to experience an easy and pleasant reentry into the normal conscious state. Often the music session, as we shall see, takes a client into a deeply altered state, and it is advisable that a gentle and non-abrupt return to the normal state occurs. The mandala interpretation which was received by the music therapist from the art therapist was diagnostic for it seemed to point toward current positive or negative tendencies which were valuable in helping the music therapist make decisions about her work with the client. In our case study the music therapist will discuss the content and affect of each music session after which the interpretation of the mandala will be presented by the art therapist. This case represents a total time schedule of 30 hours of therapy over a five-month period. As a part of his acceptance into our program a number of testing procedures were required, with the results available to the authors. The tests administered were: The 16 PF Test Profile, The MMPI (Minnesota Multiphasic Personality Inventory), The POI (Personal Orientation Inventory), and The Hypnosis Susceptibility Scale. John (a pseudonym) was a 22 year old, single college student who was referred for assistance in resolving moderate depressive episodes that he periodically experienced. He stated that such episodes typically lasted from two to four days. During these times, he had fantasies about suicide, but he had never made an overt gesture. He was referred to us by a professor with whom he had shared his problems. Personal History John was the older of two children in his family, with a sister three years younger. His father, a Navy career man, was of Philippine heritage; his mother was of German background. For long periods of time during his early maturation, his father was away on Navy tour duty. Otherwise, he described his childhood as normal.

Most of his school years were spent in a large American city. He attended one year of college, and then, like his father, joined the Navy. A month after boot camp, he began feeling depressed which he attributed to the treatment of fellow recruits whom he felt were being humiliated (a projection of his own feelings onto others). On the basis of humanistic objections to war, he was able, through his own counsel to secure an honorable discharge from the service. After this experience he felt lost and depressed. He decided to return to school, enrolled, and then transferred successively to three different colleges. At referral he was contemplating dropping out of college entirely. He had no drug abuse history of any kind and, essentially, had shown minimal sexual interest in others. He stated that he did not have much time for dating, nor was there much interest in such activities. His religious background was strict Lutheran, and he described his upbringing as moralistic. He had rebelled, however, against his background and spoke with much distaste of Christian hypocrisy and of lack of pacifism in the Church. He typified his religion as being essentially ethical in nature. He was overwhelmed by what he termed “the existential problems of the world” and felt responsible in some personal way to bring about their solution. He expressed a deep sense of hopelessness about life and held a pessimistic view of human nature. John strongly emphasized the importance of his intellect in problem solving; and correspondingly, he downgraded the intuitive facets of his personality. He kept himself very busy with outside activities to counteract his depression, and did not know what a sense of “inner peace” was like. He was presently living at home, and not happy. His stated goals for therapy were, “Personal balance and inner directionality.” He said that he was “afraid of involvement because it had no value.” My personal goals for him as his therapist were: greater self-esteem, a lessening of anxiety, emotional control (he cried very easily), uncovering and resolution of areas of frustration, anger, disappointment, and help in accepting the non-cognitive aspects of his personality—the Jungian anima. Mandala One (Pre-therapy) John drew the following as his first mandala prior to therapy. All of the darker lines comprising this drawing are black and blue; the lighter lines are yellow. There is one central circle in the middle that is drawn with red. The “X” inside the small circle is yellow.

John was given a mandala interpretation before he began therapy. About the mandala he wrote: “Possibly electron cloud mappings...the center X was the last marking.” Report on Pre-Therapy Mandala This person seems to be a rationalizer; it is hard for me to tune in to his way of being as the mandala suggests that he may be out of touch with his feelings; really impoverished. He used brown consistently which may have to do with anal characteristics. He is probably inclined to be orderly, careful with money, and preoccupied with intellectual pursuits. Rather puritan in background, not much laughter in his home, probably a model of decorum. He feels stuck as far as being able to grow because his male yellow X in the center is surrounded by a garden wall of the dismal restricting colors. (The yellow in the mandala represents a number of functions, replicating creative aspects of the sun; the cross, or X figure, points to problems in expression of these aspects, hence a crossroads, stuckness or crux.) Music Session One In John’s first session, in which relaxation exercises were followed by the playing of a music tape of some six selections, he was able to get more deeply into his imagery than anticipated considering the low score he had on the Hypnosis Susceptibility Scale. He relaxed, went with the music, at first as observer of imagery that was closely connected to the music, but later in the session he was able to briefly identify with the figures in the fantasy. Most helpful was a cathedral scene (during the playing of Tschesnekoff’s Salvation is Created) when he gave over his mind to feeling impulses leaving him “calm, solemn, sad, but not depressed.” After the session he was asked to specify the difference between sadness and

depression. He defined the latter as “frustrated anger.” He expressed optimism about his own involvement in the process. During a music session the client is encouraged to verbalize the ongoing imagery and feeling states that are being experienced. During the week after each session clients are encouraged to write intervening thoughts and reactions to the sessions. Music Session Two In the second music session, during the playing of Copland’s Appalachian Spring, he said, “There is a feeling of tragedy—crucifixion, a foreknowledge of its coming, knowing that it is there. It’s not fear—just knowing,” and later, “looking at a flower, its origins, meaning, existence. The bass notes in the music corresponded to deeper questions relating to existence; de-emphasis of the base issues, and acceptance without a real knowledge.” At the end of the session we talked about getting into his feelings. About this he agreed, but he expressed a fear of getting into sexual subjects. When I gave him the mandala, he resisted by saying, “I feel vacant.” I suggested that he draw as best he could that feeling. Mandala Two. John’s second mandala had yellow lines that spiral into the center of the circle. The figures are drawn in different colors; the hexagon is orange; the straight line and grated figure are red; the “X” and the oblong figures are blue; the wavy line extending from the center is black.

Interpretation. Whirlpool of yellow with various linear shapes that I think is another way to demonstrate his linear frame of reference. The only curved shape is on the left and is blue. I believe he has repressed his intuitive functions as well as most feminine receptive qualities. Perhaps a better way to say this is his analytical mind has developed at the expense of

his feelings and intuition. (The blue is an expression of receptive qualities, symbolically equated with feminine aspects of water. The dark blue indicates intuitive functions placed on the left side in the preconscious.) Post Session Two After the session, during the next week he wrote more expressly of his feelings, “I slipped into a state of depression today, and by mid-afternoon as I sat in the library, I felt terribly distant from everyone there. All the problems of the world seemed to weigh in on me. Something must be done, I don’t know what, I don’t know where the problems come from...It may be anger, origin unknown, which eats away at me, but in its deepness it surfaces as anxiety.” Music Session Three Fear, anger, and boredom were all emphasized during the playing of the music. He asked that the music selection be changed, again and again. Rapport with the therapist was still a question. We had not really become involved with basic problem issues. His defenses were strong; and he would, in all probability, not be able to relinquish them for a while. His comment, in the last session, that he was unprepared to talk about sex may be a major defense. Another strong defense was his “head” talk. His anger at the world definitely appears to be a projection of his anger at parents and possibly himself. Mandala Three. The lines that spiral into the center of the circle are yellow. The four smaller spirals are drawn alternately in green and red. The two arrows drawn between the spirals are both blue; and the two curled lines drawn between the spirals are both dark green.

Interpretation. This is made of whirlpools, pointing to involution (going back). It may indicate that he went with the music session well. Post Session Three From John’s personal reaction to the session he writes (in a more hopeful vein), “If some spontaneous, personal feeling could be achieved, then the question of worth might never arise. I am beginning to feel the present distance between my thinking and feeling self.” Music Session Four Preliminary to the music session, John talked about his growing restlessness with living at home. He was thinking of finding an apartment and being on his own. This would free him from what he described as the “overbearing influence of parental values and structure.” A tension-relaxation exercise was used before the music tape was started, and a more structured imagery procedure after the Guided Affective Imagery of Hanscarl Leuner (1969). The music session went well, and I felt that we were getting closer to a discussion of personal needs. Mandala Four. In this mandala, the brick-like lines drawn outside the main circle are yellow. The central circle consists of two rings and a center. The outer ring is blue; the inner ring red; the center is drawn in yellow.

Interpretation. This is frankly obsessive compulsive. When he begins to make progress, he begins to defend himself in this way. This is the target mandala, and is rather classic as a demonstration of a defense mechanism at work. When you get too deep into introspection this is what happens. Presto, a formula appears, or something triggers the nest-building circular process that keeps one so busy, one cannot reflect. The yellow web affair is a reflection of the dependency needs, the need for structure in this kind of person; but unfortunately, at the same time, this prevents the happy accidents that make for growth. Music Session Five For many clients, the fifth session usually coincides with a breakthrough of catharsis and/or insight into themselves. John was one of these. Rapport had been established. In the preliminary interview, he stated for the first time that his pessimistic feelings about the world may have been projections of his own inner state of turmoil. He felt a need to be more receptive to others; that perhaps a lack of communication was more his fault than that of others. John said that he was feeling less depressed, but that he was afraid to trust the feelings. During the music, he reported quiet feelings; and then feelings of anger came to the surface. I encouraged these feelings through the use of an Affect-Release music tape, and through bio-energetic exercises which provided muscular resistance. I encouraged him to press against the palms of my hands, as I pressed down on his palms suggesting that he push me off; he did. We repeated the exercise several times to the evocative music of “Mars” from Holst, The Planets. He reported feelings of emptiness, disgust, anger, coldness, and aggression, in that order. I repeated the music tape again applying the same pressure for some 20-minutes of playing time. No mandala #5 was drawn at his request after this session.

Music Session Six Getting John in touch with his body through the above approach was a breakthrough into his feeling state, but it was threatening to him. He asked to not have music this session, but to talk because, “I feel confused.” He talked in circles then was finally willing to listen to the music without eye shades or earphones. We talked at length about his extreme sensitivity, and of the possibility of its being a form of “tender-mindedness.” As he got into the feeling areas, John experienced confusion and uncertainty in his thinking. Mandala Six. This mandala is drawn in blue, yellow, and red. The circle is outlined in blue. The lines that swirl into the center are drawn in yellow and red. They are yellow from 12 to three o’clock and from six to nine o’clock; they are red from three to six o’clock and from nine to 12 o’clock.

Interpretation. This appears to be a reaching back counterclockwise into the unconscious area, and very good in terms of the “journey into the self.” Surrounded by a ring of negative mother blue; the red and yellow are both active aspects of himself and shows he is engaged actively in the search. Music Session Seven John had a good week and was feeling better. He spoke of his need for structure. If things are not described and discussed in detail, he feels unhappy. The music session brought up pleasant feelings of unity with nature, satisfying interpersonal relationships with people, and a realization of his need of them.

Mandala Seven. In this drawing, the small circle is outlined in white. The large star formation in the middle is drawn in blue, and flesh-color (the largest points of the star are yellow, the smaller points are blue and flesh-color).

Interpretation. Well, this one is a surprise; a new and promising center is born like a star in the sky--iridescent and luminous, pregnant with many colors or aspects of self. Lighter colors are used, a flesh color that is healthy and ruddy, so certainly his flesh was involved on a feeling level, a positive mother blue, and a beautiful yellow of mind. Surrounding it is just a white ring that in no way blocks him off from others. This is great. Music Session Eight John had two short depressive periods in the preceding week. He spoke again about his extreme sensitivity and of his strong feelings. He recalled that he cried frequently at school as a child until he reached the seventh or eighth grade. He also remembered that he had asthma that started when his father first left home for Navy duty. During the music he reported a “gut” feeling in his stomach. It was suggested that he go with the feelings and this led to remembering a Valentine’s Day at school in the sixth grade. He had a romantic crush on a girl in his class, and he proudly presented a large candy valentine to her. He was the only one to do this and was laughed at and teased by teacher and children and embarrassed in the presence of his peers. We worked with the embarrassed feeling and with the anger that came up. When I pressed down on John’s shoulders to encourage a catharsis, he stated that it was not anger he was feeling, but the need to reach out to others. He asked to reach out to me. He asked for my hand, which he held, accepting and giving warmth. I put my

arm around his shoulder; he accepted this gesture of warmth and nurturing. The basic acceptance of warmth and recognition of his need for it was the strong element in this session. Mandala Eight

Interpretation. This appears to be a conjunction of the opposites within him, a mixture of curved and straight, blue and red, female and male, from the conjunction of the four directions. But, no fifth element has appeared in the center to herald a new ego nucleus. This seeming conjunction is an illustration of the “dragon fight,” complete with swords, but it is here a stalemate and leads nowhere. (Red and blue used in this fashion can be significant as a confrontation of the libido as red, primary energy, separating from blue, the depressing, negative attributes of the negative mother image. I keep waiting for a good, firm center and some expression of yellow to indicate real progress.) Music Session Nine During the past week, John had an argument with his parents. They said that he was aloof and arrogant and that he “cut them down.” During the music session, John described love as “an abstract principle—which has no real feeling in me. My parents say that they love me, but I can’t feel it.” After the session, we spoke of lack of feelings, especially for his mother. I suggested that we work on “clogged” love feelings toward his mother and others at our next session; he agreed. Mandala Nine. This mandala is drawn in two colors: purple and brown. The three lines at the top and the three lines at the bottom are purple. The four lines on the left and the right are brown.

Interpretation. Again, the tension of the opposites; but no nucleus, just a point in space. The fight is on. Tension is mounting. We will hope it leads somewhere. (The red is lost in the blue or incorporated, yielding purple. Purple frequently points to energy locked up in ambivalent feeling in the maternal bond.) Music Session 10 This session was a breakthrough session for John. Although the scenes from school days were observed for most of the music session, there was no imagery. The feelings were very present and led to a good understanding of his problem of lack of expression of feelings, except the channeling of them into social problem-solving. As far as his own emotional needs are concerned, he seems acutely aware that he has been denying them, suppressing them, and even feeling guilty about their presence. We discussed his need to balance his life, to accept and reach out for emotional warmth for himself—in short, to stop starving himself in these areas. I encouraged such activities as music, dancing, poetry, painting, or anything which would help him to express his need for strong emotions in a way that is acceptable and good for him. After the music, there was a noticeable afterglow. He looked more relaxed and “himself” than I had ever seen him. Mandala 10A. There are four formations in this mandala. Each formation is a different color. The short wavy lines within each formation are the same color. From right to left, the formations are colored red, yellow, blue, and green.

Interpretation. This one seems to indicate a flowing expression, certainly less compulsive, and more open to possible change. It is balanced, but not compulsively. The outside rim is open as well, so a great deal of trust is apparent. Mandala 10B The outlines of the large crystal-like form are drawn in green. Each figure within the sections is a different color. Beginning with the largest circular form and moving clockwise, the forms appear as a red, wavy circle, an orange zigzag, blue crossing lines, a black triangle encased within the outline of a yellow triangle, a yellow rectangle, and a blue star.

Interpretation. This one is definitely different, rather like a crystal, just kind of growing spontaneously without worrying about preplanned order, again reflecting a kind of trust in going with things, rather than insisting on a road map. Some intense feelings via the orange; certainly getting some emotional response now. Looks good. Music Session 11 The music session was used to work through a dream which John had had that morning. The dream was as follows: he was to be placed upon a cross in a living room--not his own--by his father. His mother was nearby in the shadows. Two unknown girls were watching. The cross itself was as tall as he in its vertical beam, but very short horizontally. There was no show of emotion by any member of those present, nor did he feel any emotion. (You will remember that a scene of the crucifixion had occurred in his second session.) John said “no” to the idea of being put on the cross. The “no” was more in the anticipation of pain than to the humiliation of the event. He ran upstairs and escaped through a window. The dream ended at that point. I suggested to John that we could relive the dream in fantasy in the music session, which we did. Its ending was as follows: he escaped through the window to a railroad track, but he was concerned about where the track would lead him. More present was the sense of freedom and release. In the discussion that followed, John said, “I think of the dream symbolically, as seeing through the past the conservative emphasis, and then breaking away from it, from its restrictions.” John identified the dream with feelings of wanting to leave the insensitive past in which he had put himself up “on a cross”—as regards his interest in social action projects which

were “too big” with which to comfortably identify; what he considers his over concern with ethics and religion. He feels free now from the paralyzing effect of his overcompensation for feelings of helplessness. He is more interested now in local politics, and plans to get involved in them. We discussed the termination of therapy. He felt that a breakthrough for him had come at the previous session (10th). He did, however want to continue for a while to see how the new freedoms worked out. I reassured him that he could continue until he felt ready to terminate therapy. Mandala 11. The central circle has four lightly drawn rings of various colors. From the central ring to the outside, the colors are: green, red, yellow, and light purple. In addition, the outer ring of the circle is clearly drawn with a thin, light purple line. The square drawn at one o’clock is blue; its inside is shaded in light blue. The diamond shape within it is drawn and shaded with green. The square drawn at seven o’clock is green; its inside is shaded in light green. The triangle shape within it is drawn and shaded with blue.

Interpretation. Here we go on the nest building trip, what ticks this off is the threat of change, I believe. He began to just let it happen and, because of defenses carefully built over the years, this is called into play when change or growth is called for. I expect this will tend to happen until he practices change and is less threatened by it. The inside of it is fairly loose until he gets wrapped in the purple. Don’t get discouraged, he’ll get there; it will just take longer perhaps. (This one illustrated a new nucleus in green, significant because green is the coming together of yellow and blue, father and mother internalized, an acceptance of parenting oneself. However, the purple outline restricts growth.) Music Session 12

John is definitely over the hump in his therapy. He will be coming every other week or so now. When he arrived, he gave me three concerns which I observed as growth occurrences: (1) discontent with school, but willing to stick it out to graduation, (2) decision to move out of his parents’ home to have greater freedom, (3) a need for a close love relationship. (On the latter, I will try to be of some help in bringing out feelings of warmth in the last few session periods.) During the tapes, John was quiet, “just listening to the music.” Mandala 12. The leaves in the mandala are lightly drawn in green; the thin branches are lightly drawn in black; behind the leaves is a background shaded lightly in blue.

Interpretation. This must have been a banner week. I never expected to see anything done by him that is so loose and free. The growing branch with the curved leaves of green, are fine, pointing to the conscious side; it is growing toward the sun, with the roots in the unconscious. The other colors surrounding it are light blue and light red, and the way they are worked makes me think he might have touched, however tentatively, another dimension. So, the winter of himself, the black branches have sprouted spring foliage. (I am so very glad for him). Music Session 13 John reported some conflict about whether to stay in school or not. He felt less compulsive, more open to pursing an understanding of himself and his inner needs. He was no longer depressed, but he reported some inner confusion, a sense of shakiness. When he drew the mandala, he entitled it “a budding tree I saw in West Virginia.”

Mandala 13. This mandala is drawn lightly with green, red, and blue; the colors are blended together.

Interpretation. Very beautiful, growing out of the subconscious into the conscious, with buds at the tips. Other than feeling very good about this, there is little to say. Mandala 14 When John returned for termination, after a three-month interim, the following mandala was drawn. The flower shape in the center of this mandala has very light yellow petals and is outlined in soft blue. The center of the flower is black.

Interpretation. It appears that he is definitely a mental kind of person, but it is a soft, full kind of mentality rather than a linear kind now, more emotional life. The color of the center flower is a light yellow, so I would feel he would be an idealist in a positive sense. The green surrounding it, if it represents parenting, control, or perhaps his marriage or emotional environment, is loose and flowing and certainly not restricting but growth enhancing. There is a small amount of red, throughout, so I feel his primary needs are fulfilled. So the basic four colors are reflected; though the blue is obscured in the green, it is represented along with yellow and red. If you need visual proof for a successful resolution, this is it. (Contrary to general practice, I had been informed via telephone conversation of his marriage. The green is significant here as internalized parenting of self, perhaps). Therapeutic Outcome John’s post-testing scores showed the growth he had achieved in therapy. The MMPI was within normal limits. The 16 PF indicated increases in emotional stability, group dependence, casualness, and relaxation. The post treatment POI profile indicated some progress in self-actualization. The music tapes which were used were: Beginners Group Imagery, Imagery, Peak, Comforting, Death-Rebirth, Affect-Release, and Cosmic-Astral. Post-Therapy Interviews Gleaned from the interviewers. The impact of John’s therapy indeed appeared to be dramatic. Whereas he had little time for women and no interpersonal sexual history at the time of his screening interview, he has since been married. He started dating the woman who became his wife several months after termination of his therapy, lived together with her for a few weeks, and then was married by a justice of the peace with the parents in attendance. He

feels that his experience in psychotherapy enabled him to become more sensitive to his own needs to love and to be loved and credits this as a significant factor in his subsequent involvement with the woman who is now his wife. He strongly emphasized that he felt that therapy allowed him to be much more realistic in setting goals and making demands on himself...and he is much more compassionate in regard to his own human limitations and also those of other persons. He denies any feelings of depression during the past few months, a definite change from his condition at the time he requested therapy. He describes this lessening of depression within himself to be due to a better understanding of himself and of other people. He still finds himself to be angry at times but it is not the debilitating anger that he has experienced before, and is more realistically expressed. John commented that he feels more responsible now, primarily because he does not commit himself to attend more activities than it is possible for him to manage. He finds it much easier to set limits on his involvement in various good causes. I also noted a healthy sense of humor that was not previously apparent. As a whole, he seemed much less of a brilliant, rational robot, and much more of a warm, sensitive human being. He commented incidentally, that the sexual facet of his relationship with his wife was without conflict and very meaningful. When asked about the feeling of pessimism that he strongly expressed about the world and the future of man, he said that objectively, he still feels a sense of pessimism but “it does not upset me personally as much.” John feels that his appreciation of classical music has been enhanced by his participation in this program. He listens to music more closely now and finds that it helps him to (reach) feeling levels within himself. As far as his sensitivity is concerned he finds that it can be a gift of insight; he can be hurt, as well, because of that sensitivity. About the hurts, he has discovered that it is easier to be objective and to understand the reasons for his feelings. In conclusion, “I feel strong and confident and I feel that the things that I have gained through therapy will serve me well in my life.” Conclusion The combined approaches of Guided Imagery and Music as psychotherapy by a music therapist and the subsequent drawing of a mandala at the end of each session for monitoring by the art therapist, is one demonstration of the value of combining the creative expressive therapies. This presentation reflects the limitations imposed by the research protocol for this project that was to test the efficacy of music therapy as a treatment modality and a pilot test of art therapy as a valid monitor in a “blind study.” This meant limitations for the art therapist, the absence of patient information and lack of personal interaction with the patient and the music therapist. A research study designed to allow for interaction between patient and art therapist in regular sessions is another approach. In this latter case, the patient would benefit more equitably from both expressive therapies. The monitoring effect could be more accurate with shared information throughout treatment. A still broader conceptualization that could

encompass both therapy and monitoring, even possibly some diagnostic aspects, could be eventual goals for art therapists to explore research and document. References Bonny, H.L. (1975). Music and consciousness. Journal of Music Therapy, 12(3), 121–135. Jung, C.G. (1961). Memories, Dreams, Reflections. Aniela Jaffee, Ed., and Recorder. New York, NY: Vintage Books. Leuner, H. (1969). Guided Affective Imagery (GAI). American Journal of Psychotherapy, 23(1), 4– 22.

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

CASE TWO Music as Life and Lifeguard: Music Therapy for an Older Adult with Depression Ineke van Hest-de Witte Jack Verburgt Henk Smeijsters Introduction This chapter describes the case of Peter, a 60-year-old client who withdrew from life and became apathetic, anxious, and depressed after his wife died. At the start of improvisational music therapy, his music sounded powerless and withdrawn. As therapy progressed, he began bringing in and sharing his music collection with other group members. This gave him the opportunity to tell others about his musical taste, which was very important to him. This also changed his musical playing, which became more dynamic and improvised as he regained energy and strength through his improvisations. In these ways, another Peter sounded himself in music. Peter stayed with us for seven months. During music therapy sessions, it became apparent that a major cause of his depression was a grieving process that had become blocked. Peter could not deal with the loss of his wife, who had passed away a year earlier. He attended part-time treatment (three days a week) at a psychiatric clinic in Arnhem,1 participating in group therapy intended to provide insight. Music therapy was an important part of this treatment, and his underlying issues quickly became audible and visible. Within this context, Peter’s therapy is interpreted by means of the theory of analogy (Smeijsters, 2005), which examines the relationship between the client’s music, be it composed or improvised, and his/her core self. Foundational Concepts Analogy and Depression The people in our treatment program are elderly (55 years and older) men and women with depressive symptoms related to experiences of loss, trauma and life-stage oriented problems. Many of our clients have recently stopped working. This has significant consequences, both for the individual concerned and for his/her partner. Together, they need to find new ways of “filling in the day” in order to give their lives a sense of purpose.

Furthermore, our clients increasingly face the loss of social contacts, as many of their elderly friends become incapacitated or die. It is precisely this social interaction with group members who experience similar problems that can prove to be an invaluable source of support. A social network can be extremely supportive and powerful. It provides a sense of identity, empathy, solidarity and a solid basis for sharing experiences. In the Netherlands, music therapists are rooted in the basic principles of the Dutch creative arts therapies, which are experiential and active. This means that the core of the music therapy session involves the client improvising in more or less structured ways. During a client’s playing, we often hear not only his/her depressive features, but also the way in which he/she maintains the depression. The fact that Peter was depressed and extremely sad became apparent not only in his attitude and what he said; but the other group members could hear it in his playing, which made a deep impression on them. In order to expand upon this orientation and directly address the experiences of depressed clients, Smeijsters has incorporated the concept of analogy into clinical practice (2005, 2006, 2008). This theory is based on the psychological and neuropsychological research of Stern (2000, 2004, 2010) and Damasio (1999). The theory of analogy describes receptive (primarily music listening and discussion) and active (primarily improvisation) music therapy by means of vitality affects in the core self (Stern, 2000). Vitality affects are those processes that evolve within our psyche that tell us how we experience our environment. These processes have been described by Stern (2000) as musical phrases. As such, he suggests our psychological processes sound like music. Vitality affects are a part of the core self that, as described by Damasio (1999), evokes non-cognitive, intuitive and felt forms of knowledge. Smeijsters (2005, 2006, 2008) developed these concepts, describing analogy as the felt, non-cognitive correspondence between the person’s “inner musical phrases” and the musical phrases s/he hears in the music s/he wants to listen to or improvise. Music, therefore, makes it possible to express ourselves in a way that is very close to what we are really feeling about our environment and ourselves. Instead of describing our inner world with words and figures that are distanced from the processes we are experiencing, the musical sounds are a mirror of our core self-experiences. Within the theory of analogy, the therapeutic process is understood as a process that unfolds in music itself, and it is during this musical process that the vitality affects of the core self can be expressed, explored and changed. Before this process is translated into words and cognitions, experience comes to sound in the music. It is not always necessary to translate these experiences into words and cognitions because an experience within the core self is “felt knowledge” that is incorporated into the psyche. But a translation into words and cognitions can help the client to make sense of these experiences in a more or less cognitive way. In the Netherlands, therefore, many music therapists also incorporate techniques of cognitive therapy or insight oriented therapies (Smeijsters, 2006). These techniques are used afterward, when the music has ended and reflection on the music experience takes place. Although analogy focuses on the match between the musical forms and core selfexperiences, it is also possible that the music can evoke associations and memories because it is sounded in a specific phase of life or context. In that case, for instance, the music reminds a person of what happened in that time period, and therapy evolves from that association.

With depressed clients, the goals of therapy are therefore twofold. First, it is important that the feelings of depression can become expressed in the music in an analogous way. In receptive music therapy, composed music (e.g., songs) is used to encompass musical forms that are analogous to what the client is feeling. In active music therapy (e.g., improvisation), the client himself plays the vitality affects of his core self and is supported by the music therapist to explore musical forms that can put his vitality affects into sound. By doing this, inner feelings that have not been well articulated can be evoked more deeply in the musical form of the improvisation. The second goal focuses on exploring positive feelings by means of composed or improvised musical forms that are analogous to these positive vitality affects. The Clients Group Interaction as a Representation of Analogy Let us start by giving a brief sketch of the nature of the therapy group in which Peter became a member. When Peter’s treatment started, the group had already existed for a considerable time. Peter was fortunate to join a group in which the prevailing climate was one of respect, tolerance, and warmth. The group consisted of six people who met three times a week for a course of intensive treatment. The program comprised a number of different types of therapy: psycho-education, psychomotor therapy, group conversations, and music therapy. In music therapy, the focus of treatment was on the interactions within the group. That was how the client’s issues became visible and audible. At the same time, the group members could also experience how they could break through their isolation and express their sorrow and pent-up feelings. In this way, analogy worked two ways. On the one hand, the depression became audible and understandable within the group interaction; on the other, the healing moments within the group acted as a sounding board for what could take place outside therapy in daily life. Assessment Process After a client is referred to the center, an extensive intake consultation is arranged with a psychologist or psychiatrist. During this consultation, the client’s exact needs and requirements are assessed and contextualized with the client. For many clients, a series of oneto-one consultations may suffice; for others, a mixture of treatment programs may be more appropriate. Within the multi-disciplinary team, a treatment program is formulated. If the team considers that a client can benefit from insight-oriented therapy, with a focus on experiential work, the client is eligible for the treatment milieu that includes music therapy. The Therapeutic Process It is half past two in the afternoon. The group should be arriving any moment now. It is a small group of clients, many of whom are learning to cope with grief, loss, and sadness. It is an open group: every few weeks, we bid farewell to a client or welcome a new member to the group. Today, we are welcoming Peter.

A well-built man walks into the room. He keeps his eyes cast down. He extends a friendly hand. I see that he is struggling to smile. I immediately sense that I should not approach him too directly, that I should give him the time to settle into the group. Once the group has sat down in a circle, the “moment of truth” arrives. I ask Peter to tell the group something about himself in relation to music. Casting his gaze downward (so that we can’t see that he is blushing), Peter explains, in short sentences, that he loves music, but that he hasn’t been able to find the inner peace he needs to enjoy music. So much has happened in his life. As he continues, we can hear that the problems Peter is experiencing are also the problems of the other group members. His story makes a huge impact--so much misery, so much sadness. In retrospect, it was apparent that both the group members and I were intuitively inclined to treat Peter carefully, even though lots of emotions were evoked. We avoided asking too many questions. We avoided confrontation. We were conscious of his endearing shyness and did not wish to harm him, or cause him even more pain. His shyness and awkwardness also manifested themselves in his musical performances. He gently played the xylophone with his face close to the instrument, without any dynamic action. He seemed unwilling or unable to break momentary silences. Gradually, his most apparent character traits became the central theme of his music therapy treatment: “Why are you so terribly shy? Why do you appear so vulnerable? And, why do we approach you so carefully?” Acceptance Peter’s story is heart-breaking. He was diagnosed with autism at an early age. He married later in life. His wife recently passed away after a serious illness. He lovingly cared for her for many months until she died at home. He also worried greatly about his family and how to manage without his wife. He had four children, two of secondary school age and two of primary school age. During the same period, the situation for two of his children began to deteriorate. One of the children was referred to a psychiatric clinic; the other was placed in foster care. After his wife’s death, Peter found it increasingly difficult to cope with all these stressors. He was unable to manage the housework. He became increasingly withdrawn and apathetic, despite the help of family and neighbors. It was then that he was referred to our group music therapy program. Although Peter was shy, withdrawn and anxious, he was nevertheless able to tell his story, albeit hesitantly, to the group. The group showed great understanding and acceptance of his socially withdrawn and introspective demeanour. For Peter, it was extremely important that the group acknowledged and accepted his sense of loss and desperation. But, he was (as yet) unable to express this sense of loss adequately. This, too, was accepted by the group. Peter’s improvisations during this period were sluggish and feeble. He played the xylophone, a conga drum, or small rhythm instruments. He only gave a tap now and again, and his playing was without any melody or structure. He had no musical contact with the group. The group responded by also playing very softly. Everyone automatically adapted their playing to his. Gradually, Peter let the group hear more of himself, although they continued adapting their playing to his. In this way, Peter gained a place in the group. Parallel with his musical presence, he also developed his verbal presence, starting to talk more and take more initiative. He also

began to take up more space in a literal sense by standing up straight rather than sitting all hunched over. Coming Out of His Shell Although sessions included improvisations, the group also spent a lot of time listening to music, and it was through these music listening experiences that Peter was able to work through his problems. Group members brought along music that held a special place in their hearts, and a great deal of respect was shown for each other’s musical tastes. Interestingly, Peter began to show a genuine interest in the musical selections of the other clients. Their musical tastes appeared to have given him a new lease on life. He also began to show his impressive knowledge of the music played by others in the group. In a similar vein, he talked enthusiastically about his own music collection. When the name Ennio Morricone2 was mentioned, he came alive. He promised to bring along some music to the next session and talk about it. This turned out to be the beginning of a spontaneous and educational journey into the history of music. As he became more comfortable, Peter took it upon himself to share his extensive knowledge and passion for music with the group, using a variety of themes. One theme he chose was “folksy fragments.” He painstakingly prepared his presentation, writing everything down neatly, complete with suitable examples. He talked animatedly about the music he chose. He was clearly highly knowledgeable about music. Everyone was astounded. He had become a different person--someone who dared to make eye contact, smile, and move effortlessly during his presentation. He enjoyed the music and loved talking about it, not because of the attention he received, but because of his passion for music. Sensing this change in his personality, the group gradually approached him less cautiously. Under the guise of “music,” other group members felt able to say more, such as asking him to speak a little louder and clearer. We gradually noticed not only a change in Peter’s mannerisms and speech patterns, but also in his musical performances. He was more dynamic, more daring--even daring to improvise and laugh at himself when he “hit the wrong note.” In the months that followed, he gave other presentations on themes such as light, water, and the mystery of religion. He conscientiously prepared his presentations, but never spontaneously. Blossoming Initially, the focus of the group’s attention was on Peter’s taste in, and his knowledge of, music. He enthusiastically delved into his musical archive, which had remained unopened since his wife’s death. His interest in and love of music had been rekindled. Gradually, the group started to focus more time and attention on different ways of listening. The group discussed “technical listening,” which was Peter’s preferred method when he first joined the group. He would make comments such as: “In this passage, the theme is repeated and the second violin joins in.” The group also spent time in “associative listening.” Here, the music evoked thoughts and images. A third concept, “emotional listening,” was also discussed: What did the music “do” to an individual? What emotions and feelings did it convey? These discussions evoked a lot

of emotion in Peter. Music had always played an important part in his life, and now, gradually, he began to change the way he listened. Whereas initially he concentrated on technical and aesthetic terms, he slowly began to connect music with his own emotions. For instance, after listening to a piece of music for a brass ensemble brought along by another member, Peter played a recording of a fanfare used at his mother’s funeral. While listening to this piece, he was finally able to be emotional and to show his emotions. On another occasion, he introduced the group to a piece of music that he and his wife frequently listened to during the last weeks of her life. The tears rolled freely down his cheeks. This was a touching moment for the group and for me. I was deeply moved, yet I also sensed that we were able to support him in this moment. He readily accepted this support. Bidding Farewell Little by little, Peter managed to pick up the threads of his life again. He was extremely concerned about the well-being of his children. Fortunately, with the support of people in his community, he managed to cope. Within the group therapy setting, he had undergone a veritable metamorphosis. While he had not become a gregarious or extroverted man, he had certainly made his presence felt. He was not afraid to make eye contact, and he radiated confidence. He purchased a new computer and a new sound system, and continued working with his musical archive. He even drew my attention to several beautiful and unfamiliar pieces by Brahms. As a farewell gift, Peter surprised us all with a musical lecture on “farewells,” covering the gamut of classical, religious, and popular music. His musical choices, with accompanying narrative, are included below: Peter’s “Farewell” Musical Lecture A) Joseph Haydn: Finale from (Farewell) Symphony 45 (length: 5.00) Papa Haydn (1732-1809) served the Esterhazy Court in Eisenstadt, Germany. He composed the Farewell Symphony as a subtle protest to his employer for his grueling touring schedule. During the last movement, one musician after the other snuffs out a candle and leaves the stage. The music dies. B) Terry Qilkyson: Memories are made of this (length: 2.00) This song became a huge hit for Dean Martin (1917–1995) in 1956. Dean Martin is one of many Italian-American artists (Perry Como, El Martino, Frank Sinatra). Also a famous movie and TV star, such as ‘The Dean Martin Show.’ One of his sons was killed in a plane crash in 1987. C) John Dowland: Now, Oh Now I Needs Must Part (length: 4.00) The English composer Dowland (1563–1626) wrote a lot of music and songs for the lute. He spent much of his life travelling in mainland Europe. His works portray a particular type of melancholy. He called his instrumental pieces ‘lachrimae,’ meaning tears. This

particular rendition is performed by the Anglo-German tenor Rufus Muller, best known for his performances in Messiah and St. Matthew Passion. D) Skeeter Davis: The End of the World (length: 2.35) Skeeter Davis was born in Kentucky and lived from 1931 to 2004. He was particularly known for his country and western music, but he also composed many songs. He died of lung cancer in 2004. Don’t they know it’s the end of the world; Cause you don’t love me anymore… E) Johannes Brahms: Farewell Piece (length:3.30) A somewhat stern character, Brahms was born in Hamburg. He lived from 1833 to 1897. Brahms was linked with Bach and Beethoven as one of the famous “3 Bs” of classical music. He had a platonic relationship with Clara Schumann for many years. Most famous for his symphonies and requiem. Many songs. The Farewell is one of 14 German folk songs: Ich fahr dahin weil es muss sein Ich scheid mich von der Liebsten mein So lang ich lebe, bleib ich dein Leb wohl, adieu, du Liebste mein.

I go away because it has to be I separate from the dearest of me As long as I live, I will be yours Farewell, adieu, you dearest of me.

F) McGear: Thank You Very Much (length: 2.30) Comedy, poetry, and music trio “The Scaffold,” which included Paul McCartney’s brother. The Scaffold is best known for their chart hit Lily the Pink. The song is dedicated to anything and everything: Thank you for the birds and the bees, the family circle, love, being fat, Union Jack, nursery rhymes, Sunday times, for playing this record. G) Charles d’Helfer: Introitus: Requiem (length: 3.30) D’Helfer is a French composer who lived in the first half of the seventeenth century. This is a reconstruction of his Requiem for the two Dukes of Lorraine. This piece comprises a composition by d’Helfer, supplemented with compositions by four other composers, including Sweelinck. H) Wanda Jackson: Let’s Have A Party (length: 2.00) Wanda Jackson was born near Oklahoma City in 1937. She started her singing career in a church choir, before embarking on the rockabilly tour: country rock and roll. In the 1970s, she turned her attentions to more religious music. This is a sing-along song, suitable for a farewell party. The group was very impressed by Peter’s “musical lecture.” Equally important, he could see in himself that his presentation expressed a certain strength and quality. He also found that he had regained his love of music and thus the strength to be part of life again. Peter’s work in music therapy showed him that music could help him survive. It touched the core of his being

and enabled him to find direction and meaning to his life once again. Music was “the means” in the therapy. Fittingly for Peter, it was once more an essential part of his life. Summary Peter’s work in music therapy showed how listening to and talking with others about the music that was important to him made it possible for him to regain his strength. When Peter began therapy his music sounded weak, an expression of the inner struggles. Listening to and playing music thawed his apathy, shyness, anxiety and lack of energy. The musical pieces that were closely linked to special life events made it possible for him to feel again; not only to feel his grief, but also to feel the power to take up life again. Active Music Therapy When Peter began music therapy, the focus of sessions was on improvisation. As he played, we could clearly see how his music showed his shyness, hesitancy and underlying depression. He played very softly on the xylophone, without any dynamic variation. Further, he did not dare to break through silence with his sound. In the theory of analogy, one of the central concepts is that the client sounds himself in the music. This means that his inner forms of feelings, his vitality affects, are expressed in musical forms that have the same temporal contour as these inner vitality affects. This all happens in the present moment, as described by Stern (2004), in which the felt experience, without any distanced verbalization, is directly sounded in musical form. In Peter’s case, the music sounded his depression in a very direct way. Because of the combination of autism, the death of his wife, and problems with his children, it seemed clear that Peter had lost control of his life and therefore withdrew, becoming apathetic and anxious. The inner feeling of losing energy and strength were heard in his music in an analogous way. Peter sounded his apathy, withdrawal, and anxiousness in all he played. Receptive Music Therapy The key to working through these problems lay in his enormous music collection. When other clients started to talk about the music they loved, Peter felt invited to do the same. His deep and enduring relationship with music allowed him to structure his musical expression, and in so doing to open up to his emotional world. Peter became very active in preparing and presenting his musical lectures, talked with more animation, made eye contact, laughed and moved freely. As therapy unfolded, Peter began to share music that had deep emotional meaning: music associated with special events like the death of his mother and the final weeks of his wife’s life. This allowed associations between the music and the event to develop. While listening in the present to music that sounded in the past, memories of the event were evoked, and by means of these memories, corresponding emotions were evoked and felt once more. However, music was more than a “cue” that triggered memories of the event. Unlike a cue, musical forms encompass temporal contours of feelings and therefore directly evoke the

vitality affects of feelings. When listening to the music, Peter could remember the event while at the same time feeling the vitality affects the music was expressing. For Peter, merely talking about the event would have been very different. This would have afforded an opportunity to re-live the event and experience related emotions. But listening to the music that sounded during the event offered the same musical forms and corresponding vitality affects. The music was able to give him the feeling he had then in the present moment, without any cognitive act of association. Once your feeling is back, and you recognize that you are able to feel, you can begin to work through these feelings. Feeling “in the present” allowed him to be a feeling person in the future, knowing that life could go on. Although we can “know” and “tell” a lot about music (e.g., the composer and the performing musician), the essence of the musical experience is a process that evolves beneath this knowing and verbalizing. Musical forms evoke forms of feeling in a very direct way. Music is a felt, intuitive, conscious but non-cognitive way of being, processed in the core self. Experienced this way, music is able to do the therapeutic work without cognitive knowing and verbalization. Music is able to give back life, energy, and strength. References Damasio, A. (1999). The Feeling of What Happens. Body and Emotion in the Making of Consciousness. New York: Harcourt. Hest-de Witte, I. Van & Verburgt, J. (2008). Over leven en overleven met muziek [About living and surviving with music]. In H. Smeijsters (Ed.), De Kunsten van Het Leven. [The Arts of Life] (Part 2). Diemen: Veen Magazines. Smeijsters, H. (2008). De Kunsten van Het Leven [The Arts of Life] (Part 1 & Part 2). Diemen: Veen Magazines. Smeijsters, H. (2005). Sounding the Self. Analogy in Improvisational Music Therapy. Gilsum, NH: Barcelona Publishers. Smeijsters, H. (Ed.) (2006). Handboek Muziektherapie. Evidence based practice voor de behandeling van psychische stoornissen, problemen en beperkingen. [Music Therapy Handbook. Evidence-based Practice for the Treatment of Psychic Disturbances, Problems and Limitations]. Houten: Bohn Stafleu Van Loghum. Stern, D.N. (1995). The Motherhood Constellation: A Unified View of Parent-Infant Therapy. New York: Basic Books. Stern, D.N. (2000). The Interpersonal World of the Infant. A View from Psychoanalysis and Developmental Psychology. New York: Basic Books. Stern, D. (2004). The Present Moment in Psychotherapy and Everyday Life. New York: W.W. Norton. Stern, D.N. (2010). Forms of Vitality. Exploring Dynamic Experience in Psychology, the Arts, Psychotherapy, and Development. Oxford: Oxford University Press. ____________________________________ The Netherlands 2 Italian composer, well known for his film score music (e.g., “The Mission”) 1

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

CASE THREE The Use of Musical Space with an Adult in Psychotherapy Carolyn Kenny Abstract Robyn came to music therapy after a long history of receiving standard verbal therapies. She was a psychologist who had been in private practice for seventeen years and was disenchanted with the verbal approach both for herself and her clients. She was involved in what she described as an addictive relationship and suffered a life long battle with two depressions per year. Over a three year period, between 1984 and 1987 she received 120 music therapy sessions. In these sessions a variety of techniques were employed in the category of “musical space.” Methods included musical improvisation, authentic movement from silence, music imagery, music with art materials, etc. When this therapy ended, Robyn was depression-free, was able to leave the addictive relationship and reformulate a healthy friendship with her expartner, set a new direction for her personal and professional life, no longer needed the services of a therapist and continued her personal development through what she called her “women’s circle”. The author conducted a three-hour interview with this client five years after the therapy had ended. The italicized narrative is excerpts of the client’s comments during this interview. “ON MUSIC” Music: you stranger. You feeling space, growing away from us. The deepest thing in us, that, rising above us, forces its way out... a holy goodbye: when the innermost point in us stands outside, as amazing space, as the other side of the air: pure, immense, not for us to live in now. Excerpt from the poem by Rainer Marie Rilke Translated by Robert Bly Background Information

Robyn, a female client, was 44 at the initiation of her music therapy experience. She was raised in New York in a middle class working family. She described her parents as having an awful marriage. She was the older of two daughters. She reported that the most significant factor in her family experience was a complicated, competitive and ambivalent relationship with her mother. She described her mother as not present, neglectful, cruel, emotionally, physically, and verbally abusive, and particularly mean to Robyn, as compared to her sister and father. This colored everything in my life. The ambivalence was that she both wanted me to be all that she couldn‘t be, to grow, and expand. And then when I would do it, she would batter me because I was doing it and not she. She would connect and merge and then she would separate and do it suddenly. The image is of being dropped out of the lap over and over again. That feels really connected to the work we did together (in music therapy). There was never a safe container in my childhood. Robyn had a six and one-half year marriage to a male psychologist, then lived alone for three years. When she came into music therapy, her romantic involvement was with a woman she had been living with for seven years. There was a moment when I understood that I was in the middle of my primary experience and that it was a chance to go through it differently. Treatment Process Prelude In our initial meeting, Robyn struck me as a highly verbal, warm and loving person who was in great distress. She seemed more comfortable giving than receiving. Although she was 44 years old, she reminded me of a very small and high-strung child—insecure, extremely bright, very anxious and intense. She was always very well-organized, yet seemed extremely vulnerable. My first goal was to introduce her to play, and to offer an atmosphere of unconditional acceptance in which she could experiment, break through and get to know herself within safe limits. I never had permission not to crucify myself, so for me the biggest cyclic thing in my life were these once or twice a year deep depressions—like walking into a pit in which everything I said, did, or thought was a lie or an illusion, or a shredding. That was the place that was absolutely in full roar from the relationship that I was in at the time I came to you. I don’t know how fully conscious I was then of what I am saying now. But there was a real recognition that there was a numinous moment...I heard about you from Sandy. I liked the thought of not using words. She told me about listening to music, drawing something, then shredding it. I had no way to describe in words what I felt. But somehow that she shredded it...It was all over the floor, and you didn’t allow her to pick it up. She was to leave the mess, and you were to clean it up. That made me know in the

deepest part of my being—I can feel it again, just when I’m talking [momentarily close to tears]—that I just had to go [to you]. This was the place. This was the space that I needed It did not take long for Robyn to learn to trust the space. She seemed to know exactly what she wanted from the onset and had ways of providing me with adequate nonverbal or verbal cues so that I could design the musical space in ways that brought her to her own cutting edge emotionally, spiritually, cognitively. In the beginning, sessions lasted for one hour once a week, and progressed to two hours every other week. Toward the end, sessions tapered off to once a month. The method most commonly used was musical improvisation with instruments and/or voice, including toning. Sometimes Robyn would move to my musical improvisations on drums, gong, or piano. Sometimes she would image to taped music or my musical improvisation at the piano. She also did authentic movement, moving organically out of the silence, with me as witness. Robyn and I both often created art forms after music listening or musical improvisation, sometimes listening to and interpreting taped improvisations immediately after they were played. Sometimes we used the Runes, as a projective method or oracle. We played with sand to music. Each session included an experience, a dialogue about the experience of the day and also carryover dialogue about issues which came up between sessions. Often I gave Robyn “homework” such as in the case of her art forms. I suggested that she display her drawings or clay structures in her home, in places where they could be easily seen, and to keep working with the images which she had created during the days between sessions. The music-made space had images. That space and those images needed to be made visible. And, when they were made visible, they needed to be watched. Then I found things that had been coming from deeper places than I had been in touch with when I created them. By turning the images, they would keep on telling me more about myself, taking me through even more experiences. It’s like a swirling that continued. I would say that the art, the making of my images, or clay forms, or manifesting the inner images was important because so much of my experience in life—and my language—has been to try to get what is inside out in some way that would communicate. The words always restricted and strained out a lot of the depth. There was a need to make manifest, not just to experience—and this is what the sounds always did for me. I needed not only to be in the experience, but also to make a symbol, to make it manifest in some way. Maybe that’s because I have always been trying to articulate. The images were an incredibly powerful part of naming without words, giving myself an experience. How I feel about growing is that there is the immersion—you need not have words or brains. You need to go naked, just like a child, into the energy. Let the process carry you and have no ideas about how it ought to be or where it’s leading or what it’s about—really be able to have the trust. And I learned that in our work—to give up any hold on a conscious level, just immerse in the process. The sound was the carrier. But the art and movement were also carriers in a similar way. So there’s a time for that, and then there’s a time where it must be named in some way. The art gave me a way to name it without ossifying it, because the art then became another process that in its creation continued

to show me things. I created a symbol. That image continued to feed me afterwards because it had the same quality as the sound. It was a process that was beyond anything that I experienced in the doing of it. There were layers and layers and more layers. I remember having art work around me in the house. From our sessions I would take the stuff and hang it on the kitchen walls like where a mother would have a child’s drawings. They would always be in the periphery of my attention. It felt to me that I would suddenly one day know it was time to take one thing down... that I was done receiving from that. So the art was like the music, but it existed over time, in a different way than sound, the sound was in the moment. The sound stopped and the art became a way of moving sound into a space that let it continue over time. Beyond the objective of creating a safe play container, a musical space, my selection of specific methods was totally intuitive. The night before a session, I would review Robyn’s current situation in my mind, her burning questions, and her feeling tone. Usually in the morning when I would awake, I had a very clear and simple plan for which methods would be appropriate for the day’s work. The immediacy of our moments together seemed critical and I did not want to clutter them with unnecessary ideas. I wanted to be able to listen, in the moment. In this way, not only did I feel confident that I could be totally present, I also was able to interpret the needs of the client in the moment, i.e., need for emotional release, need for conflict, need for support, need for insight, as they would present. This seemed natural. Robyn was learning to play. It definitely was the space. The sound took place in a space that was already created. Maybe the kernel was created and the sound gave it more form. But the space was a wedge of time, a sector of time which became infinite, expanded, separated from ordinary time, ordinary reality. It was like crossing a threshold into the space, and the nature of the space was, that whatever was, was supposed to be. It was opening into this vastness that didn’t have any structure or form to constrict and bump up against. But it was like a padded space because there were boundaries. There’s a difference between form and boundary, and there was a sense of container. There was a web around this or a basket around this. It was loose, but it was really very much there within that boundary... everything was infinite and there were no forms to fit or fill. All that was asked was to be in the middle of whatever was. I felt that you would bring to the space ‘a gift’, that somehow in your reaching and opening to my coming, you would hear something that would guide you to provide the piece we would begin with. I can’t remember that it was ever wrong. It never felt that if it didn’t feel right, I couldn’t say no to it. There was always this sense of rightness, whether we sat at the piano or played bells or drums or toned, or if you had a tape to play that I could curl up and dream to. It always felt like a blessing. It always felt like that was the doorway. Death Robyn expressed a great deal of grief in her play—so much grief. There was also loss and abandonment, as if she were truly a lost and sad child. It was a deep pool of grief, ancient and

enduring. She seemed so fragile, so delicate. It felt like there was so much grief that she might die from grief. I identified with grief. Perhaps it was not the same as Robyn’s grief. Yet I also knew grief. My aesthetic preferences were based on a deep and authentic identification with feelings. My music, too, felt like swimming in a dark pit. The music was so deep and dark and lonely, full of despair and sadness, intense. In that pool of grief something did die. When we started working I had a mother inside of me. But I had a critical, hatchet lady who could just jump at anything that I did and rip it to shreds; she cut under any joyful or full-of-myself feelings that I had. The only mother voice inside of me was this really brutal, negative one. One of the women in my circle called her the Nazi MauMau Mother, and that was the only mother I knew...so I created another mother out of the dream of what I wanted. The way I described the work we did to people was that I found someone who would be “Robyn” to me. In the work that we did, in the way that you created that space and that container, was that you provided me an external amplification of a voice that did exist in me, but that never had turned on to myself. The exact opposite is that it was a voice that I could never give to myself. I could give it away, but I couldn’t give it to me until somebody gave it to me from the outside. I think that was a critical thing. I had never received that and you, by doing that “space-making,” gave me a model of a loving permissive mother acting toward me. That was really the bridge, and when we stopped, or maybe even before we stopped, I was learning to talk differently to myself I was learning how to still that other voice or talk to that other voice and ask it to step away—that Nazi MauMau voice. When we stopped working together, I continued parenting that part of myself, and more than parenting, it really feels like creating safety. When I no longer had the safe space I trusted you to create, I began to create that for myself and the language of it came later. But it began to be that when I would start with the [Nazi MauMau] voice, [a different] voice would come back and say over and over again: “That’s not a good way to talk to yourself. It’s really o.k! It’s o.k. to just be exactly where you are. It’s really o.k. to just make sounds. They don’t have to sound like anything. They are what they are and they are magic.” That’s the message of the sound work—that there’s nothing right or wrong. There’s just what there is at the moment. And it doesn’t have to have words. It doesn’t have to be defined. All that is asked is that you immerse yourself in it, and that in doing that, just being in the sound, making the sound or hearing the sound, becoming a resonance myself—that was both the method and the metaphor. Birth At a point along the way, a little creature began to appear in Robyn’s drawings out of the music. She referred to her as “the little one.” This little person was like an abstract representation of a baby. She was naked, joyful, free, innocent, zestful, delicate, capricious, and always flying, floating, or dancing. It feels to me like the work of the last five years was born in the work that we did together [in the three previous years]. That when we did the journey back and we found

the little one, who was damaged, listening to “Lullabies from the Womb,” the image it created was of bridging the pit—to go back to retrieve the little one from before. It was the first time in my life that I really felt that part of me had permission. I felt a safety to be with that part—to be with anybody with that part and that was the beginning of all the healing. It’s so hard because in the years that have intervened, about seven years since we started, this volume of words like “the inner child” “the wounded child” [has developed]. Sometimes I feel like I want to puke from it. It’s so many words and there’s such a difference from the experience of that meeting. That was the piece that I was starting in--that nonverbal space--the vision that came from that music. I remember being all curled up and covered under a comforter, listening to the sound and watching this little creature emerge who was lively and spontaneous and robust...full of life and mischief and just free...juicy, excited about life, full of herself, just fully alive, not wounded, not constricted, not constrained, not held back in any way. I can see the picture still in my mind of this little pink baby who was just dancing in the clouds and dancing in the greenery. That was the home, and that was remembering home; and what’s come after is being able to walk to that place so that I could fully live there. That moment, in that session, I found home. The little one quite literally grew and developed over time, first in the sound making, then secondarily in the art and movement. She began to mature physically in the art. She began to develop affects and character which were audible and visible in melodies, rhythms, phrasing, expressions, body contours in movement expression, and colors chosen to represent her movement and costumes. She was exciting and free and full of life. She was artistic and selfassured, strong, mysterious and illusive at times, compelling. She was fascinating. Finale As I visited and interviewed Robyn five years after we ended our music therapy work together, I was struck by her independence and autonomy, her lack of anxiety, the many musical instruments and art materials on her living room shelves, the playful nature of the decorating in her home, her graceful way of making me feel welcome in her home, not necessarily to constantly please, her insights as they had developed over the years about the value of the music therapy work, and the long-term results in her life, how it had changed her life. I was her last therapist, the one she had kept the longest in a series which stretched across the years. After we ended our work, she continued her development in a “women’s circle,“ from which, after five years she had just separated and is re-grouping once again. She had one question of me at the end: “Why did you end the work?” I had ended our work together, and I had a difficult time articulating the reasons, except that I knew that it was time for us to go our separate ways, for me to push Robyn out of the nest, to cut the cord. She said that she felt dropped, kind of like being dropped out of the lap. She said that this was the only thing in the entire three years of working together which felt like it had dishonored our experience together. This was another kind of death. I had been disenfranchised in her mind, in a sense.

At first, I felt confused as I tried to reconstruct that feeling I’d had so many years ago, that it was time for Robyn to be free, for me to be free from her as well. As we talked, Robyn was very clear about expressing the fact that she had no bitter feelings, that she had trusted the process, even the ending. She indicated that this interview and being able to put the question to me had really created a beautiful closure for her of that container we had shared. Although Robyn felt complete, I did not. I had to go away and reflect. Upon reflection, I realized that “the dropping” was the final test. Robyn was dropped by me, yet she had internalized the mother to such an extent, that she was not damaged. She only had a question. Robyn had managed to heal that deep wound at the core of her existence. She had internalized her ideal mother, given birth to her ideal child. When that child had developed to a degree that I intuitively felt she was strong enough “to fly” on her own, I cut the cord. And now after all of these years of incubation, the clarification of a question, the equalization of roles of therapist and client, the work is finally complete. The last part of our interview/dialogue went like this: Robyn: “It feels to me like the female mode, and the way that the music therapist creates safety is that the music therapist is willing not to confine/constrain and give form, but that the music therapist is willing to ride with the energy and be a companion in that space.” Carolyn: “It feels very much like that to me. I can remember moments together with you and other clients where the intensity of emotion was horrifying. The anger went into such a scary place. I felt that my job was to take a deep breath and travel with them in that space and to take the risk of traveling with them, being a companion in that space and to be expressive with them. For example, drumming or playing the piano in an outrageous way. That was where a lot of the mastery was—to stay with the intensity, as opposed to cutting it off. Robyn: That for me is really the critical difference between the two kinds of approaches (verbal and nonverbal), because in this therapy you don’t have any handles. What you have to be willing to do is to be with that intensity, because if you can’t be with that intensity inside of yourself, you can’t work with anyone else. Carolyn: Exactly. Robyn: The other system (verbal) really beguiles you to believe that you can handle intensity because you have words and things, theories and frameworks that you can sort of use like robot arms handling hot stuff—radioactive material. This is the heart of the matter. Discussion and Conclusions In a sense, it is a phenomenological faux-pas to address theoretical issues. Yet it may be a more serious infraction to address these issues in fields in which there are well-grounded theories. Music therapy is no such field. Because of this, we may be easily “beguiled.” As music therapists we are intensely aware of the immediacy of our work, and thus equally aware that any theoretical structure is an overlay onto our experience, and thus runs the risk of coloring the descriptions of our experience in a way which may misrepresent the experience itself, the work itself.

Yet as human beings we need language. We need concepts. We need theories, if only to reassure us that we have a grasp on reality. Language and theory represent powerful and valuable control mechanisms, especially for the music therapist who deals with a daily paradox. The first part of the paradox is that often our patients and clients feel out-of-control and thus beg us for containment. The second part of the paradox is that music, by nature, is expansive. It is so expansive, that perhaps the music therapist is sometimes afraid. And the set of controls which might assuage our fears is very different from those articulated in standard verbal psychological theories. It is different fundamentally, at least on two counts. First, it is nonverbal. Second, it is located in the aesthetic domain, i.e., dealing with aesthetic preferences and sensibilities, in its primary mode of engagement, music. The music therapist puts her/himself at risk. In a sense, s/he is just as vulnerable as the patient or client because s/he also expresses authentically, thus becoming involved in the aesthetic process of selection, whether that be in musical improvisation, choice of music for imaging, choice of song for performance, or for that matter choice of word, phrasing of sentences, choice of techniques. Ontologically, these choices reflect something significant about the existence of the therapist. We do not own the process of the client; and in the end, if we do not disown it perhaps the value of the therapy is diminished. Granted, the therapist often attempts to “walk in the moccasins of the client,” but the therapist will never “be who the client is.” Together, they explore a field of existence through sound, a musical space. Together they create an experience in that space. This is the method and the metaphor. Our experience in music therapy is a constant reminder that existence is our primary concern because being fully alive, fully present, fully intense, fully expressive, fully vulnerable, and immediate is what music therapy is all about. Glossary Authentic Movement: A dance/movement therapy form initiated by Mary Whitehouse in which the person moves organically from silence, listening to the creative impulse to move from within rather than responding to outside stimuli. Musical Space: The musical space is a contained space. It is an intimate and private field created in the relationship between therapist and client. It is a sacred space, a safe space, which becomes identified as “home base,” a territory which is well known and secure. In early childhood development, it is similar to the space created between mother and child. Trauma necessitates the recovery of such a space for growth and change. It is a time when a person must reorganize and reintegrate him/herself, after trauma, a break in natural and healthy development. Initial entry into this space is gained when participants are motivated to make the first sound, a creative gesture, a risk, a self-motivated action from an intention to engage. In a sense, the space is “sealed off or contained, when both participants have joined each other in these first sounds. They get to know each other in the territory. In this field of musical being and acting, the emerging process of delicate new beginnings in development is enacted in musical form (Kenny, 1989, p. 79).

Runes or oracles: The Runes are small stones imprinted with symbols which have meaning in Viking tradition. These were oracles which served as a vehicle for messages from the gods. These messages were interpreted to assist the seeker to improve the conditions of human life. Toning: A form of vocal improvisation, in which spontaneous sound-making, with the voice, is encouraged. This is not the form of toning initiated by Laurel Keyes, yet it is related. Reference Kenny, C. (1989). The Field of Play: A Guide for the Theory and Practice of Music Therapy. Atascadero, CA: Ridgeview Publishing.

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

CASE FOUR Group Music Therapy in Acute Psychiatric Care: The Treatment of a Depressed Woman Following Neurological Trauma Marcia Murphy Abstract Group music therapy was used in the interdisciplinary treatment of Fiona, a 43-year old woman hospitalized with severe depression following rehabilitation for neurological trauma. The acute psychiatric admission was based on a diagnosis of severe bipolar disorder with borderline features. The inability to cope with the discontinuity of her life had caused Fiona increasing anxiety and despair that was manifest in suicidal ideation necessitating hospitalization. Group experiences, including those in music therapy, provided Fiona not only with psychosocial support, but with greater insight into herself and the coping skills to face critical life change as her depression lifted. Background Information Fiona, a 43 year-old woman, appeared younger in years and almost childlike when she arrived for her first therapeutic group in an acute psychiatric hospital unit. Diagnosed with a history of depression, Fiona had been hospitalized for psychiatric and medical treatment of a major bipolar affective disorder that was secondary to a head trauma which had left her partially paralyzed. Subsequent to this crisis, she had been hospitalized in a larger rehabilitation center to treat the physical and neuropsychological deficits following the sudden onset of a subarachnoid hemorrhage. The primary disability that resulted from this trauma was impaired ambulation and balance. As she was adapting to her impaired mobility, she sustained a fall that caused multiple fractures. In her then prolonged recuperation and rehabilitation, her depression had become profound as she realized that she could no longer continue to maintain her independent living status, even with the help of home aides and visiting nurse services. Fiona was a withdrawn and sad individual on first impression. Biopsychosocial Profile Fiona had a complex set of psychiatric and medical problems that needed to be addressed in her hospitalization at an acute care facility. Given the interdisciplinary treatment

available at the hospital, a biopsychosocial profile of the entire person is created upon admission. Physiological Aspects. Fiona was admitted to the geripsychiatric unit due to her physical limitations and consequent need for more nursing care than the average psychiatric admission. Her history can be described in an overview of the factors that had so profoundly impacted her life. When she was 39 years old, Fiona was disabled by a subarachnoid hemorrhage that ultimately affected her motor control. Specifically, it limited her ability to walk and use her legs, and occasionally caused a slight loss of control in her hands and arms. She was able to use a wheelchair, and walk with a walker or with the assistance of one person. After her initial hospitalization, Fiona had returned to her apartment with part-time nursing assistance. It was at this time that she suffered a further setback: an injurious fall which led to another hospitalization. By this time, her partial loss of motor functioning impaired her physical coordination. Psychological Aspects. Fiona’s cognitive functioning was not significantly impaired by the neurological trauma, but she could not remain in her demanding, responsible management position. Her concentration, ability to organize and communicate information, under pressure, and to make management decisions had been affected. Her low frustration tolerance and mood swings were further liabilities to effective functioning in a large corporation. Fortunately, in Fiona’s case, the intracranial hemorrhage had not been severe. The irritative and pressure effects had been located in the tissue where the cerebrospinal fluid passes near the motor pathways; however, ramifications on the patient’s emotional status could not be discounted (Walsh, 1978). Fiona’s personal history was marked by tragedy. In her early twenties, she broke her engagement to be married. Her ex-fiancé had fatally shot Fiona’s sister, mistaking her for Fiona. Fiona was treated for depression as a result of the tragedy which had affected the entire family. Her father died several years afterwards, however. Her mother and brother moved to a community upstate. They were emotionally as well as physically remote. She had built an independent life as a self-supporting single person who held a responsible position. Now she was the recipient of a generous disability insurance income from her former employer. She had become more withdrawn and vegetative, although she had the support of her primary therapist (a clinical psychologist), a community social worker, and a regular team of nurses. However, she had made some suicidal gestures and it became necessary for Fiona to be admitted for acute psychiatric treatment. Social Aspects. Perhaps the most devastating consequence of Fiona’s disabling condition was the impact on her social life, in particular, the loss of some friends and a social life that she had built around a career. Her life had changed drastically following the neurological trauma: from a full daily schedule and social life to the collapsed world of her apartment as a disabled person, dependent on others. Nurses, aides, and homemakers were unable to motivate her. She owned and maintained her own cooperative apartment. Following the trauma, the alternative to this type of life was an adult residence with rehabilitation facilities. Fiona was very outspoken about her resistance to such a move. She denied the need for this change. Team Assessment

Team treatment objectives were for Fiona to be medically evaluated and supervised and to be engaged in the hospital’s interdisciplinary group treatment program. A house psychiatrist was assigned to her upon admission, and Lithium was prescribed for treating the differential diagnosis of bipolar affective disorder. Fiona’s moods varied from tearful resistiveness to hostile and disruptive outbursts. In the first week on the unit, the treatment team had observed her depression, along with other behaviors that were typical of a borderline-type personality. Her behavior and attitude were self-defeating, and seemed to be a continuation of the emotional and psychosocial decline that had begun while she was living in her apartment. Given her age, Fiona was an atypical patient on a geripsychiatric unit. The other patients were on average twice her age, and Fiona was understandably distressed. However, she made an effort to establish contact with several of the more alert and aware elderly that turned out to be beneficial to all involved. She adapted to the unit and initially was compliant with the team treatment plan. Fiona was intelligent and well educated; she had retained her sense of humor and common sense. However, her manic-depressive mood swings were frequent and pronounced, and therefore interfered with treatment. When her mood swings were brought under control with medication, the depression remained. Often, she became tearful when talking about her reasons for wanting to live independently. In reality, this was no longer possible, yet she remained in denial, and refused to acknowledge a need for a major change in her living arrangements. The borderline features of her personality emerged as she became overly manipulative, splitting staff (who is “good” and who is “bad” from day to day). She also sabotaged therapeutic alliances and threw periodic temper tantrums. Fiona began to participate in therapeutic groups at the end of the first week of her hospitalization. It became evident after the second week that her mood swings were a way of protesting her hospitalization to her therapist, the in-house psychiatrist, and treatment team. Her mood swings became more clearly defined, ranging from passive withdrawal to occasional disruptive outbursts in treatment group sessions. There were a few sessions in which Fiona was so disruptive that she was either taken out of the group or she chose to leave. When she was not able to tolerate a group process or to complete an occupational therapy task, she would become sullen and withdraw into herself or wheel her chair to her room. She was not overtly noncompliant because she hoped to be discharged from the hospital much sooner than medically advised. Fiona was referred to music therapy because she had an interest in music that was lifelong. Music was part of her childhood and music listening was part of her initial recovery from the neurological trauma. Her adaptation to hospitalization was supported by music therapy interventions to which she responded positively. She had the ability to express herself verbally and in song. She was able to use music improvisation to express repressed feelings of rage and hurt in percussive instrument sound and vocal toning. The music experiences opened Fiona to facing the turning point in her treatment, that is, accepting the need for change and learning how to cope with the decision.

In addition to music therapy, Fiona received physical therapy, occupational therapy, dance therapy, art therapy and recreation, and each program was individually planned and implemented within the parameters of the unit’s interdisciplinary treatment plan. Treatment Process The music therapy sessions in which Fiona participated included large milieu or dayroom programs (“Sing-Out Groups”), closed listening sessions (no more than six patients), improvisation sessions for psychomotor coordination, and closed improvisation sessions for self expression, tension release, and exploration of control issues. During the three and one-half months that Fiona was on the unit, she was engaged in 23 music therapy sessions, most of which were in a group setting. Establishing Trust Fiona’s primary nurse brought her to the first music therapy session in the dayroom, a “Sing Out Group.” She appeared withdrawn and quiet, but as she remained in the group she seemed to know many songs from the “oldies” repertoire, either singing along or responding with limited body movement or facial expression. Although she appeared to be interested, she also appeared to be depressed. She acted bewildered and tearful, resistive to talking with staff except her nurse. She had remained in her private room and was taking her meals alone there. The day after the first music therapy session, I made a point of inviting her to a morning energizing session with the support of her nurse. She responded positively, and came willingly to the group, although her participation was minimal. Fiona’s energy level was low. During the session, I provided live music at the piano for breathing and stretching followed by movement from a chair position. As the session progressed, I observed that her level of alertness increased and she appeared brighter, smiling at times. In this type of open session, a forty-five minute group might actually last only fifteen or twenty minutes or the full time period, depending on the attention span and responsiveness of the group. If group members stopped responding or drifted in attention, I closed the group and talked with individuals from the group. This session lasted a half hour, following which Fiona asked if she could play the piano. After I moved the piano to a corner of the dayroom, I helped her position her chair to face the keyboard. She picked out a few notes of a familiar song phrase and withdrew her hands as she could not complete the musical line. She seemed to be angry or annoyed, and so I asked her what she had been thinking about when she began to play. She responded easily that she had learned many songs from her father when she was a child. He had sung, accompanying himself on the piano. St. Patrick’s Day was the next day, and she had tried to play the opening line to “Danny Boy.” She had taken piano lessons as a child, but had not become proficient in playing. What became evident in the conversation were her fond memories of her father, who had been deceased for over ten years. She mentioned that the old tunes and the Irish music were a comforting memory link to him. Later that day, I was able to include her in a small group for improvisation based on the image of the annual Fifth Avenue St. Patrick’s Day parade to be held the next day. Since it

would be a Saturday parade, there would be no music therapy group on a weekend day. I had brought portable percussion instruments and the group responded to creating parade/march scenarios for motor coordination and concentration, but most of all, for spontaneous and tension-releasing expression. Fiona became totally involved, laughing and singing with assurance and control. After a particularly enthusiastic rendition of “McNamara’s Band,” she commented, “This reminds me of the good times we had at home when we all made music.” Regression The next week was the beginning of Fiona’s regression into herself and acting out behavior that clearly indicated disdain for hospitalization. I brought her into a small, closed improvisation session for psychomotor stimulation and coordination. She discovered the slit drum (Gato), and she became intrigued with it for a brief time. Then she randomly hit the drum, with no apparent purpose or relevance to the progression of a pattern and cohesiveness toward which I had been leading the group. After several minutes of disorganized sound resulting from Fiona’s self-absorbed, inattentive, and random drumming, she joined the group with her drum sound. She refused to discuss her participation in the session following a playback of the improvisation sequence. She dismissed the group’s feedback to her that her playing indicated a lack of involvement with the group and treatment itself. A window of opportunity had opened with the drumming session, but she closed it as she refused participation in all her treatment groups into the following week. She exhibited behavior that was inappropriate at times, manic and disruptive, fitting the profile of patients diagnosed with bipolar affective disorder. The depressed moods seemed to be prolonged sulking periods. Her loud, aggressive acting out was childish and a cry for attention. However, she could not achieve her main objective: to be discharged to her apartment and to continue independent living. Expression of Feeling When I next saw Fiona in a group, she had agreed to come to a morning listening session for relaxation and imagery. After a brief systematic relaxation sequence with Halpern’s “Spectrum Suite,” the group listened to excerpts from classical symphonic music that was selected to elicit a sense of quiet, space and security. Afterwards, we discussed the reactions of the participants. Familiar scenes from one’s most recent or childhood home emerged in the ensuing discussion. Fiona talked about her childhood and how much she missed her father. She stated that she was ready to move ahead in the current treatment and that she wanted to close the door on the past. After the session, she remained in the room and asked if she could play the slit drum. As she began to explore the sound, I selected a small hand drum to support her playing. What emerged was a total refutation of her reaction in the previous session. Holding and mirroring her mood became difficult as her drumming became more rapid and disorganized. She became more angry and strident, almost bashing the drum with the two mallets she gripped tightly in each hand. It was at this point that she paused and loudly announced, “This is my doctor’s head.” Fiona was clearly demonstrating her anger with the hospitalization and her frustration with the doctor, who was female. She began to cry after this outburst. I shifted the focus to her

breath and voice, and we breathed and sighed in unison which seemed to calm her. The shift in energy seemed to be soothing to Fiona as she reached deep inside to release sound, breath, and repressed pain. The gentle sobbing had been transformed through sighs, sounds, and focused breathing from the abdomen into a regular rhythmic pattern. Fiona then was able to acknowledge her sadness about the past, her anger about the current need for hospitalization and her fears about the future. The catharsis evolved because she expressed her feelings nonverbally. The words were too easy. The following day, she was ready for the scheduled music therapy session which was a small, closed improvisation group. The instrument selection included metallophones. Fiona selected the pentatonic chime bars, and she appeared to be enchanted by the sound. One member of the group commented that it was the resonance of Fiona’s instrument that made the predominant sound in the music ensemble. Although the group members were aware of Fiona’s mood swings, they were not intimidated by her. One reason is that this group was composed of older women who assumed a motherly if not grandmotherly role with her. They gave her permission to express herself, and Fiona found cross-generational sharing and support to be quite a special ingredient. Fiona’s relationship with women had become a critical part of her sessions with her doctor, and was also discussed with her psychologist, a male. In this music therapy session, the theme became change. Spring was in the air and Fiona was restless, bursting with energy. In the session, she had begun to listen to others as she played. In the closing improvisation, she was able to blend into the sound of the other instruments and thereby become the underlying solid support for the music. In the closing discussion, Fiona maintained her denial about her own need for change; but she had expressed herself as a hurt child musically. The treatment challenge was identifying who she really was— angry woman or hurt child. Although responsive in music therapy, Fiona’s coping skills were maladaptive on the unit. She had recently upset several of her older peers. In the safe environment of the therapeutic group, she had disclosed her feelings. However, this proved to be a ploy to what she thought might lead to discharge. She had become angry, reverting to acting out with staff and patients as she avoided discussing her fears about her future. On top of her anxiety, she had experienced physical stress from the side effects of the Lithium treatment. The coping skills that the team had tried to support, construct or reinforce had been lost in a matter of days. Developing Coping Skills Fiona’s ongoing psychotherapy was crucial for her resolution of unresolved emotional conflicts. The team was aware of her splitting tactics—“good” staff versus “bad” staff, and male versus female. In team meetings, we discussed her denial. After returning from a brief vacation, I observed a change in Fiona when she participated in the next improvisation. She had declined to join a larger dayroom music session in the morning for energizing before a community meeting. After our group time, she saw her psychologist for a session during the unit weekly community meeting. After lunch, she joined the small music therapy session. Her tremors seemed more pronounced than I had ever seen. Fiona chose the slit drum, but she had difficulty using the mallets. She refused a hand drum offered by one of the group and asked the group to support

her as she attempted to use the mallets with the slit drum one more time. She was able to maintain solid control and was supported by the percussive sounds of the group. As the group was about to close, she suddenly became irritable and negative, denying the feedback of the group, commenting on how direct and strong she had sounded in the music portion of the session. She then proceeded to pour out her anger about losing control of her body and her life. When she stopped speaking, she left the room with only slight signs of tremors but in an agitated and depressed state. She refused to talk with me afterwards. Change in Medical Protocol After the session, I asked Fiona’s nurse about her. It was then I learned that the side effects of her medication were escalating. Fiona was experiencing involuntary movements and tremors, causing her increased anxiety and frustration. As a result, the psychiatrist had decided to change the medical protocol from psychotropic medication (Lithium) to Electroconvulsive Therapy (ECT), scheduled to begin the end of the week. In the team meeting the next day, her behavior was discussed. Fiona had continued to manipulate staff. The team agreed that she was not coping with the hospitalization, and that Lithium was producing intolerable side effects despite careful monitoring. The anxiety and depression for which Fiona had been hospitalized were not lifting, and it was generally agreed that a change in medical protocol was necessary. At the beginning of her ECT, Fiona experienced temporary memory loss, poor attention skills, and problems in motor coordination. She also was very lethargic immediately following the treatments. During the first week of ECT treatments Fiona attended only a few groups, and participated less consistently, however her mood was relatively stable. She even agreed to participate in her case conference. As Fiona completed the prescribed course of ECT (nine treatments over three weeks), many of her problems with memory, attention, and motor coordination began to disappear. Her lethargy also began to dissipate. Her involvement in music therapy became more active. She had learned to ask for and receive support from the group, musically and verbally. Fiona also selected instruments that were less intrusive in sound than drums. She alternately used the chime bars, maracas, and tambourine. She found that she had good motor control and the soft shaking of the tambourine reflected her search for quiet and peace within herself. She was more focused on the “here and now” group process and she was able to address the relevant concerns about the transition in her life to which she had been previously so adamantly resistant. The music therapy goals were adjusted to become two-pronged: to support her expression of the difficult feelings of anger and hurt, and also to reinforce her maintenance of psychomotor control. At the same time she was encouraged to express the spontaneous, funloving side of her personality as appropriate to the situation. With the change in treatment plan, her music therapy sessions supported Fiona’s sense of autonomy in controlling emotional and physical responses as well as in controlling her life. The transition was a smooth one. Discharge

As Fiona became medically stable, her depression lifted, and her mood stabilized. Plans for discharge were then begun by both the hospital social worker and the community social worker, who collaborated with Fiona to negotiate a difficult transition period. As Fiona became somewhat optimistic about the future, she also accepted the plan for a move to long-term care. Before Fiona was discharged from the hospital, there was a brief gap in the music therapy treatment because of my absence. On my return, the remaining sessions were directed to her discharge and facing an unknown, new living situation. Music therapy groups had been critical in allowing Fiona an opportunity for expression and in helping her gain insight about her behaviors. More important, these sessions had assisted her in building coping skills for maintaining control, both physical motoric strength and emotional stability, in order for her to plan for the future and to be able to make the major transition to a new living situation. Fiona had learned to accept and acknowledge the emotional and physical setbacks in her life. She was able to talk more openly about her sadness and disappointment in the changes her disability had forced her to make. At the same time she was able to express hopes for a successful adjustment to the new life that was ahead of her, including her wish to have a relationship with a man. She had become more direct and honest in her treatment. In music therapy group sessions, this was apparent in more direct musical expression and interplay with others in the group. She was able to find satisfaction and pleasure in the outcome of her improvisation and in her newly reinforced strength as a leader. In the last music therapy session which was a free improvisation from which a theme of moving on emerged, I observed a transformed person in her presence and in her participation nonverbally. She was communicating and not demanding attention. In the closing processing of the music that had been created by the group, Fiona commented, “I can control it (body, moods, thoughts) if I want.” Discussion and Conclusions Fiona was able to address the difficulty of coping with life as a disabled person as a result of this hospitalization. Her coping skills increased as she became more actively involved in her treatment planning, less resistive to the therapeutic process, and more committed to participating fully in the treatment groups. Fiona often became tearful after a music therapy improvisation session. She was an angry woman, hurt by emotional loss in the past, and handicapped by a neurological condition that was physically disabling and emotionally devastating. Through the support of the interdisciplinary treatment team, Fiona realized success and pleasure each day she participated in a therapeutic group, and as she responded to the medical treatment. Coping with the difficult transition from living without structure and supervision to a secure environment, and at the same time retaining a sense of autonomy about her life, was the issue that faced Fiona and to which she was resistant. This immediate issue was the main focus of treatment. Music therapy sessions kept Fiona involved in the moment, as the focus was to create a musical outcome that can give satisfaction and immediate gratification. When Fiona was most aware and involved, she pursued several goals: to address the here-and-now, to control her

contribution to the music making process, and to explore nonverbal ways to ask for and receive response. When she was able to accept the positive feedback of the group members about her contribution to the group music, she was responding as well to the medical treatment. As Fiona’s depression was lifting, she was able to move beyond playing, and stopped masking her real emotions and demanding attention. She also used the group process to reinforce and experience her increased control and strength. In fact, her self esteem was improved and she acted with conviction and confidence in every aspect of her participation on the unit. Another important outcome of the treatment process, including the music therapy sessions, was Fiona’s interaction with women. Those on the unit were, chronologically, peers of her mother, and in some cases, her grandmother. Fiona’s relationship with her female psychiatrist had been strained at best in the first month of treatment. As she accepted herself and her changed life, Fiona also was able to examine her relationship with her mother. She began to select group peers to have meals and socialize with her. The social worker was able to arrange a meeting with Fiona and her mother. Fiona’s brother had brought their mother to the hospital, and he himself had visited Fiona on several occasions since he had business in the city. It took the hospitalization and the effort of the hospital social worker in collaboration with Fiona’s community social worker to schedule the family meeting. This signified a family reconciliation of differences that was a contributing factor to Fiona’s acceptance of the move to long-term housing with rehabilitation. The support Fiona received from members of the music therapy group was critical to her recovery and adjustment-recovery from a severe depression and adjustment to disability from neurological trauma. The group gave Fiona permission to express her feelings, but not to act out and regress to childish behavior; to cope with her anger and sadness in closed groups by either supporting her music or responding to her in discussion; and to provide her with ego supporting feedback that enabled her to acknowledge her capacity for control within the limitations of her disability. All of the services, including the music therapy sessions, helped Fiona to learn to cope with hospitalization and to better cope with her losses. Her most recent loss of physical functioning became less devastating to her when her older group peers presented the reality of her relative youth and the time she had to take her life in a new direction faced with the change in living. The age disparity often played a part in Fiona’s recovery drama that worked to her advantage. In return, Fiona was able to offer her respect, and thereby reinforce the strength shown by the older group members in coping with their respective need for continuous care. All were able to share their feelings about their lives and concerns about the future in music therapy groups and other groups on the unit. In hospitalization and in wellness, most people need support from outside themselves in order to maintain their activity, productivity, or creative pursuits. Support groups offer a forum for reinforcing strengths and skills (Knox, 1977). The music therapy group became for Fiona an avenue to discharge from hospitalization because it was through this group that she could demonstrate her strength and leadership skills. All her positive group experiences in acute care enhanced Fiona’s ability to cope and to acknowledge the talents and creative skills that she had shown as she adapted to an irreversible condition that had transformed her life.

Glossary Bipolar Affective Disorder: A disorder characterized by alternating episodes of depression and mania. Depression is an emotional state marked by lethargy, decreased appetite, disrupted sleep patterns, withdrawn and isolated behavior, sadness, and apprehension which then changes to mania. Mania is an emotional state characterized by intense but unfounded elation evidenced by talkativeness, flight of ideas, distractibility, grandiose plans and spurts of purposeless activity (Davison & Neale, 1978). Borderline Personality Disorder: A disorder characterized by any five of the following symptoms: impulsivity or unpredictability in two potentially self-damaging areas (over-eating and physically self-damaging acts); inappropriate, intense anger or lack of control of anger, temper; affective instability: marked shifts from normal mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days, with a return to normal mood; physically self-damaging acts such as suicidal gestures or accidents; chronic feelings of emptiness or boredom; identity disturbances; and a pattern of unstable and intense interpersonal relationships. The symptoms are current and long-term rather than episodic, and lead to significant impairment in social or occupational functioning or subjective distress (APA, 1987). Fiona exhibited the first five of these symptoms. Electroconvulsive Therapy (ECT): Treatment which produces a convulsion by passing electric current through the brain; useful in alleviating profound depression based on stimulation of neurotransmitters, affecting the neurological biochemistry. Subarachnoid hemorrhage: Intracranial bleeding resulting in damage to brain tissue as well as irritating and creating pressure in the area through which the cerebrospinal fluid flows (Walsh, 1978). References American Psychiatric Association (APA) (1987). Quick Reference to the Diagnostic Criteria from DSM IIIR. Washington, DC: Authors. Davison, G.C. & Neale, John M. (1978). Abnormal Psychology (pp. 633-656). New York: John Wiley & Sons. Knox, A.B. (1977). Adult Development and Learning. San Francisco: Jossey-Bass, Inc. Walsh, K.W. (1978). Neuropsychology, a Clinical Approach (p. 87). Edinburgh: Churchill Livingstone.

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

CASE FIVE Group Improvisation Therapy for a Resistant Woman With Bipolar Disorder – Manic Paul Nolan Abstract The elicitation of a chief complaint within a client’s musical behavior can engender a cooperative therapeutic relationship, especially with a resistant client. Group music therapy helped Carla, a 27-year-old woman, to reduce resistant behavior and enter into a supportive relationship through which she acquired awareness and acknowledged elements of her illness. At discharge, she was able to focus less upon internal stimuli and more on external events. She appeared to generalize progress made in the group to outside situations. Background Information Carla, a 27-year-old black woman, was voluntarily hospitalized by her father because she had been unable to sleep for several days. This was her third psychiatric hospitalization in five years. Her admitting diagnosis for this admission was Bipolar Disorder - Manic. Carla is the first born of two female siblings. She is single and lived alone for the past six months. She has been employed as a part-time cashier at a local supermarket for the past seven years. She reports that she is close with her father but has little contact with her mother. She states that she belongs to a religious group but did not specify other information about the group or of her participation. First Hospitalization Her first psychiatric admission occurred in 1981 for a six-week period at a local psychiatric hospital. At that time she was brought to the hospital, involuntarily, by her father because, for two months prior to admission, she had been wandering the streets, not eating well, frequently absent from work, sleeping more than usual, and having frequent irrational outbursts at home in the context of increasing family problems. Carla claimed to have psychic powers and that she was being followed by customers from work. She denied alcohol use but admitted to marijuana use once or twice per day; she had also used cocaine, angel dust, and speed within the past year.

At the time of admission, she did not appear to demonstrate symptoms of Bipolar Disorder, however she reported that she could not concentrate and denied any other problems. She was diagnosed as “Schizophreniform Psychosis—rule out Drug Induced Psychosis.” Following admission, her psychiatric condition seemed to clear up rather quickly. She then had a period of manic-like behavior and displayed irritable, inappropriate, excited, euphoric, laughing, and hostile behavior. Anti-psychotic medication produced neurological side effects. A Lithium trial proved initially successful in eliminating psychotic symptoms, but before a psychiatric free plateau period could occur under medical supervision her insurance coverage ran out and she had to be discharged. Just before discharge it was noted that she began to develop alterations in blood chemistry relating to renal functioning which were abnormal. It was suspected that these changes were due to the Lithium, and it was discontinued. Upon discharge, Carla was diagnosed as having Bipolar Disorder-Manic and R/O Multiple Endocrine Adenopathy Syndrome with a guarded prognosis. She was scheduled for follow-up appointments with an endocrine specialist and with a psychiatrist. Second Hospitalization Her second psychiatric admission occurred in 1984 and lasted just under two months at this present hospital. She appeared flamboyantly dressed with a turban. She was observed to mumble aloud to herself, with loose associations and flight off ideas. She also appeared to be hallucinating. Her hospital course was characterized initially as uncooperative, agitated, and delusional. Her course of treatment over the two month period vacillated between partial remission (reduced reports of hallucination, less delusional) and decompensations. She demonstrated side effects from Haldol, however when this was reduced there was a return of psychotic symptoms. Her laboratory data were normal and it was felt that Lithium treatments could begin. She exhibited no adverse blood chemistry reactions from this medication. Carla’s initial contact with this music therapist came during her second hospitalization. In fact, one of the unit treatments which Carla attended consistently was group music therapy. She was placed in a regularly meeting group which met three times per week. Throughout her stay, Carla exhibited no overt verbal manifestations of psychosis within the group sessions. However, her musical behavior generally seemed to show marginal realitytesting in relation to her use of the musical elements (i.e., poor sense of pulse and meter of the music in the group and little musical or verbal demonstration of awareness of her musical expressions in relation to others in the group). She was better able to organize her musical expressions and maintain some involvement with the group when she used simple percussion instruments. A primary goal was to increase her awareness of the musical structure and of her effect upon that structure. She was then able to work toward increasing the number of musical options available to her within group improvisations. In other interpersonal matters, she was able to talk to the group about her anger and conflicts with the nursing staff, and stated that she felt safe to express herself in the group. She regularly attempted to “help” others in the group, but this was actually understood as a means of control and deflecting the focus away from herself. One example of this was her manner of diagnosing other group members and prescribing behavioral regimes for them. This was similar to her interpersonal behavior on the unit. By the end of her hospitalization, she became more

organized in her musical expressions and was better able to lend musical support to the musical expressions of others. Carla was discharged with a diagnosis of Bipolar Disorder - Manic and received Lithobid, Haldol, and Symmetrel to control side effects from the Haldol. Following discharge, she attended outpatient treatment with a psychiatrist from the hospital and took her anti-manic medication. She also was placed with a community mental health agency which specialized in re-entry to the community following hospitalization. Within six months she discontinued all of these treatments. Although it is not clear why she discontinued going to her doctor and the agency, she discontinued the Lithobid medication because it made her feel “bloated and dehydrated.” Present Hospitalization The present hospitalization, one year later, seemed to be precipitated by several factors. Carla was upset that her father lost his job because the industrial plant closed. She was unable to sleep well; she was becoming irritable at work and aggressive with the customers (“I would diagnose the ones who looked like they were on Haldol”). She was unable to attend work for several days. She apparently was psychiatrically stable and off of all psychotropic medications until approximately two weeks prior to this hospitalization. She began to fast for religious reasons whereby she could not eat during daylight. This occurred one year following her last discharge. Carla’s admitting diagnosis was “Bipolar Disorder—rule out Organic Brief Psychotic Reaction, rule out Dehydration.” The mental status exam upon admission included the following information: “Young black female flamboyantly dressed in red turban with a skirt with sparkles, bright blue painted fingernails, very euphoric and expansive manner. Mood was irritable with constricted affect. Flight of ideas present. Paranoid ideations. “No Haldol, no tricks please”... The client did have some ideas that she had special powers... Abstraction was intact. Insight and judgment poor. Could not state reason for admission or precipitating events.” During her hospital stay she had changes in her electrocardiogram which seemed related to taking Mellaril, an anti-psychotic medication. This required a cardiology consultation and outpatient follow-up. She was also found to have a mild iron deficiency anemia and was given iron supplements with good response. She was resistant to multiple staff recommendations to continue her Lithobid due to her history of good response psychiatrically. She did take Mellaril 400 mg orally at bedtime. Since there were no reports of psychological testing in the discharge summaries from previous hospitalizations, testing was ordered. The report is summarized as follows: 1) Cognitive functioning: Carla is functioning in the Borderline range of intelligence although it appeared that she was functioning below her capacity. She scored best in areas of fund of knowledge and social judgment. Her worst scores were in areas of

arithmetic, concentration, and verbal concept formation. It was indicated that she was impaired in her ability to focus her attention. 2) Emotional functioning: She presented as an “acutely and severely disturbed woman” who “if provoked, is petulant and angry.” “Her reality testing is severely impaired and she is disorganized in her thinking.” She is unable to defend against the intrusion of primary process thinking, uses regression, denial, splitting, and vacillates between the extremes of despair and grandiose euphoria’s. In short, Carla’s ego functioning is severely impaired. She has a difficult time tolerating her angry feelings, in that she is highly fearful of the angry impulses which might be provoked. 3) Diagnostic impression: Carla’s “functioning is consistent with the diagnosis of manic - depressive illness with underlining borderline personality disorder.” Method Upon admission, all patients on the twenty bed unit are oriented by the psychiatry resident to the milieu services. These include music therapy (group and individual), family therapy (where indicated), activity groups (arts and crafts, current events, and other discussion groups), community meeting, psychoeducational groups, and relaxation training. The music therapist then meets with the client to describe music therapy and to schedule the initial session. The results of this meeting are communicated to the treatment team and initial goals are discussed based upon input from others concerning the client’s projected length of stay, strengths, and areas of immediate clinical concern. Carla was not scheduled for the usual individual orientation to music therapy due to her involvement in music therapy with this therapist one year prior. Because she threatened to leave the hospital, it was thought that group music therapy should begin immediately to allow for the inherent supportive contact from the therapist and the group members, and because she enjoyed these groups during her prior admission. She remembered the music therapist and seemed to look forward to her first group. Her group consisted of three other low-functioning clients and met three times per week for one hour at regularly scheduled times. The room was located across the hall from the nursing station, but was reasonably sound proof, and contained a piano, stereo system, movable tables, and closets for instruments and was approximately 15 x 20 feet in size. The room was also used for meals, community meeting, some of the activity groups and relaxation training. Generally, musical experiences included various forms of live music making such as improvisation, song writing, singing with instrumental accompaniment and ensemble adaptations of popular and folk music. Carla was placed in a group in which improvisation methods were used exclusively. In this group, the approach to improvisation was to use varying degrees of therapist or client suggested structure. Often, the improvisations began with one person who was responsible for the creation of a musical statement or mood. The group members and therapist would join in when each member felt that he or she could understand the opening musical expression and felt comfortable adding their instrument to the music. At the close of each piece the group often spoke about the musical experience or about their own thoughts from the

music. The therapist could use this opportunity to assess issues such as the comfort level of each member, emotional responses which seemed to be elicited by the musical events, reality testing and the presence of other psychiatric concerns from the verbal content. The therapist would also use this “rehash” to assess group interpersonal functioning by asking the members what they were aware of during the music. This information would provide data concerning the amount of structure needed for subsequent musical experiences and if any other changes are required. By evaluating the group statements concerning the musical and interpersonal events, the therapist could tune into his own involvement in terms of the awareness of his own feelings and their relation to technical decisions made. At times, tape recording the music was used to assist this process. Finally, all musical, verbal, and other non-verbal behavior from the group members and the therapist provides information related to the evaluation of treatment progress. The treatment orientation consisted of psychodynamic (with emphasis upon interpersonal theories) and humanistic approaches. Carla’s group behaviors were understood as responses, rather than random occurrences, to here-and-now events. Yet the orientation allowed for an understanding that behind her resistance was a need for a declaration of self. This combination allowed for an understanding of Carla’s behaviors in terms of her reliance upon the defense of denial, as manifested partly by her pervasive resistance to treatment, and her perceived need for acceptance by others. Since it was apparent that Carla enjoyed music therapy and seemed to benefit from supportive, positive acceptance, the orientation pointed to an approach which allowed for a flexible style, with emphasis on the constructive elements of group treatment without a great deal of limit setting (which she seemed to perceive as criticism). Improvisation methods were employed so that Carla could freely use musical elements in a manner to establish her way of relating to others with few restrictions, supplied mostly by musical structures. Structured improvisation methods were primarily used with the degree of structure related to variables such as: the immediate level of functioning, topic and level of conversation prior to the use of music in each group, mood of individuals, overall level of energy, and so forth. The initial goals from this approach were to provide a musical holding environment in which Carla could feel: (1) that her communication was accepted and understood within a musical context, and (2) that she was connected, to some degree, to the group. Eventually, it was hoped that she could begin to see that her musical expressions were related in some way to her feelings. Encompassing these goals were those which related to improved reality testing, and a decrease of her hostile resistance. These goals were constructed as a preliminary means through which to assess her response. Confrontations by the therapist were avoided since this was often the response used by many other treatment personnel, to no avail, and because it was not congruent with the construction of a supportive environment. This approach was maintained throughout music therapy treatment based upon the evidence that Carla attended regularly with few absences. She had very poor attendance in all other groups. Treatment Process

Phase One Carla’s first three groups were marked by her attempts to counsel the other members. She attempted to clarify the treatment goals of each member. Verbally, she exhibited behavior which was suggestive of mania such as pressured speech and flight of ideas. These symptoms seemed to dominate her xylophone playing in that she chose rapid successions of notes with frequently changing motifs without a bridging of some common feature to connect the phrases. Generally, during this phase her melodic contour seemed to be shaped by which range on the instrument she happened to find herself, at which point it seemed that she would simply reverse direction. In response to this playing the therapist responded on piano with chordal accompaniment in an attempt to envelope the motifs, echoing rhythmic groupings but leaving space to convey the therapist’s background role. In this manner the therapist attempted a response which communicated an “understanding” of the melodic statements without suggesting a specific direction which Carla had to follow. During these interactions, Carla’s musical behavior, although not clearly organized as a sequence of developing musical events, seemed to differ from her verbal interactions. For example, she would verbally direct others as she began an improvisation, at times in a hostile manner: “Wait until I get started before you come in and don’t bug me like that again!” Musically she was beginning to accept some feedback from group members in that she would occasionally reorient to the musical structure by reentering in the same pulse pattern of the person playing the drum and cymbal. By the end of this period she would at times repeat a rhythmic motif and follow a brief change of dynamics initiated by the therapist on piano. These behaviors seemed significant in how they differed from her hostile and controlling verbal interactions with her doctors and nursing staff. There were signs that she was less resistant and at least partially willing to have brief periods of mutual interaction. Psychotic behaviors were still apparent within these first group sessions. She mumbled, apparently to herself, during her playing, was not able to recall events which transpired between group members, and continued to show virtually no insight into her condition. At this time she could only identify her inability to procure an out-of-hospital pass from her doctor as her only problem. She continued to refuse medical intervention other than a small dose of Mellaril at bedtime. The goals in music therapy began to focus upon her conscious awareness of musical organization, i.e., to create and respond to musical ideas. Phase Two By the beginning of the fourth group session, Carla, although still locked in a power struggle with the staff, began to accept some suggestions from the therapist concerning her musical organization. It was apparent to the therapist that Carla was able to maintain a steady pulse in time with the group music when she played simple percussion instruments. Although she always chose the xylophone for improvisations which she was to lead, or begin, she would accept the suggestion to play maracas or snare drum with brushes when she was not leading the improvisation. Now she was able to accept the suggestion by the therapist to “try to maintain a steady beat so that Bob can locate the group rhythm on this piece.” By the next

session this suggestion expanded to “see if you can make sense of Bob’s playing before you add your instrument.” Carla was able to take the therapist’s suggestion to begin her own pieces on xylophone with one mallet so that the group and therapist could easily follow her ideas. This suggestion was meant to encourage Carla to begin her musical ideas simply and to reduce the possibility of not being understood. Although Carla heard similar suggestions many times from the staff in terms of slowing her pace of speech the suggestions raised within a musical context seemed to be received by her without the usual resistance. The quality of her melodic statements seemed to begin to convey intentionally expressive qualities. She was also able to comment on the playing of other members in terms of hearing aspects of them differently than in verbal realms. During her improvisations the therapist made more direct musical responses on piano in attempts to form antecedent-consequent dialogue. This change seemed to add length to musical interactions which the therapist understood as “musical thinking.” This level of musical “dialogue” was only possible for brief periods in each improvisation. Following some of the group improvisations either a group member or the therapist would suggest that we listen to the tape playback. Often we would hear Carla’s mumbling in the background on the tape without verbal acknowledgment by the group. During the fifth session one member said, “Who is that talking?” Carla turned her attention to the tape when another member stated that it was Carla’s voice and that she mumbled all the time when she played xylophone. Carla appeared slightly embarrassed and said that sometimes she had too many thoughts in her head at once, and it caused her to have concentration problems. This admission seemed to become a turning point in that the therapist understood this statement as her chief complaint. Also, the statement appeared as a manifestation of a symptom of mania known as” flight of ideas,” and seemed to correspond to her frequent shifting of musical motifs and tempo in her xylophone playing. Later that afternoon when Carla was brought into the treatment team meeting the usual power struggle occurred over why she was in the hospital. She again threatened to leave the hospital against medical advice. By this time the nursing staff was frustrated in their dealings with her. Their attempts to treat her were continually met with hostile resistance, and they fell into a series of verbal confrontations with her. The music therapist reminded Carla of her complaint voiced during the music therapy session concerning her problems with concentration. It was suggested to Carla that she may be able to improve her concentration through the treatments available on the unit. She agreed that she would stay a little longer to improve her concentration. She also agreed to a slight increase in her Mellaril but she continued to refuse Lithium medication. Although there was now an established “chief complaint” in Carla’s own words which corresponded with a diagnostic criterion for Bipolar Disorder-Manic, she was not markedly compliant with treatment. Although Carla was also felt to have an underlying Borderline Personality Disorder, the therapist chose to focus upon the problems stemming from her psychosis. This was decided because the psychotic symptoms were acute and responded to treatment in the past and left unattended they could become worse and pose a real threat to her safety. Also, the treatment for Borderline conditions usually requires a longer term and different approach than the treatment for acute psychotic disorders. The therapist attempted

to observe and guard against high degrees of borderline manifestations but this was difficult to separate from the resistant behaviors that often accompany the denial found in psychosis. Preparing for Discharge With her discharge scheduled one week away, Carla attempted to maintain a pleasant mood and seemed preoccupied with her leaving the hospital. Nevertheless, she paid attention to verbal attempts by the therapist to focus her concentration on her xylophone playing (i.e., “See if you can follow the pattern of the drum while you play”). There was a noticeable decrease in her mumbling while playing and she could establish clear pulse-oriented rhythmic patterns with brief pauses which seemed to define phrases. Although she was able to respond in an echo response to dynamic changes initiated by the therapist she did not show signs of accepting suggestions in areas of melodic contour or the repeating or extending of musical statements. When she accompanied the improvisations of other group members on the drum she seemed to demonstrate a somewhat higher level of functioning in that she could maintain a particular style of playing without erratic changes in tempo, dynamics, or out-of-time subdivisions of rhythm. She began to accept direction from the therapist to play with just one hand to simplify her organization. She also followed suggestions to try to listen to the xylophone and orient to the mood expressed by that person. This represented the peak of any cooperation she could offer within interpersonal realms while dealing with her symptoms. The therapist was able to join on piano with the pulse and rhythmic groupings of her drumming in these accompaniments. This imitation by the therapist was intended to reinforce the musical decisions and organizational boundaries created by Carla in her attempts to meaningfully add to the group music. The therapist made efforts not to anticipate her playing but to stay with it while also responding to the group as a whole. Carla’s musical relation with the therapist seemed now to be able to tolerate some degree of direct synchrony, or moving in the same rhythmic direction together. When Carla’s discharge date arrived she was offered to decide the musical experience for the group. She elected to lead an improvisation on xylophone and told the two other group members to choose what they wanted to play. She asked that the therapist join in last on the piano. She offered no verbal instructions before playing but spoke clearly while she and the group played about her plans following discharge. Although her playing did not appear to contain the organizational elements which she demonstrated in the prior group her verbal content was clear. She did not say good-bye nor did she acknowledge the events from her stay in the hospital. The group and the therapist wished her well and expressed hope for her return to her job. The session closed with listening to recordings of group selected popular music with some general discussion. Her discharge report notes that initial behaviors of threats to sign herself out of the hospital, hypomania, pressured speech, hostility, magical thinking, preoccupation with detail, poor concentration, and possession of special powers improved during treatment. She was referred to a cardiologist and to a community mental health center. She refused to follow-up with her prior outpatient psychiatrist because he insisted that she take Lithium as a condition for treatment. Carla stated that she would continue taking Mellaril.

Discussion and Conclusions Although Carla’s treatment did not result in a “therapeutic triumph,” in that all issues were solved, she seemed to make gains in areas which seemed important to her in an otherwise very difficult situation. Her involvement in the overall treatment process was extremely limited, unlike her prior hospitalization one year earlier. However she seemed to make a therapeutic connection within the music therapy group which may have provided some support to her during this trying episode in her life. It was believed that the group music therapy treatments were somewhat helpful to her based upon the evidence that she maintained a degree of regular involvement. This was not the case with any other group treatment. This also may have had to do with her prior involvement in music therapy which provided some familiarity for her of the process. Her relationship with the music therapist changed in that the degree of resistance lessened. This also was not the case with her relationships with her doctors and with the nursing staff. It seems that the main ingredient which allowed for this change within music therapy was due to the method which encouraged acceptance and support of her expressions via musical processes. The improvisation style provided a combination of flexibility and structure which seemed to eliminate the need for her defensive resistance. Her symptoms and her health (her willingness to join in the music making process with others) were accepted within an environment which was intended to convey an attitude that what she expressed was worthy of a non-judgmental response. The musical responses by the therapist were intended to allow Carla to experience that she could be with others without limit setting restrictions, thus reducing her manipulating and splitting behaviors. This approach allowed her to evaluate and alter her own behaviors in terms of musical processes. It seemed that she reduced her psychotic behaviors (responding to internal stimulation over external musical events) based upon feedback from others and from her own awareness that these behaviors detracted from her musical thinking and her ability to be with others in the group. The opportunity to isolate and express a chief complaint as a result of her own experiences in the music, rather than from the judgment of the treatment staff, seemed to provide a bridge whereby she could become involved in some aspect of the treatment process. This was evident in that Carla connected her problems of poor concentration in the music with her experiences outside of the group. The use of music within group treatment provides for a here-and-now experience which is considered to be the heart of the inpatient group therapy process, and helps members to learn invaluable interpersonal skills such as: to communicate more clearly, to get closer to others and to become aware of personal mannerisms which push others away (Yalom, 1985). Within this approach Yalom suggests that the therapist attempt to emphasize the positive rather than the negative aspects of a defense. This may require that the therapist provide support in a direct fashion. The use of music within this group model, especially with severely regressed members, allows the therapist to help the client spot interpersonal problems and reinforce interpersonal strengths. The tendency of short-term inpatient group treatment to demand some concrete result often invites tension, resistance and splitting (Hannah, 1984). The improvisation method employed in this case allowed for the emergence of a realistic and

realizable goal and provided a bridle for the therapist’s negative countertransference responses which can occur when goals are enforced without the client’s involvement. The final evidence of the benefit of the music therapy group to Carla’s experience was acquired by accident when the therapist encountered Carla months after discharge in a supermarket. Carla said she was doing well and was maintaining employment. She also thanked the therapist and said that the music therapy experience was enjoyable for her. She wished the therapist well as she said good-bye. Glossary Bipolar Disorder - Manic: A major mental illness. Typical symptoms of mania include pressured speech, motor hyperactivity, reduced need for sleep, flight of ideas, grandiosity, elation, poor judgment, aggressiveness, and possible hostility. Borderline Personality Disorder: A pattern of maladaptive behavior typified by significant instability of mood, inconsistent and unpredictable behavioral changes, and serious conflict in self-image or identity recognition (Cameron & Rychlak, 1985). Countertransference: The unconscious feelings of the therapist toward the client. Decompensation: Collapse of defenses and regression of the personality in general. Drug-Induced Psychosis: An organic mental disorder brought on by ingestion of drugs. Flight of Ideas: A symptom found in mania when thoughts race erratically from one topic to another without transitions. Haldol: A major tranquilizer for use mostly in the management of manifestations of psychotic disorders. Lithobid: An anti-manic medication containing Lithium for oral administration. Loose associations: The breakdown of the logical ability to connect persons, things, or ideas. Mellaril: A high dose, low potency tranquilizer used in the management of psychotic symptoms. Multiple Endocrine Adenopathy Syndrome: A syndrome involving enlargement or swelling of endocrine glands with possible results in changes of behavior. Reality Testing: The ability to distinguish one’s thoughts, feelings, and perceptions (internal reality) as separate from external reality. Schizophreniform: A brief manifestation of schizophrenic symptoms lasting less than six months.

Symmetrel: An anti-Parkinsonism medication used to eliminate side effects from some antipsychotic medications, such as Haldol. References Cameron, N., Rychlak, J. (1985). Personality and Psychopathology: A Dynamic Approach (Second Edition). Boston: Houghton Mifflin Company. Hannah, S. (1984). Countertransference in inpatient group psychotherapy: Implications for treatment. International Journal of Group Psychotherapy, 34(2), 257-272. Yalom, I.D. (1985). The Theory and Practice of Group Psychotherapy (Third Edition). New York: Basic Books.

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

CASE SIX Through Music to Therapeutic Attachment: Psychodynamic Music Psychotherapy With a Musician with Dysthymic Disorder Paul Nolan Abstract Individual music psychotherapy was used with a musician for one and a half years to address dysthymia secondary to his developmental problems in object relations and in the formation of the self. Resistance was encountered in the interpersonally--avoidant use of rhythm. Therapeutic attachment occurred through the use of melody within the therapeutic relationship. The client’s identity emerged as he discovered musical pauses, or breaths, as a means to achieve and maintain contact with the environment. He begins to experience pleasure in the use of his voice in musical compositions and interactions. From this, he was able to emerge as a musical leader. Reduction of depressed feelings, interpersonal tension, and authority conflicts resulted from the discoveries in his music psychotherapy experience. Introduction This chapter will address some of the concepts and processes of music psychotherapy as a psychodynamically-oriented psychotherapy. For the purpose of description of the clinical style presented in this case study, the basic assumption of psychodynamic music therapy is that music invokes our primitive constitutional, as well as our environmentally acquired, responses to sound. These responses serve affective and cognitive functions. The affective qualities, in particular, are fused with our interpersonal life. Hence, the psychodynamic focus of music therapy in this case study includes the invocation of mother-infant interaction, through the use of music, to activate early modes of sensory and cognitive styles (Nolan, 1994). Music serves as a means for the client to develop a therapeutic attachment with the therapist. Within this adaptive relationship, problems with self-image and interpersonal functioning are able to be addressed as the music therapy relationship evolves. In this case study, the role of the therapist defines the psychodynamic approach in two ways. First, the music therapist allowed for the therapeutic relationship/environment to change in response to client growth. Second, the music therapist based clinical decisions upon interpretations of: 1) the dyadic musical relationship; 2) the client’s and the therapist’s music; 3) the transferential and countertransferential forces; and 4) the real relationship. Music and the Therapeutic Dyad as Objects

Some music therapists refer to music itself as a transitional object (Nolan, 1989) and as an object. David John (1995) suggests that music has, as one of its uses, to function as the transformational object, a concept developed by Christopher Bollas, a British psychoanalysist. The concept of the transformational object describes the infant’s experience of the object as a process of alteration of the infant’s self experience. It is as if the transformational object is the infant’s other self, in that the mother transforms the infant’s internal and external environment. According to Bollas (1989), the transformational object “refers to the mother’s function as a processor of the infant through her continuous action that alters the infant’s psycho-somatic being.” (p. 213) From this experience of the mother as a process of transformation, a trace remains in adult life as the person seeks out others for their function as a signifier of the transformation of being. John (1995) believes that this transforming quality is at the core of music “in that we expect music to do something to our self-experience” (p. 161). The process of seeking out music to organize, or transform our experience, as when a teenager looks for a particular song on the radio, contains a trace of the search for the transformational object. John again relies on Bollas when he compares music with “a particular object relation that is associated with ego transformation and repair” (p. 161). I agree with John’s conception of the music therapist, as one who develops a relationship with the client in a similar way to what Bollas describes as the transformational mother, as the infant’s “other self.” In the case example that follows, this stage represents the very beginning of therapy. Change is seen and influenced by the client “using” the music therapist and the therapy experience. This use not only facilitates the transformation of the client’s immediate world, or self-experience, but eventually makes possible contact with the other, transforming the self in relation to the other, thus achieving some level of adaptation. The Evolving Therapeutic Relationship I have found that the music therapy relationship, including the client, the music therapist, and the music, within a long-term psychotherapeutic relationship can be conceived as a gestalt. This gestalt consists of identifiable factors, or forces, which change over time. The client and therapist dyad function as two objects (as in object relations) held together in changing ways by the forces they exert upon each other. The music serves as both a process and an object. The development of the music over time exerts an evolving force over the dyad. Likewise, the evolution of the therapeutic relationship results in change in the function, as well as the content, of the music. Thus, the gestalt changes as the forces within redistribute their energies. In the beginning of treatment, a greater emphasis is placed upon the music, something shared by client and therapist. As in a gestalt, the music may be seen as a figure and the beginning therapeutic relationship serves as the background. As therapy progresses, the healing emphasis often shift as the dyad becomes more of the figure, held by the music as more of the background. In the early stages of therapy, where the role of the music is so important, I see music serving the function as the transformational object. In the case which follows, and as seen quite regularly by music therapists, transformational experiences, such as moments of deep rapport experienced with the music, and the experience of fusion, or of being held by the music, are experiences of being rather than of mind. These “music as therapy” moments, especially as part of an aesthetic occurrence,

are experienced as such “because they express that part of us where the experience of rapport with the other was the essence of life before words existed” (Bollas, 1987, p. 32). These inarticulate contents of psychic life are termed the “unthought known” by Bollas, in that they are recognized from a time when the infant experienced the illusion of deep rapport between subject and object, both in the primary transformation experience of emptiness, rage, and agony becoming fullness and contentment, delivered by the mother’s aesthetic style of handling, and in the creating of Winnicott’s “facilitating environment.” In the music therapy relationship, especially early in treatment, these experiences of transformation are identified with, and attributed to, the music. As therapy progresses, these experiences are increasingly identified with, and attributed to, the relational aspects of the creators of the music (the dyad). It is through this representation of music, early in treatment, as the transformational object, that the music therapy experience can create the environment (initially internal) necessary to strengthen attachment capabilities in the client. As the therapeutic relationship develops, transformation occurs in the external environment. Change can begin in terms of how the client experiences the self in relation to others as true object relations. Interpretations of the Music One of the main processes used by the music therapist that separates psychodynamically-oriented music therapy from other music therapy approaches is the interpretation of the music by the therapist and the client into nonmusical realms. This is also one of the least developed areas in our profession due to a lack of a shared, agreed upon, empirically derived data base which reliably demonstrates the relationship between music behaviors, non-music behaviors, and mental processes. However, my belief is that most music therapists make at least some interpretations regarding a client’s musical expressions. Music therapists should continue in the development of methods of clinical musical interpretation. There are two reasons why a music therapist is capable of, and should develop, clinical interpretations of the music, the client, and of the music relationship. The first is that the music therapist has been a musician for a great deal of his or her life and has developed sensitivities and intelligences pertaining to musical expression and communication. The second reason is based upon the premise that within normal development, all people should be able to identify and reproduce rhythms and tonal arrangements with some degree of accuracy. The normal development of music cognition allows for all music listeners to make at least some degree of interpretation that relates music to mood states, levels of tension, and good gestalt qualities, such as the laws of proximity and good continuation. All listeners are generally capable of identifying some culturally congruent connotations in music. These sophisticated cognitive processes are so well ingrained in humans, beginning in utero, that music cognition seems to be preserved even in the presence of cortical dementia. This ability of the music therapist to perceive and understand affective, cognitive, and interpersonal nuances within a musical interaction can integrate with the therapist’s psychological mindedness, personal history, and clinical education/supervision to produce some ability to form hypotheses (through a process of interpretation) about possible relationships between a client’s musical behavior, his or her internal world, and extra-musical life. The therapist uses interpretations as one of the determining factors in making clinical

decisions. As illustrated in the following case example, my use of musical and verbal interpretations served as a guide through which I developed clinical hypotheses. My interpretations develop into increasingly more specified questions. The interpretations do not become set facts. In the case which follows, I will demonstrate how a psychodynamically informed model of music therapy allowed for the client to experience developmental growth, thus limiting the level and effect of depression in his life. Background Information The client, Rick, was a thirty-three-year-old man with one older male sibling. He experienced a normal birth and the early developmental years were, according to Rick, normal, in terms of physical, cognitive, and social development, although it was difficult to get a report on his emotional development. There were no reported events of physical or psychological trauma. Other than a brief psychiatric hospitalization for depression, his medical history seemed to be unremarkable. Shortly after the beginning of treatment, he informed me that he had been involved in treatment with various alternative medical specialists for a variety of medical issues involving his back, stomach problems, and a spastic colon. His mother and father were alive at the time of therapy. He lived with his dog in a house that he owned. Education In high school he was an average student where he reportedly developed the role of the “jokester.” Following graduation, he attended two years at a community college where he began to use marijuana, but no other drugs. He denied the current use of drugs. Current Occupation He worked for his parents’ floral business, mostly as a driver, transferring materials between stores and making deliveries. His older brother served as his boss and seemed to have all of the success between the siblings. They had a very uncomfortable relationship. The older brother seemed to view Rick as not being serious enough with the family business, while Rick believed that the older brother was overzealous, too driven, and competitive. Rick was certainly no match for his brother in terms of gaining parental approval in relation to the family business. Rick was not able to commit to the business with the intensity of his brother, yet was unable to consider alternatives for an occupation. During treatment he described a wish to be able to make a living from his music in some way, as in being able to bring people together through music-making. I thought of this as indicating, to some degree, a positive transference. Eventually, during the later stages of treatment, he was able to develop group musicmaking into a much larger part of his life, often as a facilitator of drum circles and other musical gatherings. He was also later able to develop as a professional accompanist for dance groups. Musical Experiences and Interests

Rick was interested in playing music and was a self-taught percussionist. He enjoyed hand drums and slit drum, but stated that he had a hard time playing with others. Although he had no formal training, Rick possessed a fairly sophisticated level of musical ability. Over several years, he had acquired a vast collection of African and Middle Eastern percussion instruments. He spent many years playing hand drums and regularly sought out opportunities to play music with others in various forms of drum circles and jam sessions, usually related to variants of what may be called “world beat” styles (combinations of non-Western and Western musical styles). He never joined with other musicians in a band, which would develop repertoire and work toward giving performances, although this was one of his wishes. He regularly attended a weekly community improvisational dance at a dance studio. This was his primary social exposure and most of his acquaintances were met through this setting. Rick’s role was a drummer, as part of the musicians who played music for the improvisational dancers, although occasionally he would also join the group dance. The leader of the music group was a man who Rick described as a rather powerful, authoritative leader. Often the group’s musical direction was chosen and directed by the leader. Rick’s role in the music seemed peripheral in that he seemed to be allowed to play along with the musicians. He usually played African drums. Rhythmically, Rick would choose to play complex subdivisions of the basic pulse of the music, using sixteenth and thirty-second notes. These subdivisions would be broken down into repeating patterns with subtle changes in accent and grouping. There was very little use of rest or sustain, in that all temporal space was filled with fast subdivisions, regardless of the tempo. Prior Psychological Treatment He reported entering into mental health therapy on ten different occasions, each time at the suggestion of his rejecting and “domineering mother” and his brother’s wife, with whom he did not get along. He reported that his prior therapy experiences included group therapy, bioenergetics, gestalt therapy, and cognitive therapy. He was currently seeing a therapist for transitional analysis for four weeks prior to our initial meeting, lasting for a few months. He reported that the longest he remained in any therapy was for four to five months. He reported one psychiatric hospitalization, four to five years ago, for depression, following the break up with a girlfriend. He stated that his depression began at around the age of 20, at the end of another relationship. His current interest in receiving music therapy began when his former girlfriend entered an expressive therapies education program and began to describe to him connections that she was able to make between her dreams and her artwork. Since that time, he again experienced a loss when she ended the relationship and he again felt more depressed. He stated that “the end of that relationship helped me to see.” Although I was not sure what he meant by this, and he did not elaborate, I generally understood this statement, and his entering into therapy with me, a music therapist, as his seeking a means to elaborate upon his internally activated quest or “vision” to stop this repetition of failed relationships. Clinical Impression Interpersonally, Rick seemed to be preoccupied with his problems and with his negative self-appraisals that he described as “the knives I throw at myself.” The experience of growing

up with an emotionally unavailable parent can result in the child, and later the adult, developing a complementary model of the self as unlovable, and as the other to be unloving (Bretherton, in Dozier, Stovall & Albus, 1999). Although he longed to be a part of a community, to have a relationship, and to have a meaningful occupation, he regularly distanced himself from any situation that would require ongoing responsibilities and he generally avoided conformity. Rick had an odd way of initially relating when standing face-to-face with another person. He would appear to have a questioning, slightly disoriented facial expression. He seemed as if he was awaiting instructions. He reported that when he met someone, typically a woman, he would at first see the experience as an opportunity to guess what type of man the woman would like him to be. This would lead to ruminations and staging of affected personality traits in an attempt at impressing the woman. He reported that he was regularly criticized for not showing an awareness of others. This was a frequent complaint of the women with whom he had attempted to develop relationships. Clinically, Rick’s symptoms and complaints seemed to fit the description of dysthymic disorder (formerly referred to as neurotic depression). This disorder is defined by Cameron and Rychlak (1985) as a mood disturbance in which “tension and anxiety are expressed in the form of dejection and self-depreciation, somatic disturbance, and repetitive complaints of feeling inferior, hopeless and worthless” (p. 296). Using diagnostic categories from the Diagnostic and Statistical Manual IV, dysthymic disorder seemed to describe Rick’s history and current state, in that his depressed mood seemed to be more often present than not for at least two years, accompanied by difficulty in making decisions, low self-esteem, and frequent complaints of fatigue, low interest, and consistent self-criticism. There was no history reported of manic episodes or any other psychotic episodes. The mood disorder contributed to a distorted selfperception and to his ongoing interpersonal problems. His symptoms did not meet the criteria for major depressive disorder. In the description of a person who experiences Dysthymic Disorder, Cameron and Rychlak (1985) described many of the maladaptive outcomes that were reported or presented by Rick. His continual need for, “reassurance and his complaining is the chief defense against the internal assaults of his destructive superego attacks” (p. 297). He regularly, “reaffirms his dejection and self-depreciation, which in turn encourages others to try more assurance and counterclaims” (p. 297). Considering the length of time that Rick experienced his symptoms, and the similarities of his symptoms to the known clinical descriptions of dysthymic disorder, I approached his clinical problems with this diagnostic category in mind. Rick was not under the care of a psychiatrist and his prior psychiatric medical records were not available, therefore this diagnostic impression could not be confirmed. He was not taking medication for depression throughout music therapy treatment. He was receiving medical attention for a spastic colon throughout the first half of therapy. Methods and Treatment Music therapy treatment took place for one and one half years on a weekly one hour basis at a university-based music therapy studio. Treatment occurred on a fairly regular basis without major disruption. Most of the sessions used clinical musical improvisation approaches. The instruments used differed over the course of treatment and serve as indicators of the

phases of treatment. Initially, Rick relied upon various drums that were within the collection of the studio. Over time, he expanded his instrument use to piano, xylophone, tone bells, voice, and, finally, voice with drums. Usually the sessions began with Rick entering the studio followed by a brief greeting and updating about events of the week. Following this, a musical experience would emerge from either Rick or me in a number of ways. Rick may have been holding an instrument, quietly, half consciously, playing while talking. In this case I would encourage him to stay with, and focus upon, his musical expression. I would then choose an instrument upon which to join his music. In another session, I would choose a musical experience, including instruments for both of us, based upon what Rick verbally expressed and, to some degree, based upon what had transpired in prior sessions. In yet another bridge between discussion and music, Rick would pick an instrument without making a verbal statement about the music and begin playing. I would then choose an instrument and join in with the music. The music served varying functions within the sessions. Most of the time it served nonreferential purposes, where the musical process had no stated specific purpose other than itself. Therapist’s Roles in the Music During all of the musical experiences, I took various positions as accompanist, cocreator, and/or initiator, in different musical pieces or within the same piece, while maintaining my role as therapist. Sometimes, especially in the early stages of treatment, my musical presence functioned in a similar way to Bollas’ description of the transformational mother, in shaping or exerting musical structure in the form of style, and in the determination of many musical elements. Other times, I provided a support by accepting whatever expression in musical sound, “spoken word,” or chanted formats, emerged. Musically, I matched the energy level and “fanned the flames” of primal musical expression, or confronted/challenged Rick’s various efforts and expressions directed toward the object of transference, or at the “real musician” (during late stages of therapy) who was his therapist. At times, my musical function was influenced by my imagined manifestation of what he was attempting to create through me. At other times, my role reflected where, developmentally, he needed, and seemed equipped, or capable, to go. During our music therapy sessions we used improvisational styles that were structured by Western music styles, tonalities, and meters. We also used free, atonal improvisational models. Sometimes the music served as a backdrop of sounds for Rick’s “spoken word” monologues. (This is my own loose description based upon the contemporary art form that includes non-rhyming prose dramatically recited over a musical, or sound landscaped, background.) During these times he would pace and hit a drum as an effect to emphasize a complaint regarding his current unfavorable interpersonal status. Outside of the context of the music therapy relationship, these events may be seen as a type of patient acting out, or exhibitionism. However, within our sessions, I felt that it was important for Rick’s self-esteem to allow him to communicate his sense of being a part of the non-conservative, postmodern, or avant-garde, artistic community. By posing no resistance to the apparent exhibitionist qualities of Rick’s “spoken word” events, we were both able to broaden the expressive range of therapy

and yet maintain a therapeutic alliance. In this way, I believed that it seemed to be always understood that Rick’s expressions were in some way linked to his chief complaint of his depressed mood, and his insecure, unfulfilling relationships and low self-esteem. By allowing these expressions in a musical medium, there remained the possibility that Rick would eventually hear and accept those aspects of the music which seemed to be creative, thus providing a contradiction to his “unloved and unlovable” self-image. Rick was usually able to develop a rhythmic “groove” to the therapist structured Western musical formats, and likewise, was able to invent, or produce, rhythmic dance music patterns on percussion when he initiated dyadic improvisations. He was very familiar and comfortable, from his past experiences with other musicians, with these ways of making music. The music portions of Rick’s treatment sessions presented an opportunity that simulated a “real-life” social interaction for Rick. This type of relationship requires the therapist to maintain a sophisticated level of music-making. In that level of musical play, I was able to allow myself to draw upon my own creativity toward the matching of the musical intensity and sophistication in Rick’s playing. Hence, the three components of the therapeutic relationship, developed by Greenson and cited by Gelso and Carter (1994), were present: 1) the working alliance--the alignment or cooperation of therapist and client; 2) the transference configuration; and 3) the real relationship--the degree of genuineness between both parties to see each other in a realistic way. Each therapeutic relationship simultaneously contains some ratio of these three types of relationship. Depending on the style of therapy and the current stage of the therapeutic progress, one of these relationships will be prominent with the other two having lesser, but identifiable, roles. For example, the beginning stages of therapy will demonstrate a greater transferential, but less of a real, relationship. This balance will probably change near the ending of therapy, with a greater emphasis on the real, and less of a transferential, relationship. In the give and take of two musicians exploring musical styles, musical problems, and musical solutions together, it would seem that the real relationship would be prominent early in therapy. Also, it is both impossible, and counter therapeutic, for the music therapist to maintain distance from the music while engaging in the aesthetic and creative field of music improvisation. This inevitably invites therapist disclosure in the way one organizes the self in the music, preferences, roles, figure, and background habits, and of course, areas where there is a lacking of musical abilities. However, these issues can also heighten the transference/countertransference relationship, largely, I believe, due to the self-consciousness of the music therapist regarding musical abilities. This was the case on those occasions when I had to reach into musical resources and take musical risks that were not typical in my work with lower functioning clients. This level of playing together brought up feelings in me about the music and about the way we would play together. Staying in touch with these feelings was very important for me within my role as his therapist. It allowed for an awareness of what Rick is like in a musical relationship (or, a real relationship) both in terms of his tendency to disengage through an overuse of rhythmic subdivision and in terms of his potential to recognize his creativeness as a contributor in building a musical relationship with others. It was through this awareness of his musical and relational potentials that I hoped to move his self appraisal from the distortions that he created and through which he lived (“the knives I throw at myself”). These types of musical experiences

in therapy can blur the real with the transferential relationship. In order to maintain the necessary boundary within these relationships, it was helpful for me to remain focused upon the therapeutic alliance component of the relationship. This perspective helped to maintain an awareness of Rick’s experience of our relationship. Although often our music playing was very “together,” Rick was still experiencing transferential issues with me being a male authority figure. Suppressing this component of the relationship would have limited the therapeutic benefit of therapy because Rick’s basic problems were manifested within his relationships. Treatment Music Assessment and Overview of the Therapy Process It seemed the therapy progression occurred over three stages, although material and processes from each stage were also observable in the other stages. The first stage included the acceptance of, and working with, Rick’s persistent rhythmic subdivision on percussion instruments. I made an interpretation that this musical behavior was a compulsive defense in an attempt to bind the anxiety that he felt in interpersonal experiences. This quality of his playing, and my response, will be described in further detail later in this chapter. Sometimes I allowed him to maintain his distance with this rhythmic behavior, to let him know that it was accepted in our relationship, and other times I would musically confront him and go “toe to toe” by providing syncopations against his subdivisions in an attempt to learn how fixed Rick was with his interpersonal positioning. Also, modeling musical figure/ground roles seemed important in demonstrating other ways that we could relate musically. Even though parts of the second stage of treatment were clearly apparent in the first stage in Rick’s melodic inventiveness, I felt that I had to support what I identified as Rick’s rhythmic defense while encouraging his melodic exploration, which is where I heard his potential for ego flexibility. It was through Rick’s explorations in creating a melodic figure in the second stage of treatment, supported by a responsive background (therapist), that he began, over time, to stand alone with confidence and with a greater sense of himself as a complete person. Musically, this seemed to occur in a developmental process whereby he began to cocreate melodic phrases with me, moving toward the creating of his own melodic fragments. Then he would trade, mirror, and vary the melodic material with me. Following these melodic improvisations he seemed to experience relaxation and pleasure from the music. He verbalized that he was becoming aware of his musical role as a figure, in a figure/ground relationship, with support from the ground of musical structure, and was better able to notice and accept his creative strength. Within melodic improvisations, I encouraged his use of motive development and “breathing” between phrases. I believed that when Rick engaged in his rhythmic subdivisions that he was, in a sense, not breathing. He was not experiencing a neutral space in his music, for which a breath would allow. In this space of a musical breath, I believed that Rick could begin to increase his awareness of the musical relationships. The second stage also brought with it Rick’s interest in using piano. Although he had no prior training on piano he seemed less defended and more open for interpersonal relating on this instrument. Rick began to use the piano to develop a compositional base for our

improvisations. During his piano playing, I would stay away from harmonic instruments and use drums or the tone bells in order to encourage his feeling, and experience, of control. I believed that he was ready to accept that his musical creations could be felt as the source for his felt transformations. During these pieces, Rick would occasionally give me solos. He would communicate this by dropping his volume and by removing any melody, limiting the right hand to open intervals in an accompanying style. The third stage was a period where Rick was encouraged to use his voice for chanting and singing. This was a continuation of his using his breath for a way to maintain awareness of his musical expression, the musical field, and on my presence within that field. It was in this stage that he began to develop “his own voice” as a leader, and he began to hear himself in a more self-expressive way. Also, in this stage his depression seemed to have less of a negative effect upon his self-image. He reported that he began to establish more comfortable relationships with men and women. Within these relationships he reported less of a tendency to ruminate and was more able to focus upon the matter at hand. The following seven subsections include specific clinical interpretations, therapist responses, and key areas of focus in the therapeutic process that describe how a psychodynamic music therapy approach was able to address Rick’s depression and interpersonal problems. Early Stages Rick’s musical productions were at first guarded, self-conscious, stifled, and relied upon rather conventional rhythm patterns. However, as what I believed were his communications to me that he was different from others, he would occasionally leap into somewhat impulsive flurries of sounds of an arrhythmic, convulsive quality. I sensed that Rick was attempting to convey to me that he was familiar with the avant-garde world of music, although I also held onto the possibility that these were impulsive discharges of his anxiety and, in a way, communicated his issues with authority. During the improvisations in this first stage, my countertransference became conscious as memories and images of my past jam sessions in my personal life, where new acquaintances would “size each other up” and briefly show off their abilities. This competitiveness was expressed by me as a self-conscious disclosure of stylistic nuances, or “licks,” that I could demonstrate in a “cutting session” fashion, as seen in jazz jam sessions. This sibling rivalry countertransference reaction was important to recognize. In addition to supplying a safeguard to prevent countertransference derived destructiveness to our relationship, awareness of these feelings became an important source of information for me about Rick’s tendency to use passive-aggressive behaviors in his relationship with his brother. In that relationship, passive-aggressive expressions would provoke a competitive response by his brother, as the authority in both birth order, and as Rick’s boss in their family business. Rick would withdraw from aggressive responses because it fit the defense of repetition compulsion in maintaining his low self-esteem. Our therapy together was able to progress, due in part to my consciousness of his defensive use of projective identification. Withdrawal Behaviors in Percussion Playing

When playing music together it was soon apparent that Rick would use a very intense level of rhythmic subdivision (long passages of sixteenth and thirty second notes), grounded by accents that had an overpowering effect in both intensity and volume. Throughout the early stages, this manner of playing was pervasive, even on melodic instruments such as xylophone or thumb piano, where Rick often used similar organizing patterns. Although Rick was able to maintain the tempo and stylistic invariants of each musical piece, his frequent emphasis upon relentless rhythmic subdivision without the use of rests would eventually become autonomous, such that two-way musical communication became very limited. These patterns developed subtle accentual or note value changes, seemingly only in relation to Rick’s overall music. As mentioned earlier in this chapter, I had the awareness that this pattern may have served as a withdrawal defense. I cannot say that this musical behavior was always meant to reduce anxiety, as is the purpose of a defense, although at times it was clear to me that he could use this technique to avoid having to deal with my music. From Rick’s rhythmic “subdivision phases” I could imagine being imbedded in the maternal womb, a confluence of pulse and subdivisions, no need to breathe, as in distinguishing between phrases, because it is done for you. This type of rhythmic playing was like playing along with a recording, with no expectation of a response from another person. I believed that this behavior was an attempt for Rick to be in the music without having to deal with the other party making the music, hence a resistance to therapy based upon some fear. Conversely, when I would initiate an improvisation with a slower tempo or a style which was not associated with underlying rhythmic subdivisions as part of its rhythmic invariants, Rick, while on xylophone, could become melodic in creative, playfully inventive, and much more interactive ways. It was in his melody-making that I could hear his health, and this is also where I began to encounter further resistance as I made interpretations to him about the health I heard in his music. In later, final stages of treatment he would focus for long periods on his own creations on piano. These events involved periods of isolated creative activity, yet these experiences had a wholly different character, in that they did not serve a withdrawal function. I felt that in these experiences Rick had a need for a witness for his play, or musical composing. This type of activity always led to dyadic music-making based upon the musical material that he was composing. Other relational differences in this area will be described later in the third stage of treatment. Relatedness Ability From our first session, Rick demonstrated the capacity to create melodic motifs on xylophone, and to respond to musical interaction with me on piano, in ways that did not seem defensive. This tendency would emerge on occasions when his incessant rhythmic subdivision relational style was relaxed. His ability in these areas seemed counter to the clinical description of dysthymia, in that there were no displays of low energy, low self-esteem, poor concentration, inability to make decisions, feelings of hopelessness, or other signs of impairment. At other times, his musical relational style would change and he would switch instruments randomly to create sonic nonsense, although it seemed to allow him to play in very free methods, with no set tonal or rhythmic structure. There is less opportunity, within this type of improvisation, for the music therapist to use echo, imitative, and other interactive

responses. Thus, there is a possibility of a countertransference response. I had to be careful to distinguish when this musical behavior seemed to serve a defensive function of acting out, or when its function was a rejection of authority to allow for the beginning of individuation as he began to develop more of a musical identity. Verbal Processing Following most of the music improvisations, we would discuss what affect the music, and the music therapy experience, had on Rick. It became apparent to me that although Rick could articulate various affective states and memories, verbal processing did not serve his progress. In fact, it had a regressive effect. In these processing conversations, Rick resorted to complaints about his depression and would tend to use overly dramatic, exhibitionistic enactments of recent events in his life. In this case, these regressive behaviors, associated with the symptoms of dysthymia, served as a defense to diminish the anxiety associated with the affective descriptions of his life. Although he certainly was expressive, these affected techniques never allowed him to cross the gap between subjectivity and objectivity. He was not able to experience himself in an authentic and integrated way. I realized that one function of his behavior, during this verbal processing, related to his conflicts with authority. For no matter how well we were able to construct a positive musical relationship, Rick, in his apparent image of my role, saw me as an authority and persisted in his projections of authority anxieties. For me, these situations allowed me to experience Rick’s interpersonal behavior when he was anxious. He would resort to behaving like a clown, again, in an attempt to frame an appearance of himself in terms of his interpretation of how he could be liked by the other, seemingly based upon past successes in this role. When these behaviors were not supported or encouraged by me, or when they would not result in a transformation of his state, Rick would complain about his low mood (even if the mood of his melodic music-making clearly expressed the contrary) and refute or become unable to understand how it was possible to hear, through my interpretations, any other mood in the music other than the depressed feelings he would describe. I decided to neither confront nor support these rejecting defenses. From this awareness, it became clear to me why past experiences in verbal therapy were difficult and unsuccessful for Rick. I began to see that the music relationship could be used for him to experience his health, as long as there was no, or very little, verbal processing of the experience. It was clear that his verbal defenses served to promote his depression and complaining-fostered oral dependency. Positive verbal descriptions of the music, in terms of their health content or health potential, were dystonic and alien to Rick’s sense of self. Statements by me, such as “your melodies seemed to be very invigorated and bright” were actually experienced as confrontations to his dysthymic position that “rejects, despises, and looks down upon the self” (Cameron & Rychlak, 1985, p. 301). Therefore, I had to use caution in making interpretations about his music. However, in accepting or supporting (not confronting) his syntonic verbal expressions of low self-esteem, I believed that I was allowing him a self injurious pleasure and was partially reenacting the role of the disapproving mother. In Rick’s case, my role in the music as an occasional transformational object could provide him with a stronger sense of support from which he could then explore new ways of relating through the music.

Later Stages During the later stages, our improvisations included mostly melodic work, through bells and xylophone and finally, Rick’s singing voice. These instruments allowed Rick to further his explorations into composition, using motives and phrases, which required segments separated by breaths. This contrasted with the earlier stages where Rick’s use of mallets on melodic instruments was like drum sticks. His use of the xylophone was actually a reproduction of his rhythmic, subdivision defense. Therefore, the use of bells was introduced because they produced more sustain, a greater sense of space, and their use is not as conducive to the extremely fast, rhythmically subdivided manner of Rick’s typical playing. This introduction of the bells was a way of confronting Rick’s resistant playing. I believed his resistance expressed a fear of his newly developing ability to meaningfully relate to another. However, it was clear that his ego strength could support experimentation in this new way of relating. Simpkins (Bruscia, 1987, p. 373), in his integrative improvisation therapy, used a similar method in handling client resistance by working in a medium where resistance could not be expressed (in Rick’s case, within slower melodic improvisations). Within our second and third stages we found a way for Rick to begin, in his individuation process, to experience mastery over his felt threat from authority, and to begin to experience his true self within a relationship. Composition on Piano When Rick composed on the piano, it became clear to me that he was allowing more thought and affect to emerge, as if a positive presence from an internal object was allowing this experience to be fun, rewarding, and nurturing. He was able to create edits into his compositions that I understood as allowing for a degree of healthy narcissism. He began to “own” the compositions as products from his self. Thus, he was aurally experiencing a transformation derived from his actions. This capacity represented what I had earlier heard in his melodic expressions as his health. These melodies were now becoming aesthetically pleasing to him. This use of libidinal energy could serve as a guide in his having an experience in the creation of beauty. This seemed to represent the presence of a healthy, yet still partially hidden, self-esteem. He was now able to focus libidinal energy toward a true inner representation of the self. This contrasted favorably with his former method of projecting images of himself onto others in an attempt to create a socially approved self, albeit, a false self. This same process was later transferred (in the third stage) to his voice. The breath now was considered as being part of the composition, in that it set the mark for phrase endings and also allowed for a pause. I began to see that these pauses, in contrast to incessant rhythmic subdivision, were opportunities where Rick could achieve consciousness of his creations. Vocal Compositions

By the final stages of therapy, Rick used voice for compositional purposes, creating pieces which included scat, or nonsense sounds, accompanied by a large African drum. The drum, formerly used to distance him into a peripheral role within an ensemble, was now functioning as a sustained supporting ground that provided a temporal setting to accompany his voice. My musical involvement now allowed for shifting between figure and ground roles in the music. There was less of a focus on my providing structure in terms of musical style and instrument selection. Rick enjoyed the experimentation in using his voice in musical leadership, and he was able to incorporate my musical input. The idea for encouraging Rick’s voice to emerge followed what actually became an informal supervision with a psychologist friend. When I described Rick’s tendency for intricate, closed-off rhythmic subdivision, my friend said, “It sounds like he doesn’t breathe.” Not only would the use of Rick’s voice allow him to breathe, but also it could allow him to listen and think. He was also able to experience pleasure through discharge and through the tension and release of singing, as well as through the gestalt qualities of melodic creation. Afterward, I noticed that his use of singing in our sessions allowed for a return to a healthier level of object relations experience. While taking a breath one can at least hear what is taking place in the environment. Thus, a relationship based upon a shared reality, in this case the music, can grow. His use of voice in our sessions may have also allowed for him to sublimate, through compositional “rules,” or stylistic constraints, while allowing for the use of vocal nonsense sounds. This allowed for discharge while maintaining contact with me and with a recognizable style. It was my view that Rick’s choice of nonsense sounds in his musical vocal productions was a way to bridge his transformational object desires with a developmentally more successful (for him) means of musical communication. His vocal role could move him from a diffuse background role (playing along with the music) to a position where he is heard and can interact in musical reality in a more authentic way Now that Rick’s ability at musical relatedness was developing, the “transitional space” between Rick’s inner world of music and the external reality of other people in the music, could be bridged. The use of musical structure in Rick’s compositions could now allow for others to enter into the music with him in a variety of ways — rhythmically, melodically, or harmonically. Changes in Personal Life This phenomenon of relatedness was beginning to take place within Rick’s social life, on weekends during musical gatherings with friends and others at private homes. Rick was later asked by members of a band to join them as a percussionist and vocalist. This became a source of pleasure, as well as a creative outlet for him. His musical life led him to additional social contacts. These contacts and relationships began to provide a source of gratification and an improved self-esteem, as seen by fewer and fewer negative self-appraisals. The closure process to our therapy was summoned by Rick telling me to play our next improvisation “like a musician, not like a therapist.” My interpretation of this statement, outside of appreciating the humor contained within, was that he had grown away from needing a source outside of himself who would adapt to his needs and to his experience in the music. He was ready to coexist as peers, maybe even allow for competition to “kill off the therapist” within the music. His medical problem of a spastic colon was no longer present and his social life was showing changes similar

to those that were taking place in his music therapy. He met a woman with whom he was able to relate in a less dependent manner than in past relationships. He began to entertain thoughts of leaving his family’s floral business and starting his own music merchandising business. Discussion I believe that Rick was able to benefit from a psychodynamic form of music therapy because within the musical elements and musical structure lay both his conflict and his solution. Rick’s pattern of distorting relationships, and dissecting the image which he believed that others formed of him, was expressed in his musical attempts to try to fit in rhythmically with others. His attempts at doing this were accompanied by so much anxiety that he created pseudo musical interactions that actually led him into patterns of isolation within his musical ensembles, and within our improvisational duets. These may have been linked with projections of a false self in his interpersonal relationships. By concentrating upon his voice, via melodic explorations on xylophone, Rick began to discover a true musical identity that he preferred over his defensive rhythmic musical behaviors. Rick found a way over the course of therapy to emerge as a figure or, as a true identity, from within our relationship. He was able to develop trust in his musical voice, which carried over into musical and other relationships. The music therapy relationship functioned, in part, as the maternal mother who provides opportunities for the infant to acquire experience and develop an ability to grow. Also, the transferential relationship allowed Rick to experiment with ways to deal with authority, while incorporating components of the transference to allow for the emergence of his own capacities as a musical authority. This was first experienced as a melodic figure in our improvisations and later supported by the emergence of his voice as a force within a medium where he could have influence. Rick’s beginnings at mastery over his anxieties within relationships, and with authority, were derived from his experiences as a musical figure that received support from my role as a therapist. The music therapy experience provided for structure building, in that it allowed Rick to incorporate successful and fulfilling aesthetic experiences and to attribute their source to his own creative ability. Opportunities for his experience of a sense of autonomy with adaptive strengths resulted from his ability to make use of the flexibility allowed for in the musical roles in therapy. Conclusion Fortunately, I was able to come into contact with Rick on more than one occasion following the conclusion of therapy. In each situation he greeted me with an embrace and a bit of an update regarding the positive elements and processes that were current in his life. It seemed that he had not completely “killed off’ the therapist, yet was able to maintain the boundary that we were no longer conducting therapy. A mutual acquaintance of ours recently invited me to a sold-out musical revue, produced by Rick that featured several contemporary musical acts; including Rick’s singing and drumming. During intermission, Rick greeted me and upon receiving my compliments for his performance and in producing the event he replied that “therapy had a lot to do with it.” Although he may experience an occasional relapse of symptoms, as is the prognosis for dysthymic disorder, Rick seems to have found, and further

developed, his interpersonal strengths through his music therapy experience. Although it is not known how the therapy results will affect his later life, the self-report after more than a decade from treatment closure seems positive. References Bollas, C. (1987). The Shadow of the Object: Psychoanalysis of the Unthought Known. New York: Columbia University Press. Bollas, C. (1989). Forces of Destiny: Psychoanalysis and the Human Idiom. London: Free Association Books. Bruscia, K. E. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C. Thomas Publisher. Cameron, N. & Rychlak, F. F. (1985). Personality Development and Psychopathology: A Dynamic Approach (2nd Ed.). Boston: Houghton Mifflin Company. Dozier, M., Stovall, K., & Albus, K. (1999). Attachment in Psychopathology in Adulthood. In J. Cassidy & P.R. Shaver (Eds.), Handbook of Attachment: Theory, Research and Clinical Applications. New York, London: Guilford Press. Gelso, C. J. & Carter, J. A. (1994). Components of the Psychotherapy Relationship: Their Interaction and Unfolding During Treatment. Journal of Counseling Psychology, 41(3), 296-306. John, D. (1995). The Therapeutic Relationship in Music Therapy as a Tool in the Treatment of Psychosis. In T. Wigram, B. Saperston, & R. West (Eds.), The Art & Science of Music Therapy: A Handbook. Chur, Switzerland: Harwood Academic Publishers. Nolan, P. (1989). Music as a Transitional Object in the Treatment of Bulimia, Music Therapy Perspectives, 6, 49-51. Nolan, P. (1994). The Therapeutic Response in Improvisational Music Therapy: What Goes on Inside? Music Therapy Perspectives, 12, 84-91.

Taken from: Priestley, M. (1985/2012). Music Therapy in Action (Reprint of Second Edition). Gilsum NH: Barcelona Publishers.

CASE SEVEN Case Study: Couple Therapy Mary Priestley Fred is a 66 year-old tall, powerfully-built man with straight grey hair, dark eyes and glasses. He had retired as an engineer, and had suffered prior to this from agitated depression. At first he looked dejected and let his wife answer for him unless directly questioned. His attitude seemed to be that of a small child coming to his teacher with his mother. His agitation showed mostly in his clasping and unclasping his hands. He is a handsome man and gives the impression of suppressing rage. Inge is also tall, with straight brown hair done up on top of her head in a knot. She has a good figure, a pleasant unlined face, and a bright and cheerful manner, though this felt to me like a veneer. She is a controlling sort of person, likes everything neat and tidy, answers for Fred in an apparent eagerness to be helpful and to protect him, but underneath this, one senses that she would be very threatened by any change in their relationship or mode of life. She was formerly a secretary. Fred was referred to me by a Consultant Psychiatrist who was encouraged by the success we had with a previous agitated depressive patient of 62 who came for individual analytical music therapy. His consultant psychiatrist said that Fred first attended hospital at the age of forty-seven, with symptoms of endogenous agitated depression. He was then admitted three years later for three weeks, six years later for seven weeks and in the next year for 10 weeks. In between, he regularly attended the out-patients’ clinic. The present episode had lasted for two years. For four months, at the end of the first year, a female clinical psychologist gave Fred relaxation and concentration training and a focus on leisure interests. For the next year the principal clinical psychologist tried to improve his motivation via a cognitive approach, and in his final report stated that he felt that the marital relationship had improved, but that there was little more that could be achieved with this approach. (Fred said that the psychologist had persuaded him to drive his car again and this had been very important to him). Fred was referred to me eight months later by the consulting psychiatrist. It was not my original intention to take both of them on as a couple, but, as at first I only had a fortnightly vacancy, I thought that perhaps this could be helpful for several reasons: they would have the opportunity of carrying on the therapy attitudes in between sessions and in holidays; each could see alternative and possibly more fruitful ways of interacting with the other; the therapist could see the main influence that each one was under for 167 hours a week and, if necessary, try to promote helpful changes. Fred and Inge would have the opportunity to grow and develop together, instead of one getting left behind and then being dispensed with,

as frequently happens when one of a couple is having therapy. The therapist could validate their relationship as a potential force for good, intrapersonally, interpersonally and in society; the therapist could validate them each as unique individuals (this is especially valuable for the average wife) not just in their marital roles; the therapist could open up areas which the couple had not discussed previously; couples who have become totally “Adult” and “Parental” (as in the Transactional Analysis sense) could perhaps also learn to play together; and there would be the opportunity to work with, and explore, the subtle emotional nuances of the couple at various levels. When we first started I thought it could be helpful for them both to answer the Beck Depression Inventory, which consists of 21 questions all with four possible graded answers on such subjects as self-image, level of depression, sexual appetite, hunger, sleep, and so on. The higher the score the more depressed the patient. Throughout the period of treatment their scores were as follows (out of a possible maximum of 84):

It was significant that apart from the last score, which was affected by their anxiety about being able to do the tasks, as Fred became less depressed, Inge became more depressed. At first Fred was resistant to any attempt at history-taking. But he agreed to answer this questionnaire, during which it came out that he felt very suicidal and was eyeing the sharp knife in the kitchen with a thought of slashing his wrists. Inge collapsed in tears as she had not realized that he felt like that. Their first music was an improvisation on how they felt. Fred had the 16” drum, xylophone, cymbal, and gong, and Inge had another drum and a glockenspiel. Their music, though tentative at first, became robust and rhythmic. However, it somehow always produced in my piano improvisation a level of banality of which I was ashamed but could not alter. It was clear that their music afforded both of them a much-needed outlet for self-expression. I asked Fred to give us a loud cymbal clash as our signal to finish. Throughout our working period I treated him as the head of the family, trying to ease him out of the “Woman-on-Top” position, as his original attitude was very much that of a sulky four-year-old child who has everything done for him but has no status in the family. Inge spoilt him and nagged him. She felt very angry that he got so behind with the gardening and home maintenance jobs that normal husbands in suburban homes take upon themselves. Fred felt only faintly guilty about this but mostly his attitude appeared to be a mixture of triumphant smugness and brooding sullenness. The idea that there could be any way round this stalemate seemed unacceptable to both of them. As they were not cripplingly short of money I asked if they had thought of hiring a lad for a weekend to cope with the backlog. Fred could not think of letting someone else do his jobs. It seemed that this cold war was entirely necessary to both of

them. Internally Fred mourned for his life with working men, and Inge resented him sitting like an immovable object intruding into the time and space of her queendom. As depression is often based on anger bound by guilt, I devised some exercises to express aggression in a non-threatening way on two 16” tom-toms. Each of them had to play on their own drum then reach over and bang on the other’s drum. First the other had to reply, “NO” and then, when Fred gave the signal, to say “Yes” and afterwards share feedback. When Inge poached on to Fred’s drum and he said, “No!” he stared fixedly at her for some time as if wondering: “Is it going to be accepted or will she burst into tears?” At home this was her answer to any attempt on his part to alter any of her established ways. When Fred mentioned that a retired friend was having cookery lessons Inge said she would go mad if he came into her kitchen. In the fourth session, two weeks later, Fred reported seeing two boys fighting while he was mowing the lawn, and going over and stopping them. He then remembered his mother giving him boxing gloves and then taking them away when he and his little brother began sparring. He said he was never angry, although to me he looked as if he were seething with an anger that could find no possible outlet. At this time it showed only verbally in the occasional snide remark. For example, when Inge said that as an only child she was very self-willed and her mother had said she always managed to get her own way, Fred said darkly and without humour, “You still do!” She ignored this. When they came on their 36th wedding anniversary he muttered grimly that it was not like it used to be 36 years ago. From the questionnaire it emerged that they were not sexually active though they still slept in a double bed. There was obviously a lot of tension in this area but I did not feel that they were ready to speak about this problem. It crossed my mind that Inge might have a lover. In the eighth session, we had three drums and my poaching on to their drums was to represent an intrusion into their marriage or a stimulus. Their “NO” response was rather restrained but their “YES” was gracious and inviting. These exercises were alternated with “Cave Mouth” and “Mountain Climb” visualizations with improvised music. Assagioli (1965), creator of Psychosynthesis, used these techniques and others as diagnostic tools. The couple responded readily and vividly to visualization with music, and I felt it would give them a release from the frustrating prisons of their present daily existence, promote a more fruitful interaction with the unconscious, and give Fred especially, an area of creativity and action that his present state denied him. We also improvised on “Holiday,” which they both used for reminiscence, and the reflection on their lives between the ages of 0 and 30 (curiously both only had memories from the age of 18), and 30 to 66, which brought up their happy holidays abroad (which Fred used to organise) and the old age and death of both their parents. In the eleventh session, we did a musical acting scene. Two people were to meet, chat together, find that they disagreed quite vehemently, argue, then cool down and part. When Fred and I did this in music his physical response was quite striking. His face went into a snarl showing his teeth, his whole body squirmed but his drumming expressed very little. However, Inge and I were able to be quite sharp with one another. Repeating the exercise with Fred, having told him how he looked and sounded, he was able to be more forceful on the drum and more relaxed in his body. After this, for the first time, Inge began to cry very modestly, wiping

every tear meticulously with her handkerchief. She gave vent to very despairing feelings: “What’s the use of anything? There is so much to do in the house and garden and he just sits there like a lump.” She was afraid to tell him what she felt for fear of making him worse. He was afraid to speak to her as she cried at the slightest thing. She could not bear to see him all tense and clutching his hands. As previously she had maintained that she was never depressed and always busy with two jobs at once, I felt that sharing these despairing feelings could be a helpful gain in truth with a subsequent access of the energy which had kept these feelings suppressed. At the end of this session we did the first of the musical visualizations on “Creating My Room,” “My Garden,” and “My Village.” Interestingly enough, in Inge’s series there were animals, tropical fish, swans and ducks. Her animal nature, being denied both sex and normal relaxation, was begging to be considered. Fred visualized a swimming pool, light and brilliantly coloured flowers and football games. This gave me a clue as to what activities he might become involved in later, and the fact that he would like to experience strong feelings as a normal part of his life. In response to Fred’s interest in swimming Inge said that she hated water. In certain ways the couple was very closely attuned to each other. To see what would happen in a physically “Man-on-Top” situation, one day I brought some records of dance music which they had spoken about, and they danced most beautifully together with Fred taking a definite lead and Inge following, their bodies in close and perfect physical harmony. Another day we did the “Tapping Game” in which one person goes out and has to come in and perform an act pre-decided by the others in the room; the only clue they get is the tapping by their partner or someone else in the room, loud for “on the trail” and soft or silence for “wrong direction.” Their tuning to each other verged on the extra-sensory as without hesitation each in turn found their way to carrying out the secret act with their partner doing the tapping. Perhaps they were too closely attuned and vulnerable to each other’s negative signals and that was why Fred could not function at home as he did in the session where he was more in tune with my belief in him as a separate and capable person. In the thirteenth session, Inge came alone, distraught. Fred had refused to get out of bed. She wept and said, “It is all too much, I have to do everything and we never do anything nice together.” They had had a quarrel because she had felt obliged to mow the lawn with the heavy motor mower. Then, having been invited out to lunch and a film, and feeling guilty about leaving Fred, she had banged a door in fury and he had woken with a start, thinking it was an electrical fault. As Inge reiterated that she was not the patient, we did no music, which she believed to be the therapy, being unaware of the psychotherapeutic aspect of our verbal exchange. I tried to ring Fred at once but gave up after waiting in vain for quarter of an hour for our hospital operator to answer. When I later spoke to Fred on the phone he was cheerful and apologetic. I said that it was when one felt really bad that the therapy was most useful. In the next session we explored feelings about “Going” and “Not Going.” I explained that we were working with energies and they might find themselves getting quite irritable until they had learnt to use these energies constructively. There was a lot of guilt floating about. Inge’s unconscious death-wish for Fred made it impossible for her to adapt to the unhappy circumstance of his illness by allowing herself any pleasure. Also, her frantic need to control made her a slave to the house and garden and

hairdresser, and to respond negatively and destructively in our sessions to Fred’s little sparks of enthusiasm for cooking, cycling, swimming, football, a weekend break away, and his stamp collection. In sessions 26 and 39, I tackled her on this, pointing out the difference between nagging someone to make them do what you wanted, and encouraging them when they showed some enthusiasm for something themselves. In session 39, she became quite hysterical, weeping and screaming, “You don’t have him 24 hours a day; he never says he wants to do ANYTHING! I can’t stand it, any more! If I had anywhere to go I’d run away!” I asked Fred if he thought she might leave him and he said, “Yes, sometimes.” To illustrate my point Fred said he had felt that he could, as the head of the household, fill in the Electoral Roll form but found that Inge had already done it. In some ways Fred’s illness fulfilled an unused early maternal instinct in Inge. Through it she could experience the total power that the mother has over an infant. But real motherhood compels the mother to adapt herself gradually to the child’s growing independence and selfdetermination. Inge had not had to learn that. In another way Fred’s sitting at home represented a frightened baby part of her being kept from terrors such as floods, storms, and terrorist attacks which she often spoke about. The fact that Fred, in his depressed and apathetic state, fulfilled a meaningful, though unconscious, function for Inge, was a factor in the couple wanting to preserve the status quo, as it at least gave Fred a kind of usefulness and meaning, albeit pathological, whereas the life of retirement seemed utterly meaningless to him. It also meant that Inge could split off this anxious little part of herself, and project it on to Fred, and then see herself only as a normal, busy and cheerful person. During all this time their music was vigorous and rhythmic and Fred became increasingly musically inventive. They came into the sessions eagerly but Inge wanted to make therapy a social occasion and competed with Fred conversationally for my attention. From session 31, I let Fred lead the sessions. In 31, he wanted to talk, in 32 to relax to music, in 33 to improvise to “Shopping.” In 31 Fred said he was afraid that he had Alzheimer’s disease. I said the fear hid a wish for an excuse to live blamelessly like an infant. I told him to tell the Consultant and wrote to him myself. Inge had by now actually been out to lunch alone, but Fred had made her feel guilty by only eating a banana. In session 36, he came in looking pale and ill. The Consultant had said there were no signs of Alzheimer’s disease. In 38, they came in strangely excited. Inge was to have a cataract operation and be away for a week. Now that she was not going to enjoy herself, she felt sure Fred could cope alone for a week. Fred said rather hopefully that last time she was ill and away he ate his supper in a cafe. Inge said she would fill the freezer for him. (Mother again!) Inge talked, almost hopefully, about dying. Fred felt that life had become one routine for him with breaks for dentist, hairdresser, and therapy. I felt this as the “Kiss of Death” for our work and started once more to direct the sessions myself. In sessions 40 and 41, they each did a musical “Family Sculpture.” They became very lively with vivid memories. Later Fred remembered that his brother had had a secret early breakdown and he phoned him for the first time in years. Family sculpture is a technique that I learnt in the Institute of Group Analysis and later adapted to include music. The client places instruments of his choice in positions to indicate his emotional distances from his family members. We wanted to reveal the patterns of childhood. He then describes how he felt about

each family member and they improvise duets, she (or the therapist) in the role of each member in turn. After feedback, the partner tells what she, as family member, felt about each emotional and geographical placing. The client regards the pattern of instruments and decides if he would like to move anyone. It is a strangely powerful technique. In session 43, I decided to crack the whip. The time of my retirement was approaching and despite our lively sessions, their home life was still so stagnant that I felt it necessary to try to heal the split between these states. In life there are life-preserving routines and deadening sleep-producing routines. I felt that this couple had a mutually collusive conspiracy to remain in one of the latter. I rang the principal clinical psychologist who had felt the same. The vortex of stagnation alarmed me as one of our patients had stayed in a depression for 18 ongoing years. I told the couple that our department had a waiting list and unless they personally could do the tasks appointed during the next seven sessions they must leave. Each week each was to do a self-chosen enjoyable “ego” task and Fred was also to choose a duty to do. We played stormy music about this plan and Fred was given a notebook to record their progress because in an exercise about work he had said he had enjoyed taking the minutes at meetings. Fred, with prompting, chose to fill in his income tax form for his duty, and to go to the pub for his ego task, and then he looked miserable and said no, he wouldn’t enjoy it. Inge suggested that he watch football instead, and he agreed. It became the pattern that they could not think of ego tasks unless their partner suggested them. (Privately I translated this sexually into “I cannot have sex unless my partner initiates it and I cannot masturbate in our double bed.”) They came to session 44 tense and glum. Fred had looked at his tax form but not completed it. However, both ego tasks had been done and enjoyed. As Fred had totally ignored their wedding anniversary Inge bought herself a new needlework box and rung her friend in South Africa at some length without guilt. After our music, Fred said reparatively that he was making real melodies. And he was. By session 46, the routine of the tasks was well established, the expectant mood had come back as all tasks were done, the “duty” ones sometimes minimally but the “ego” ones were producing spin-offs. Inge brought me flowers from their garden but kept bleating, “Fred only does what I say.” I began to realize that there could be an element of jealousy and of fear of loss of control. In the same session, each of us in turn danced our “Inner Music” while the two others accompanied it. Inge’s dance was graceful and Fred danced in a Polynesian style, wiggling his posterior at us provocatively. For the first time Inge came out with a whole-hearted compliment. “Fred used to be a lovely dancer.” He denied this but from his smile we could see he was pleased. I realize that I have said very little about the couple’s actual music. From the beginning their music was energetic and rather deadeningly rhythmic. Fred favored a longish improvisation. Inge would beseech him, non-verbally, to stop three-quarters of the way through, but for once Fred was “Man-on-Top” and was not going to terminate before he chose to do so. The music revealed them as being sustainers rather than innovators. Perseverance was their virtue. As Fred, especially, found it threatening to express aggression or even assertion verbally, the music became a reliable container for his rage and rebellion. It always reduced his agitation. But it also could express delight and a playful approach which began to verge on the musically creative.

From session 47 onward, Inge started to rebel against the ego tasks, preferring to make an effort to do something enjoyable involving Fred. She took him shopping to the West End and later to the local Garden Centre. I reminded her that I had suggested the ego tasks on the basis of her saying that she was so unhappy that she wanted to run away. But at least they had helped to give her a clearer feeling of direction. In answer to her repeated frantic, “When will he be better?” I felt that they were strong enough now for me to say that no one knew, we could only work at each day as it came; some depressions lasted days, one patient was still depressed after eighteen years. I thought it was a risk telling them this but nevertheless I felt intuitively that for them it was right. The reaction to it was a great leap forward. During the next week they visited Kew Gardens at Fred’s (first) suggestion, went to a pub where Fred had his first pint of beer since retirement, and almost completed the dreaded income tax form. In the last improvisation before the completion of this paper, “Playing for Fun,” Fred put tremendous energy into his music with a cheeky drummed “dum dada dum dum--pom pom” motif, echoed on the piano. It seemed that he was giving us courage to believe that he was by no means such a hopeless case. This was a stubborn and difficult case, and I believed that the couple’s consolidation of their growth and development evinced in the sessions would take much longer than the time available for our work. For Inge, Fred represented unconsciously both her dependent and submissive child and a frightened agoraphobic part of herself. Therefore she was very threatened by any voiced enthusiasm or interest on his part, discouraged it promptly and then denied its existence. As Fred was unable to be affirmative still, even less aggressive, his reaction to this was rebellious apathy punctuated by the odd snide remark. I think my ability not to be black-mailed by Inge’s hysteria at mild criticism, or Fred’s intense agitation when asked to choose an ego task, gave each a model for being a bit firmer in daring to speak to the other. Several times during reminiscences Inge reported being surprised to hear Fred relate something about his past. For example she was amazed to hear that his father beat him when he was naughty. “Fred naughty? I can’t believe it!” she said. However, she never surprised him in that way. Our exploration of the history of the pair as a couple helped their dyadic group image through their reminiscences of the good holidays Fred organised and their support of their old parents. Their personal identities seemed to be totally group-oriented. Fred had no activities at home to express his individuality; he was either Inge’s servant or nothing. He could only be something through his male peer group. The ego tasks were an antidote to this. Inge also functioned as she thought wives should and did, rather than responding sensitively and creatively to Fred’s needs of the moment and her own wishes for growth and development personally. For example, she continued to serve him huge three course-dinners when he was overweight from inactivity and drugs, saying, “My mother always cooked a good dinner for father and me.” If he did not make a clean plate, she wept. Fred could complain about this in the session, trusting me to contain Inge’s emotional reaction, but not yet at home. His aggressive and playful feelings had an increasingly free outlet in his music but the transition from musical expression to verbal would have had to take more time. Furthermore I felt that Inge’s brittle but fragile ability to cope emotionally could easily crumble disastrously if rigorous methods of confrontation were employed. And that could mean his re-admission to hospital. .

Writing this in April, the therapy was due to terminate in five months, when I retired from institutional work. During that time I had hoped to help them to learn how to disagree more constructively, and how to evoke their Homo Ludens aspect through musical games, creative experiences with their bodies and dancing. I hoped that this might invalidate Fred’s remark that their lives were, “All work and no play.” After 15 1/2 months of music therapy, Inge was increasingly able to accept some of her own depressive feelings thus using less energy on defending herself against them. She felt more able to see friends and to set goals for herself and Fred (though I doubt whether he was yet included in the planning of them). She was also a little more inclined to try to make the best of the present rather than feeling that nothing could be achieved until Fred was better. She said that her aims for the future were to help housebound old people and to enjoy more of their successful holidays abroad again. Fred showed much more initiative verbally and musically in the sessions. His posture was more upright and his self-image somewhat improved. He was beginning to take real pleasure in improvising music, to see himself as a member of a musical family and even entertain a faint wish to learn to play tunes in the future. He realized that he needed to get back into his peer group and this was to be achieved by joining his firm’s retirement club at a later date. He said he also would like to be a volunteer driver for hospital patients when he felt strong enough. Altogether I felt that the work showed that music therapy can offer a useful and multi-faceted approach to couple therapy but with an older couple there needs to be a much longer time for readjustment with support and understanding. I was sorry that in this I had to let them down.

Taken from: Priestley, M. (1985/2012). Music Therapy in Action (Reprint of Second Edition). Gilsum NH: Barcelona Publishers.

CASE EIGHT Case Study of a Depressed Patient Mary Priestley We, in the music therapy department of the psychiatric hospital where I worked for 20 years, felt grateful to have had the opportunity to work with so many different people with almost as many unique kinds of personal damage, though often given the same labels. However, to protect our younger colleagues full of initial zeal and idealism, we have to admit that the work had many frustrating aspects. Patients would often be discharged without our knowledge just as the work looked as if it was getting somewhere. Occasionally, a senior colleague from another discipline swooped down and took over a case that was looking quite promising, not always with brilliant results. Sessions could be interrupted in the middle of sensitive interactions by one’s patient being called to wash up, or they could be obliviated by the patient being whisked off to a trip to Brighton. This was, of course, because in our initial zeal and idealism we wanted to pack in as much contact work as possible in our two days there. This meant that we did not always take time to nurture the vital links with other staff. Thus, decisions would be made on the days when we were doing work elsewhere with no communication coming through to our department. The result, in my case, was frustration and fury. Present-day colleagues are more aware of the need for establishing interdisciplinary lines of communication and links as well as developing their personal work with patients. However, now and then one was able to complete a bit of work and feel quite good about it. This case study was one of those happier occasions, though admittedly this patient was far less damaged than many with whom we worked. As usual all identifying details have been altered or omitted and the name changed. Lillian came to the psychiatric hospital in April and was referred by her psychiatrist to music therapy in May that year. She joined the patients’ choir run by the Head Music Therapist Gillian Lovett, and was the ideal patient: polite, intelligent, thoughtful, and musical. However, Gillian thought that she needed more radical treatment and so suggested to the psychiatrist that I should take her on for analytical music therapy. Lillian, 34, was small and slim, with bushy red hair, a pointed nose, and pleasant face lit by her undoubted intelligence. She described herself as “introverted, not a very happy person. I’ve lost things I used to do, like squash.” She was born overseas and had come to this country eight years ago. She had had an extremely taxing and responsible job in a large firm but, becoming depressed, she had accepted a less demanding post working as an assistant to someone who was doing a job similar to the one she had just left. She was depressed but on no medication, and spasmodically attended the hospital psychologist’s therapy group as well as the choir.

On the day of her first session (my first in the morning), the buses were held up and I was twenty minutes late. She was waiting. I took her history. She couldn’t speak to her mother. Her father was “remote,” and she did not get on with an elder sister. She thought that her trouble was that because of difficulties in her private life she had pushed herself to work harder and harder at her job. She had been ambitious and thought that having a good job was everything, but she now felt that being happy was more important. I pointed out that these aims were not necessarily mutually exclusive. Her immediate problem was that her television needed a new aerial and she had told the man to come between 4:00 and 5:00 p.m. He had come before that, when she was still in hospital, and left a card to say he had found no one in. She felt really furious with him for being so inefficient in his job when there was all this unemployment, but felt that she could not confront him. I said she must have been equally angry with me being late this morning, “Oh no,” and so on. I took for our improvisation title “Telling the Aerial Man”. She held the beaters and erupted into great convulsive sobs. I shouted, “Put it into action” and with a moan she crashed down on the cymbal and pounded fiercely on the drum. Then she cried again. Once more I asked her to put that into action and she drummed furiously and then played some glissandi to soothe herself. When she finished, smiling, and tearful, she said that she had thought that music therapy was listening to music on records to soothe herself, like she did at home. The next week she returned, looking much firmer, brighter, and less guilty. She had seen the aerial man and told him what she thought. She had taken something back to a shop, and played squash, even scoring (which she previously had not been able to do). She said that she had a “thing” about knives so we used “Knives” as a title, but her music was less explosive and her thoughts were of the rejecting and accepting aspects of her family, and thoughts about her job prospects. I said that she had not been using her aggression assertively until recently and she had projected it outside and symbolized it as threatening knives or frightening split-off possibilities of using aggression. Next week she spoke about meeting a young man with her girl friend and freezing him out, so the girlfriend grabbed him. She played her feelings about this with great energy but no longer wept. The next week she faced discharge from the hospital and I offered to see her at 6:00 p.m. as an outpatient. She agreed to this. It was the end of choir. The man had not rung her. She felt boring. We played “Ringing Ken.” There was panic and anger at being put in this situation then she remembered, to gentle music, how nice he was. She never imagined speaking to him. I said I thought that she was angry with me for putting her in this situation. “Oh no, neutral with staff,” she replied. Then we played “Telling Ken What I Think of Him,” using angry clashes followed by sweet, docile music. Next week she said that she had rung Ken and he was coming to supper, bringing tomato soup. She had refused a more taxing job at work. She kept mentioning “Being Dull” so we took this for a title. Her music was discordant and lively, then aggressive and empty, and I said it was punishing my delicate and plaintive melodies. She was not ready to see this. She felt that dullness covered all these fierce feelings that she was now using. I said she was afraid of what she might do as she had, as she had said, been a tag-along friend and was unused to initiating events.

At the next session she reported a set-back all round. At work, she had been put on the pay-roll and given no job. Ken had brought the soup but had been bent on sex, which she did not feel ready for, and she’d had to throw him out. A dominant girlfriend, Zoe, had invited her to a raspberry supper party that lasted for hours, ending up in a nightclub at 3:00 a.m. Every time she had wanted to leave, Zoe said “Don’t be so boring.” She felt suicidal when she got home. We played “Zoe,” to get back her projection on to this friend, and her music was direct and aggressive. Next week I was ill and had to miss the session. The week after, Lillian was exploring the reason why she had not told her parents about her illness. We played “Telling Parents.” She didn’t want to write, was angry with herself, got blocked, and ended up dreaming of a really free communication. She was very angry with her parents for sweeping family secrets under the carpet: a breakdown here, an illegitimacy there, an odd in-law, and so on. Next week, the last of the two first months, she was back at work, in total chaos, with no desk, and not taking her lunch hour. She wondered how much unreasonableness was hers and how much was theirs. She decided to have lunch every day, stick to two early nights, and create her own small territory at work. I did not record the music in my journal. As a result of the session before, she did write to her parents and had a loving telegram by return from her mother. She organised her office and sorted out that she was to have only one boss. By the 10th session she was quite rid of her depression and the aggression was directed outwards: she was in a foul temper and expressed this dynamically on the drum and cymbal. By the 14th session she said she felt so good that she wanted to stop. It transpired that she feared dependency. She was brought up to be independent but had a secret longing, of which she was ashamed, to lean on someone. I was experiencing countertransference feelings of acute inadequacy, and told her that she still had these feelings to explore. She said she had always felt a failure and so had run away. Her flight to England was part of this pattern. In the 16th session she reported that she was really happy, having held a good and adventurous dinner party. She had been high the week before but this was real solid happiness. The celebrating music was quite dizzy and fun. She gave up the group therapy. In the 20th session she said she had been assertive in the office but was afraid of being irrational. Her imagination exercise about an irritating colleague, Lena, revealed Lillian cutting off Lena’s head, chopping her to bits and throwing them in to the sea to be eaten by lions. By Talion law she feared “losing her head” and being “cut up.” She laughed uproariously when I pointed this out. (This is not an exercise for psychotic patients). In the 22nd session she said her married friends who had met through a marriage bureau asked why she didn’t try this. She wanted to do so and I agreed to extend the session until Easter. In the four last sessions she struggled with her feelings of inadequacy, and met two unsuitable men. Work went well and she was more alive but more vulnerable to anxiety. In her last session she realized that either she would have to change her old social patterns now or she would end up like her maiden aunt, Kathy, solitary and embittered. She also realized that music therapy was not a magic wand and she, herself, would have to do the work. She was rather apprehensive about stopping and we agreed on a four-month follow-up.

At the follow-up she looked well but a bit defended. She had had some depressive happenings but had been able to sort them out for herself without getting depressed. She had met three men, discarded two and kept one as a friend with whom she planned to do some clothes designing. Work was boring but she did not want to take on a more responsible position. She had been bad about keeping up with friends, as she had been seeing a lot of her neighbor. Evidently she thought that this was a depressing note to end on, so sent me a card saying: “I wanted to let you know how grateful I am to you for your help and quiet confidencebuilding over the last year. I have appreciated beyond words the help everyone at the hospital has given me, but particularly the patience and care you have shown me. I cannot thank you enough but I hope you know how much it has all meant to me. Thank you for everything.” What did the music mean to her? I think finding an outlet for her aggression in a harmless way gave her the courage to use it assertively in life situations. I think that it also gave her the power to face her own painful feelings of inadequacy in the containing dyadic improvisations and then explore these in words. She was a fighter and in many ways a delightful patient, but struggling with the countertransference inadequacy feelings before she was ready to face them herself was very uncomfortable for the therapist. In a way the therapy was painful for her too, as she exchanged her global depression for an awareness of all that she needed to do to create a satisfying life for herself. The therapy did not end with a magical solution to all her problems but rather presented her with a possible new beginning, which she sadly lacked at the start of the work.

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

CASE NINE The Song-Writing Process: A Woman’s Struggle Against Depression and Suicide Georgia Hudson Smith Abstract This study describes individual and group music therapy with a 27-year-old suicidal woman, dually diagnosed with Major Depressive Disorder and Borderline Personality Disorder. Through song writing, Jean found a creative way to share her thoughts and feelings while also developing positive self-regard. The creative process also helped to access unconscious material and unlocked repressed memories that were important in gaining insight about herself. Background Information Jean was a white, obese, 27-year-old, single female when first admitted to a psychiatric hospital. Prior to admission, she was in the last phase of her training to become a nun. She had converted to Catholicism approximately eight years earlier, and had entered the convent six years earlier. Jean felt that these decisions were a major source of conflict between herself and her Protestant parents. The referral to the hospital came from a private psychiatrist due to several recent suicide gestures and depression. Jean subsequently had three hospitalizations over an 18 month period. With each admission she was placed in an open hall music therapy group for high-functioning, non-psychotic patients. She was also seen privately two times per week for individual music therapy for eight months between her second and third hospitalizations. During the months prior to her admission, Jean began to feel increasingly troubled and depressed. She identified several stressors: moving to a new convent house while attending a new college, conflicts with two other nuns in the house, and her brother’s discharge from the Marines due to alcohol problems. She also felt constant disapproval from her father for becoming a nun. Approximately two weeks prior to admission when Jean was feeling troubled, she swallowed some windshield washer fluid. This was brought to the attention of her peers, and Jean was seen by a psychiatrist in private practice. Initially, this was considered as impulsive, and Jean appeared to make a reasonable response to office treatment. However, prior to her second visit, Jean superficially slashed her wrist and, following her doctor’s reevaluation, hospitalization was recommended. Jean grew up in a rural setting, attending a small town consolidated school. Her father had been alcoholic as far back as she could remember, and, he had had numerous affairs when

she was younger. Jean considered her father to be very harsh and negative in his relationship with her. She reported that her paternal grandfather was an alcoholic as well. Jean described her mother as kind, and genuinely concerned that Jean be happy. Though her mother was passive toward the father’s verbally abusive behavior, she would try to comfort and reassure Jean when the father was not present. Jean reported that her mother was physically abused as a child by her own father. Jean’s brother was five years younger, and had a severe drinking problem. He had been charged several times with “Driving While Intoxicated” and he had been involved in several lifethreatening auto accidents. As he became older, Jean felt that he also became verbally abusive toward her. During her first hospitalization, Jean characterized her childhood as fairly uneventful. She did well in school and had numerous friends. She reported dating and having normal peer relationships during her adolescents, despite always being troubled by her home life. Jean began working after graduating from high school. She enjoyed a responsible position in an office, making good money, and, occasionally taking a course at a local community college. After saving her money, she moved into her own apartment, hoping to provide a healthy separation from the constant bickering at home. A few months after Jean’s emancipation at age 19, her mother showed up at her apartment, suitcase in hand, saying that she had left Jean’s father. Jean let her move in. They lived together for almost a year. Jean worked hard to try to get her parents to reconcile, to no avail. She finally gave up the apartment, and she and her mother moved back home—she did not want the expense if she could not also have the freedom. During the time Jean lived in her apartment, she had begun attending a local Catholic church. She found the worship comforting and peaceful. After returning home, she continued attending as a way to “get away” from the confusion and pain she experienced at home. During the first few months back home, Jean completed a catechism class, was baptized, and became a member of the Catholic Church. Jean reported that her father threatened to disown her and engaged in hurtful verbal degradation. Within six months of returning home, Jean made a decision to become a nun, and began the process to enter a convent, which she did at age 21. Treatment Process First Hospitalization Jean was first hospitalized at the age of 27, six years after entering the convent. Her therapy focused on a growing awareness that she had difficulty in communicating her needs to others. She became hurt or resentful when her needs were not met, but tended to have excessive feelings of guilt or hyper-responsibility concerning the behavior of others. What Jean was able to initially identify was a sense of guilt and helplessness over her brother’s “difficulties” in the military. She felt that if she had been a better sister, he would not have been discharged from the military. As Jean’s depression had deepened, she had begun questioning her decision to become a nun. During the early part of treatment, she further explored her sense of vocation, and decided she could continue with the help of counseling aimed at improving her communication

skills. Her feelings were complicated when her order decided to terminate her religious training because of her suicide attempt. After further discussion with them, they modified their decision and extended her training period. Jean expressed relief to have another chance, but remained moderately anxious about her relationship with the sisters, fearing dismissal if she “messed up” again. Jean had been placed in a music therapy group to promote improved communication skills through a creative, expressive media, and, to increase social interaction. The group met daily for one hour. Since the average stay of treatment at the hospital was three to five weeks, members were added at any time as space allowed, and generally, left the group at time of discharge. There was an almost constant flow of members in and out of the group, and music methods varied accordingly. The group most frequently operated on an individual-within-agroup basis, with brief periods of stability of membership allowing for true group dynamics to function. Jean was initially quiet and withdrawn, refusing to participate in improvisation sessions, and passively participating in singing or listening exercises. She borrowed relaxation tapes to listen to in her room to help her sleep at night. She remained fairly quiet throughout her four week tenure in the group, but her affect noticeably brightened. Eye contact became good, and peer interaction, though still limited, was more open and friendly. After 30 days of treatment, due to apparent resolution of suicidal ideation, cessation of self-destructive behavior, and brightening of affect, the decision was made to discharge Jean. Second Hospitalization Jean appeared to do well after her discharge. She returned to the convent where she was doing her religious training and continued seeing a psychiatrist privately for four months. Then, she began to regress again, following a visit home, where she was once again confronted by the severity of her family’s dysfunction. She grew increasingly depressed and irritable. She once again began to question whether she should continue her religious training. She was sleeping poorly at night and unable to concentrate or function well during the day. As her suicidal ideation increased, arrangements were made for her readmission. This time, she remained in the hospital for four and a half months. At Jean’s request, she was placed in my music group once again; she felt safer exploring more difficult family history issues in light of the positive rapport we had developed in her previous hospitalization. Jean became more actively engaged in the group process this time. She found that song-writing was particularly helpful in expressing inner feelings that she had difficulty verbalizing. She also learned how to fantasize while listening to music in a relaxed state and then using the images to help her be more aware of unconscious forces and repressed memories that influenced her current behavior. The positive response of group members to Jean’s songs also served to help her build a more positive self-image. Approximately three weeks into treatment, the group did a series of song writing sessions where many childhood and family issues surfaced. Jean contributed actively, by generating ideas and putting the words into meters to fit the melodies; however throughout these sessions, she did not personally identify with any of the issues that were raised.

One day after group ended, she asked if she could bring a song to the group that she had written. This was the first time she had indicated that she ever wrote her own songs. At the next session, in a very nervous, quiet voice, she sang the following song of her own. Children’s lives are precious and rare Treat them gently, handle them with care See their precious eyes, feel their gentle smile They’re so young and there’s so much they really want to know. Butterflies and worlds of “Let’s pretend” Daddy’s hand and joys that never end Some will never know the joys that life can show Fear and pain and loneliness is all they’ll ever know CHORUS: Lives are precious things Fragile like a tiny string Just some love is all it takes To start a life anew Little hearts are broken easily Little souls, when cut, will quickly bleed They must know they’re loved, that somebody cares Otherwise they’ll hide away and never take a chance. Beautiful is laughter ringing out Let them feel the feelings that they feel Let them dream their dreams; do not block the way Let us not destroy the hearts and souls of ones we love. The group responded positively, indicating that she had put into words many of their own feelings. They asked if she would permit them to make copies of the lyrics, and over the next few days the whole group worked together to learn the song. Jean still had not shared much of her personal motivation for writing the song, saying only that her father had been overly harsh and negative, and her mother highly passive and ineffectual throughout her childhood. Jean began lingering in the room after the group had left, helping me clean-up and rearrange the room for the next group. Gradually over several weeks, she began to tell me bits and pieces of her story. She had a life-long pattern of keeping secrets that made it difficult for her to share her history. At this time she confided that in order to survive in her home, she had had to keep her thoughts to herself. The threat of emotional abandonment was real, as demonstrated by her father refusing to talk to her for months at a time if Jean displeased him. She reported being confined to her room at age 12 for an entire summer due to arguing with her father about a minor rule infraction at school. She ate all her meals alone in her room, only coming out to use the bathroom and occasional walks in the yard. It took Jean a long time to trust staff and peers to not punish (or worse yet, shun) her if she displeased us. And she feared that sharing her childhood pain would bring on retribution by her family if they found out and abandonment by staff and peers if we did not believe her. She

was highly self-conscious about not “looking foolish” as demonstrated by her refusal to participate in any form of improvisation. She said that it felt “too open ended, with too many possibilities of failure.” Medically, Jean had begun experiencing marked ataxia, falling on several occasions, bruising her nose and eyes, and requiring wheel-chair transport to off-hall groups. During this time Jean became highly discouraged, and shared with the group that she was having renewed and intensified suicidal ideation. A variety of pharmacological combinations were tried over the coming weeks to reduce both depressive symptomatology and negative side effects. In music group, her level of participation decreased and she often appeared very depressed, withdrawn, and defeated. She insisted on attending group regularly, saying that it was one of the few places she had found acceptance and comfort. After several weeks of being “stuck” in this depressive state, she asked that we sing the song she had written. Jean then shared that she had begun having flashbacks to a time in her childhood when an older neighbor-boy had raped her and threatened her “with more of the same” if she told anyone. She was seven years old at the time, and related how she tried to tell her mother, but that her mother rebuked her, saying that “good girls” don’t talk about such things. Jean said that she had not begun to remember the incident until about a week after she originally shared the song in group. She told us what strong feelings she had when the group had worked together to write songs and share their experiences with one another. As she tried to understand why she was reacting so strongly, and why she had written the particular song she wrote, her memory of the childhood incident had become conscious. She said that she experienced a lot of embarrassment and shame in telling the group, but felt she had held it in long enough. The group reassured her that the rape had not been her fault, and that she did not need to feel ashamed. Suicidal ideation began to increase after this time of self-disclosure in group, and Jean engaged in several episodes of superficial wrist cutting. She also developed flu-like symptoms, but later told staff that she had taken a small bottle of aspirin to overdose. She was placed on eye contact supervision for several days as she continued to work through the sexual abuse memories in individual sessions with her doctor. She was not permitted to attend off-hall groups during this time, but the music group made a cassette recording of familiar songs we used in sessions, and gave it to her to listen to until she could return. She expressed deep gratitude for such a caring response. During these months of hospitalization, Jean made the decision that the life of the convent was not right for her, and began to separate from the sisterhood. Notification from Rome of the official dissolution of her vows arrived at this time, further intensifying her regression. She repeatedly became immobilized by the fear generated from her memories, and the day-to-day decisions she needed to make to establish an independent life-style. Jean had made plans to move in with a patient she had met at the hospital, and had arranged for a job after discharge. However, in the latter period of hospitalization, these plans fell through due to reasons beyond her control. She had no recourse but to move into a women’s shelter in the city and begin looking for a job upon discharge. Jean’s intense sense of hopelessness would appear to wax and wane, but finally, she began to stabilize. Due to her insight into the roots of her depression and low self-esteem, and her hard work to use stressreduction strategies to manage her impulses, it was decided to prepare Jean for discharge.

Preparing for Discharge Continued treatment with her psychology intern was arranged through the hospital’s out-patient clinic. Jean’s medication was to be monitored by the clinic’s psychiatric resident. Jean also asked me to work with her post-discharge to help provide some stable transition to independent living, and to continue her expressive outlet through music to help defuse continued self-destructive tendencies. Her primary therapist and I quickly established a supportive working relationship to head off Jean’s attempts to split. Our goal was to provide consistent treatment to best meet her needs for working through parental transference issues, and to nurture and support her while she mastered tasks of independent living. Two weeks before her discharge, Jean experienced a high level of anxiety over leaving the safety of the hospital. She had experienced tremendous gratitude toward, and comfort from, the staff and peers who had supported her for the past four months. She seemed to be searching for a way to focus and express her feelings, so I suggested she try writing another song. Two days later she brought the following to group: Deep within each of us Lies a special kind of place A place where love can root and grow And touch our very hearts and souls. No one finds this special place By searching hunting on their own For this place cannot he found It needs another’s love to guide the way. CHORUS: You touched me You reached into my darkness You found me crushed and broken I turned away in fear and you didn‘t walk away, No, you stayed. The path is long and sometimes hard There are many times I want to quit Then I feel your love within my soul That’s when I find the courage to go on. How can words express my gratitude? For the kindness that you’ve shown If your love had not reached out to me There’s so much of me I would have missed. The group once again affirmed her ability to put into song a similar sense of gratitude for the support they had felt and the increased sense of personal growth they had experienced in treatment. This time Jean was better able to share how the song expressed her feelings and had grown out of her experience.

Outpatient Treatment Jean moved into a shelter and began the process of job hunting. She did volunteer work at the hospital, helping with evening recreation activities. It provided her with further staff contact, participation in group activities and a sense of contribution to the recovery of other patients. We spent the first three to four weeks adding to her group song recording. She would choose two or three songs per session, practice them once or twice, record them, and then talk about why she wanted them included on her tape. Jean quickly secured a job in a nursing home as an aide, but left after only a few days. She became discouraged by the hard physical labor required and the depressive surroundings. Shortly thereafter, she took a job with a family of two professional adults and three small children, doing house cleaning and child care. She initially experienced a lot of anxiety about whether they would like her. She would come into sessions anxious or in some way upset, but often unable to identify why. Using New Age style music (her choice), we would do imaging exercises to help her explore, and hopefully identify, the source of her feelings. For several weeks her images included some type of ferocious dragon or mythical beast. She finally was able to identify this image as a symbol of her self-destructive impulses. She learned to gauge the seriousness of her impulsive thoughts according to the size and degree of danger felt in her imaging. When the “beast” began approaching equal size with her, she needed extra reinforcement in the form of phone calls, relaxation exercises, journal writing and/or other expressive activities. The strategy of sharing about her self-destructive feelings, but not permitting acting out, seemed to help manage her behavior well into the fourth month of her out-patient work. Writing a life Song During one of our imaging sessions in the tenth week of treatment, I used the title track from David Lanz’s “Cristofori’s Dream.” Jean had a very different experience, imaging scenes throughout her life, feeling sadness and hurt, as well as moments of hope and well-being. She described her images as giving her “little windows” into the future of “what might be.” She was so moved by the music, she asked if I would play it again. As the introduction led into the melody, she began quietly singing: Storm clouds and darkness and fears Shadow the days of our lives Filled with long lonely hours I quickly began writing--she stopped the tape and rewound it, singing the lines again, then adding: Days pass so quickly and yet Too many hours to think

Of the sad regrets. She talked about how the housework part of her job afforded her too many hours to ruminate on past memories. She could have fun in the morning with the kids, but a sense of doom or hopelessness would override all the good feelings as she did laundry in the afternoon during their naps. Her fear of going out and about in a strange neighborhood also contributed to feelings of loneliness and isolation. We closed the session by deciding to continue working on this song. Jean had been feeling a strong desire to write another song, but felt her melody ideas were too simplistic for what she wanted to express. She felt that “Cristofori’s Dream” could become an expression of her own dream. For the next nine weeks, we spent one session a week talking, writing and processing until we had completed lyrics for the entire piece. The other session each week was used for singing, relaxation or imaging. Stanza Two Rainbows and moonbeams and sunshine and candlelight All flicker softly And gently they light up The darkness which covers our dreams and our mem’ries Of days in the sunlight, Which guided our way through The caves and the caverns - the labyrinth patterns, The maze that we follow throughout The days of our lives. Jean had been feeling frustrated at how elusive the moments of hope were. She felt she was wandering through dark caves of hurtful memories that blocked her ability to feel gratitude for her current situation—living with a caring, concerned family, safe and warm, with two committed therapists and several good friends. She felt guilty for not feeling gratitude. Stanza Three Spiraling downward, we follow the child Which can lead us to heights Which we thought we’d forgotten. The laughter and joy that we shared with a toy It was special and innocent Loving -forgiving. Always afraid that the moments of peacefulness Soon would be stolen And smashed in an angry attack.

Jean began to realize how she did not trust “good” feelings because she was always vigilant to anticipate when “the attack” was going to come. Her relaxation exercises worked for the moment she was engaged in them, but the positive effects quickly dissipated as she began wondering when the punishment or negativity would begin. She began to have some insight about how that fear was a learned response from her childhood, due to her father’s behavior. As an adult, she knew on a cognitive level that she would not actually be punished for everything she enjoyed, but internally she still felt the fear of the child and anticipated the punishment anyway. Stanza Four Feeling afraid to let go Of all the pain and the sorrow I know Fearing that change just won’t work out. I don’t know how to believe In all I am or the things I can be. I just don’t know... This was the first time Jean began to articulate her fear of “getting better.” Her borderline personality features had been evident from the middle of her last hospitalization, but her narcissistic neediness and fear of abandonment seemed to move into uncharted territories at this point. Her symbolic dragon began growing with no abatement. Jean talked about her fear of the psychologist and me terminating treatment if she mastered independent, healthy living. She recalled the death of a neighbor woman who had been particularly supportive throughout her childhood, and how difficult it had been for Jean to cope with that loss. She also recognized that at least part of her motivation for joining the convent was to surround her with a stable resource of supportive people. Her emotional instability had escalated when her training forced her to move about, frequently changing the people closest to her. Stanza Five Just when I feel all the pain’s been discovered Another new memory Sends me to depths of Despair and confusion well up all around me I feel I am drowning and sinking I panic. The voices of Daddy The silence of Mommy... Jean was tapping into her rage toward her parents and then increasing her selfdestructive thoughts as an intense sense of guilt and disloyalty took over. She also continued to experience fear that her primary therapist and I would terminate treatment. No amount of

reassurance on our part helped to decrease her obsession with this fear. We began to work from the premise that she was projecting her desire to leave therapy onto us, caught in an internal battle between wanting to be free of self-destructive thoughts and behavior, but not wanting to mature and live independently. Stanza Six As each new day starts to dawn I want to look at the face of the sun letting the dark drift away. I need to hear things anew Try to believe in the things I can do No matter what those things may be I have a right to be free... As Jean’s primary therapist and I approached the idea of her internal conflict over treatment and what “getting well” symbolized for her, she was able to more consciously grapple with her fear of becoming a mature, independent adult. The locus of control was still external; the pain would “drift away,” and it was the responsibility of others to tell her what she needed to hear. Stanza Seven Storm clouds and darkness and fears... Shadow the days of our lives... Out of the past will come voices which haunt me, And though they are strong, I can’t let them beat me. Jean was beginning to recognize her need to identify negative inner messages and replace them with healthier ones. The locus of control was beginning to shift inward. As her cognitive understanding grew, unfortunately, so did her symbolic dragon - she was calling her primary therapist with increasing frequency, almost once a day, as self-destructive thoughts increased. It was during this time that she shared with us that her in-hospital fall attributed to ataxia had been a deliberate, self-destructive “accident.” We became increasingly concerned over Jean’s ability to maintain independent living. She was clearly using her phone access to her primary therapist in a manipulative way, promising to not hurt herself if he would just talk to her for a while. We worked on additional back-up with the psychiatric resident following her for medication. During the next month, we each took a week’s vacation, and her employment family prepared for a four week vacation trip. There had also been increased stress at work with the birth of a fourth child. Stanza Eight

Small seeds of hope that lie deep down inside me I’ll nurture and care for Until they have grown into Hopes and the dreams that had long been forgottenThey struggle for life in the midst of suppression. Jean took a dramatic “flight into health” this week. She made many connections about how she was acting out her fear of independence by calling for more frequent support. Her phone calls dropped to twice per week. She made arrangements to meet a friend for dinner and a movie. She was appropriately assertive in asking her employers for some much needed time off. She shared openly about her fears that each of us would be traveling on our vacations, and how that brought up irrational fears that we would be injured or killed. She expressed relief that we were not taking the same week off, so that she would still have some continuity of treatment. We planned to use our last week before my vacation to finish the song, and make a recording of it for her to keep. Stanza Nine A light in the darkness A path through the troubles I’ll follow until I have reached The way of new life. Jean talked about the sense of loss she was experiencing as I prepared to leave on vacation. She also expressed relief that we had finished and recorded the song to help “hold her over” until I returned. The week-end that my vacation began, Jean made an unplanned visit to see her parents (only the second visit since leaving the hospital). We had talked about how destructive her father’s negativity was for her still fragile self-image. During this visit, she was able to ask him to stop putting her down, and she helped him cut paneling for a family room. She found that having a work project to share helped ease their time together, and at the end of the weekend, he thanked her for her help. These were big steps in their relationship. The next week-end, she went to the convent alone to pick up the remainder of her belongings. She had not discussed either of these out-of-town trips with us prior to our vacations. In the meantime, she was helping her employer family pack and prepare to leave on their month’s vacation. The series of reminders of previous losses and of temporary vacation losses seemed to unravel any progress Jean had made. Her intense need for reassurance that we were not leaving her seemed at times to be a regression to a two-year olds fears around “object permanence.” If we were not in sight, she was not emotionally convinced that we existed, although cognitively she knew we did.

When we both returned from vacation, the threats of self-injury took on renewed vigor. We tried to convince Jean to admit herself to the hospital in her catchment area, since she could no longer promise her own safety. As we worked to pursue legal avenues to have her committed for an evaluation, she put her face through a storm window and was rushed to the hospital for emergency treatment. It seemed at the time to have been a cathartic experience, releasing repressed psychic energy. Jean was finally able to accept that we were not going to repeat childhood patterns of abandonment. She was also, for the first time, able to identify positive qualities in herself, strengths that she could use to help her continue to grow and heal. She successfully worked through several anxiety attacks without resorting to self-destructive behavior to relieve the tension. She felt she could use these experiences to say “no” to herself and utilize more healthy coping tools. With understandable reservations, Jean’s employer-family required tremendously restrictive “promises,” creating an increased subservient situation for Jean. She decided to “house sit” alone for a friend in long-term residential treatment, and procured a job in a national department store’s catalogue mail room. Three weeks after her release from the hospital, her primary therapist and I held a joint session with Jean and her family. She had first suggested it to them in her visit home, and with her readmission to the hospital, her parents requested a session to help them understand Jean’s continued suicide attempts. Their concept of emotional illness was similar to “getting over” the flu. Jean was able to share the pain she experienced in not being supported by the family. The parents were able to share how hurt and frustrated they were hearing this; essentially, they felt their actions of providing food and shelter were ways to show support. They admitted that they did not know how to be supportive “with words.” The parents also related some of their personal history. There was clearly multiple generations of alcohol addiction and physical abuse on both sides of Jean’s family. They expressed interest in continuing to meet, and certainly used their first session in a surprisingly useful manner. During Jean’s first week of full-time employment, two weeks after the family session, she reported having been sexually molested on the way home late one night. We each had several extra sessions that week. Due to inconsistencies in her story, we were never certain about what, if anything had actually happened. Jean became increasingly needy as additional vacation time for her primary therapist and I approached. The primary therapist was also beginning to suggest various options for their continued work once his residency ended at the hospital and he began private practice work. As Jean’s anxieties continued to escalate once again, we decided to set clearer boundaries, giving her the choice of working through her feelings without hurting herself, referring her to a psychiatrist for more support, or having her become part of a day treatment program for more support. We made it clear that we were willing to work with any outside support needed to ensure her safety. Eight weeks after her emergency hospitalization, she once again went to her parents’ home without notifying us or planning ahead with us. A week later she was re-hospitalized, having taken an overdose of Trilifon. I had a joint session with her hospital therapist, outlining my desire to have her in a safe, structured program, as I could not assume sole responsibility

for her treatment. Her out-patient primary therapist had also made it clear that he was concerned about continuing to work with her unless she was involved in a more structured program. Jean agreed to enroll in a day-treatment program, and would look into various options while I was away on vacation. She remained in the hospital for three and a half weeks after my return from vacation, primarily due to the slowness of making arrangements for her discharge. The seriousness of her suicide attempts disqualified her from various half-way house programs where she could have lived in a more supportive environment. We felt concerned that her fear of living alone would undermine any sense of support found in a day-program. She finally contacted the public mental health agency near her parents, deciding to move home, attend a day-program there until a bed became available in a half-way house in her home town. Jean talked openly about the risk involved in living at home, but she felt strongly that there were few other viable options available. I regretfully agreed. We worked through closure as she prepared for discharge, reviewing the history of our time together, naming the strengths she had begun to discover and reframing the hurtful experiences as resources from which to learn. We maintained contact over a six month period, with approximately once a month phone calls. She was briefly re-hospitalized two more times before finally being placed in a halfway house. The program had a blackout period and she has not contacted me since. Discussion and Conclusions All of us who worked with Jean marveled at her determination to put herself in potentially healing situations. She certainly had a strong desire to find a more satisfying way to live, and she desperately wanted to share that insight with her family. She showed great determination in trying to take suggestions, she was grateful when people put forth effort on her behalf, and she helped draw us in as willing co-workers in her healing journey. At times, her indomitable spirit led the primary therapist and me into countertransference reactions: we would use her willingness to work as an excuse for us to assume care-taking roles, when firmer boundaries would probably have been more useful. It was through music that Jean was able to first experience her creativity, and to share her inner self with others. She described few moments of feeling fully human in her life until she shared her first song in the music therapy group. She felt empowered to release her “inner dragon,” and hopefully, find a way to subdue it. I do not know how significant the music experience will prove to be in Jean’s life, probably because our time together ended long before any ultimate sense of healing or renewal was evident. Jean made copies of our music tapes so that she would not wear them out playing them over and over again. As she was preparing to move to the group home, she was making a fresh set to take with her. Jean’s primary therapist and I felt frustrated that better support systems were not available for her, especially when she needed safe transitions from out-patient to in-patient and more structured living situations. Cognitively Jean was too high functioning for typical longterm psychiatric day-program clients. And yet she clearly did not have the stability or autonomy necessary to live independently. We seemed to be trying to provide early infancy stability that

Jean needed to develop trust and ego strength, and at the same time, we had to encourage Jean to become more autonomous and independent. I felt both privileged to have been able to share in Jean’s courageous journey, and frustrated at my personal and at society’s limitations in providing adequate, healing care. Glossary Borderline Personality Disorder: “The essential feature of this disorder is a pervasive pattern of instability of self-image, interpersonal relationships, and mood, beginning by early adulthood and present in a variety of contexts. A marked and persistent identity disturbance is almost invariably present. This is often pervasive, and is manifested by uncertainty about several life issues, such as self-image, sexual orientation, long-term goals or career choices, types of friends or lovers to have, or which values to adopt. The person often experiences this instability of selfimage as chronic feelings of emptiness or boredom. Interpersonal relationships are usually unstable and intense, and may be characterized by alternation of the extremes of over idealization and devaluation. These people have difficulty tolerating being alone, and will make frantic efforts to avoid real or imagined abandonment...Recurrent suicidal threats, gestures, or behavior and other self-mutilating behavior (e.g., wrist-scratching) are common in the more severe forms of the disorder. This behavior may serve to manipulate others, may be a result of intense anger, or may counteract feelings of ‘numbness’ and depersonalization that arise during periods of extreme stress. Some conceptualize this disorder as a level of personality organization rather than as a specific Personality Disorder.” (APA, 1987, p. 346). Major Depressive Disorder: “One or more depressive episodes, and has never had a manic episode or hypomanic episode” (APA, 1987, p. 228). Major Depressive Episode: “Dysphoric mood or loss of interest or pleasure in all or almost all usual activities and pastimes. The dysphoric mood is characterized by symptoms such as the following: depressed, sad, blue, hopeless, low, down in the dumps, irritable. The mood disturbance must be prominent and relatively persistent, but not necessarily the most dominant symptom, and does not include momentary shifts from one dysphoric mood to another dysphoric mood, e.g., anxiety to depression to anger such as seen in states of acute psychotic turmoil.” (APA, 1987, p. 218) Reference American Psychiatric Association (APA) (1987). Diagnostic and Statistic Manual of Mental Disorders - IIIR. Washington, DC: Authors.

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

CASE TEN The Doors and Windows of the Dressing Room: Culture-Centered Music Therapy in a Mental Health Setting Brynjulf Stige Introduction Living a troubled life in a rural area of Norway, Ramona encountered the possibilities of music therapy when she was hospitalized due to deep depression and suicidal tendencies. When she first came to the mental health center, she wanted to leave this world and she wanted to live. Vacillating between these inclinations, she one day heard sounds from the music therapy room and asked one of the other inpatients about this. She was informed that there is something called music therapy, which — the other client suggested — could be good. Later Ramona told me how she immediately had a strong feeling that she needed to find out if this could be something helpful for her. Ramona referred herself to music therapy and was invited to an initial mutual assessment period of four sessions. After this we decided to work together and we collaborated for another 62 sessions over a period of two and a half years. She then decided to leave music therapy because she felt that the worst crisis was over and that she was ready for “going back to the world,” as she would put it. The music therapy room became a space where Ramona could sing and play, listen and be listened to, move and be moved, act and reflect. Her journey from depression and suppression to vitality and healthier interdependence was long and windy. Music therapy was not her only support, but an essential one with a unique contribution. The story that I will present in this chapter is based upon my own field notes from the therapy process and interviews with Ramona where she talked about her experience of music therapy. Foundational Concepts I have written about parts of Ramona’s story previously.1 When I now approach her story again, it is with a different purpose and mode of presentation, with less orientation toward the theoretical ideas of the author and more focus upon the process and what the client tells about her experiences of music therapy. By taking one step back in order to let the client step up, I hope to be able to illuminate how culture-centered perspectives imply an integration of client-centered and contextual practice. In my previous presentations of Ramona’s story, I described how my work was informed by narrative therapy (White & Epston, 1990; McLeod, 1997), Nordoff and Robbins’s (1977)

approach to clinical improvisation, Mary Priestley’s (1994) combination of free improvisation and verbal processing, Diane Austin’s (1999) approach to vocal improvisation and modified versions of Helen Bonny’s method of Guided Imagery and Music (Summer, 1988; Moe, 1998). This is a broad range of influences indeed, and in some ways many of them are incompatible, given the fact that they are informed by very different assumptions about the nature of music, humans, health, and therapy. Reviewing my previous attempts of communicating the therapy approach taken, I think that the following sentence may be one of the more important: “These techniques were integrated in an approach designed to suit Ramona’s needs and resources and my strengths and weaknesses as a therapist” (Stige, 2003 p. 288). This simple statement--which suggests that the approach was to not have a predefined approach--requires some elaboration. The idea that therapy is recreated in each new encounter is not new. It could, to a large degree, be contained in the humanistic tradition of psychotherapy, as developed by Carl Rogers (1951/1999) and Rollo May (1969/1977) and extended by many music therapists. Anderson and Goolishian’s (1992) ideas regarding the client as expert and the therapist as “not-knowing” is another source of inspiration. These terms make sense if you focus upon humans as meaninggenerating beings. As “not-knowing therapist,” you enter the therapy dialogue with a focus upon the client’s narrative truth rather than your own pre-defined knowledge. This questions the traditional idea that the professional is the one who knows (Ulvestad, et al., 2007), but as I have suggested previously, it takes a lot of knowledge to take a not-knowing position, since it requires that you flexibly adjust to the client’s theory of change without losing hold of your own judgment and experience (Stige, 2001). In relation to therapy practice, two ideas that seem to be based upon incompatible premises have been much debated lately, namely the idea of evidence-based practice and the idea of empowerment and user-involvement. The first is based upon a deductive premise: preexisting knowledge on what (usually) works should inform your practice decisions. The second is based upon an inductive premise: the work should evolve from the goals and values of the participants of each context (Stige, 2008). It is beyond the scope of this chapter to discuss this schism, but the attempt of Duncan, Miller, and Sparks (2004) to suggest a new path should be mentioned, since it reflects the above-mentioned focus upon the client as expert, adding a concern for what works. These authors suggest that the effectiveness of therapy could be improved through client-directed, outcome-informed therapy. This implies a focus upon practice-based evidence and a radical breach from the medical thinking that informs the evidence-based practice movement. The logic of the medical model has influenced most models of psychotherapy, these authors suggest, so that therapists tend to focus upon the effect of specific interventions based upon a diagnosis of the client. The alternative they offer is to focus upon client resources and resilience, client theories of change and client feedback about the fit and benefit of service. In her elaboration of resource-oriented music therapy, Randi Rolvsjord (2007, 2010) has explored similar perspectives for music therapy in mental health care. To link client-centered and contextual perspectives requires a rethinking of conventional therapeutic practice. To take interest in everyday life experiences, and to reflect upon them during the therapy process, is standard procedure in most models of psychotherapy, but to think of the client’s use of everyday activities as an integrated and essential part of the therapy process is not. These contemporary debates contextualize some of the ideas that I tried to

develop in Culture-Centered Music Therapy (Stige, 2002). I did not attempt to develop another model of music therapy but a meta-perspective that implies a reorientation of music therapy practice in relational and contextual directions. I therefore defined music therapy practice not as an intervention but as a process of collaboration. In discussing therapy processes I suggested that we should take interest in the availability of a range of resources, such as the arena and agenda and the involved agents, activities, and artifacts (Stige, in press). When we take interest in the possibilities of resources such as these, the client is often the one who is competent to take the lead. Therapists could not rely on a predefined model and might need tools to redefine their roles and navigate within the clients’ view and world. In an attempt to illuminate such a relational and contextual perspective, I developed a figure that I here will present in a slightly modified version:

In the figure, music is included in the modes of artifact and activity, as these are two of the central ways in which we encounter music: we search or stumble upon songs and instruments and other artifacts that enable us to take part in various activities, such as singing, playing, listening, dancing and reflecting. How we use the artifacts and take part in the activities

is embedded in interpersonal relationships and the agenda of the collaboration. These microsystem processes may involve appropriation of mesosystem resources such as roles, rituals, rationales and relationships from other contexts (often in the local community). It is also colored by various macrosystem influences, such as institutional, aesthetic and political contexts. This description of music therapy processes is abstract, and intentionally so. Concrete models would more easily be interpreted as prescriptive or regulatory at the level of technique, while what is proposed here is not technique but a radical willingness to listen to the clients in the context of the lives they live. The rationale for this is grounded in a relational conception of health: Health is a quality of mutual care in human co-existence and a set of developing personal qualifications for participation. As such, health is the process of building resources for the individual, the community, and the relationship between individual and community (Stige, 2003, p. 207). A relational conception of health exemplifies a relational understanding of human life, where freedom is understood not just as self-realization but also as self-care and care for others (Vetlesen, 2004). The Client Ramona was a married woman in her late forties and a mother of three children. Due to her family and life situation, she had limited experience with paid work. In the mental health center, she was diagnosed according to the conventions of the medical model. For an understanding of Ramona’s music therapy process, this is of less relevance than how she presented herself and perceived herself in the therapy process. When Ramona first came to music therapy, she spoke with a shy and low voice. I was struck by the emotional suffering that I could feel and the restless energy that still seemed to be there. Some of the apparent contradictions in how she presented herself were demonstrated in the second session by the way she approached a djembe that she spotted among the other music instruments. In the middle of a conversation where she shared aspects of her traumatic personal history, she discovered the djembe. With some curiosity, she asked what kind of an instrument that would be. I explained briefly and asked if she wanted to try to play it. She said she was not sure, but there was something in her posture that I interpreted as an eagerness to try. Just a few seconds later, she was playing quite loudly on the djembe and I was improvising on the piano. I was surprised by this quick start, but the improvisation ended as abruptly as it had started. After less than 30 seconds of music, she stopped and asked, with a voice I could barely hear, if her playing was o.k. and if she was doing the right thing. This question seemed to relate to the story she had been telling, about a childhood of sexual abuse and an adult life with a relationship in which she was also abused and suppressed in various ways. Maybe it was not so surprising that she would almost automatically take a subordinate position in relation to me and ask if she was doing the right thing. There was one important discrepancy involved, however, and that was the way she played the djembe. Her

playing was lively, with strong and vigorous movements, a stunning contrast to how she presented herself verbally. Throughout the therapy process I gradually became more informed about Ramona’s story, suffering, and resilience. Together we explored how the music activities would relate to her verbal narratives, sometimes in analogy, other times in thought-provoking contrast. Assessment and Evaluation Some authors promoting client-directed therapy have developed rating scales that can be used to monitor client change (Duncan, et al., 2004). I did not use such scales with Ramona, one obvious reason being that I was not aware of these authors’ work at that time. The approach to assessment and evaluation that I used was careful attention to client statements in sessions, combined with qualitative interviews for metareflection. I consider this to be a relevant alternative or supplement to the use of rating scales. It is a more time consuming approach and it may also be less helpful if the therapeutic relationship does not work too well. But it is an approach with many advantages, the main one probably being that it is congruent with the therapeutic process; it is dialogic and gives space for unexpected comments and directions. One of the things Ramona told me in the first session was that she had “lost her music.” She used to sing, but now she could not. The only songs she knew were hymns and other religious songs, and she explained to me that she did not feel that these songs were true anymore. Some years earlier she almost lost one of her children, due to an acute illness. The child survived, but was seriously handicapped. After this, Ramona’s struggle to endure emotionally had become even tougher. She told me how she first approached the situation with all the fighting spirit she could muster. Then she collapsed and became confused and depressed, suicidal at times, and no longer able to function in the everyday roles that she was expected to fulfill. She had then been offered anti-psychotic medication and individual verbal psychotherapy. She told me that she felt she needed this but that something was missing. These services could not address the fact that she was not able to sing anymore, and that was one of the reasons why she came to music therapy. She wanted to learn new songs: “Ordinary songs, songs that ordinary people sing.” This was seemingly a trivial request, but in the light of her story I believed it was an important one. I heard it as an expression of a will to redefine her life. I informed Ramona that to learn new songs, certainly, would be a possibility in music therapy and that there were also many other ways of using music that she could try if she wanted to. We could improvise instrumentally and vocally, we could listen to music, and we could move, write or draw to music. I suggested that we could arrange a sequence of four assessment sessions and then evaluate whether we thought it would be worthwhile to continue working together. She accepted this idea, and in the next few sessions we tried out a range of activities. She told me she was interested in trying these things, as long as I could promise not to force her to sing when she did not want to. She also stressed that any movement to music was absolutely out of the question. Ramona found some pleasure in all the musical activities that we tried out, but things also developed in ways she had not expected. In response to her wish to learn new songs, we

had taken a traditional song book from the shelf and started to practice a well-known song called Lykkeliten. Many people think of this as a rather sweet little song, but the lyrics about a little child in a tough world drew Ramona in other directions. All of a sudden, she was filled with strong feelings of grief for her handicapped daughter. Ramona told me that previously she had not allowed herself to be in contact with the grief, not even in verbal therapy. As she shed tears, she expressed that it surprised her that music could create such strong feelings. When we evaluated the four assessment sessions together, this was one of the episodes Ramona talked about. She felt that, until this moment, she had repressed her grief and--since she had experienced how emotional the experience of music could be--she now speculated about the lack of contact with her emotions as one reason why she had lost her music in everyday life. She therefore expressed that she wanted to continue in music therapy and to expand her ideas about activities, to include improvisation and music listening. She was still interested in learning songs, but added that she now knew that there could be a range of emotional experiences linked to that activity and that we therefore would need to relate to her life situation and story. This resonated with my experience of the four assessment sessions, and we agreed to continue to work together. We decided to have weekly sessions of one hour and to supplement the sessions with interviews where she could reflect upon her experiences of the process. These interviews were originally conceived as research interviews, but they turned out to be an important part of the therapy process also.2 Ramona’s voice, as documented in the interviews, will therefore be part of the presentation of the process. The Therapeutic Process When describing therapy processes, there are many possible trajectories to explore, including changes in the activities, in the relationships and in the client’s experience and participation, both in the therapy sessions and in everyday contexts. One pertinent place to start in relation to Ramona’s process is to describe the negotiations around agenda. They reveal changes along several dimensions and were central to her process and to my understanding of how she was using music therapy. As described above, negotiations about agenda started already in the initial assessment sessions. She came to music therapy with a concrete plan; she wanted to learn some new songs. The experience of the first few sessions made her realize that this plan implied some other things that she had not considered consciously, such as relationships to her emotions, to me, and to her life story. From the beginning, we established a simple ritual: every session would start with a conversation about how she would like to use this music therapy session. The ritual was open; she could choose whether she wanted to go directly to a music activity or whether it was helpful for her to share verbally some of her personal history, either from the last week or from earlier periods of her life. This ritual also served to clarify that alteration between action and reflection was a possibility that she could choose to use at any point in any session. Given the fact that Ramona had some experience with verbal psychotherapy, the idea of verbal reflection was not alien to her. What was new was the possibility of combining this with musical activity. After just a few sessions, she would share that the ritual stressed her. Several days before each session she would start worrying about which song to sing and what else to do the

next time she met me. She wondered whether I could help her and suggest things to do. I responded that to think about the sessions during the week could be a good thing, because that would help her discover relationships between music therapy and her everyday life. I also suggested that to come to a session without knowing what to do would be completely legitimate. We could always come up with something together and maybe in a session she would discover wishes that were not so clear the day before. These types of negotiations continued in session after session, and they opened up reflections about many themes, including the roles, rituals, rationales and relationships that characterized her everyday life. She discovered that the role she would take in our negotiations was not so different from some other everyday rituals of her life, where she tended to take on a subordinate role and want the other to decide. One of the processes that seemed to challenge this in music therapy was a negotiation about rationale. She came to music therapy because she wanted to learn some music, but what exactly do the words “learning” and “music” mean? This became much more than abstract questions for Ramona. In the first few sessions, she often played percussion instruments while I played the piano. She would then be surprised when I used the term “music” about what we had done. “To me it’s only noise,” she would say, and then add that she was talking about her own contribution. The “name of the game” was something we talked about over a long period of time. To open up the possibility that what she did could be accepted as music was a slow process, even though she had some breakthroughs quite early on, such as in session seven when we agreed to try to free ourselves from the “tyranny of pretty chords” by playing together on the piano, as “ugly” as possible. We both enjoyed the experience, and it was one of the steps she would take in order to open up her conception of what music could be. This seemed to open up other things too. After a year in music therapy, she looked back at the process in an interview, and this was one of the things she commented upon: When I asked to start in music therapy I thought: “Now I will at any rate have a chance to learn some music.” But I have discovered that the main thing would not be to learn music, but to have the possibility to be in charge of the sounds myself. How should I explain? The alphabet has letters that can be made into words. It is me who decides what words. I had a picture of music as being a ready-made world, something I had to learn and memorize; to learn chords, to learn where I could find the different sounds. But you have contributed to making it into another world than what I had thought of. The sounds have become mine, I can put together the sounds I want, I can say that this is to “play music,” even though it’s nothing that I’ve been taught. It’s impulsive; it’s the use of sounds. This statement clearly reveals that to work with her conception of music was a relational experience for Ramona. Gradually, during this first year in music therapy, our relationship had become part of the agenda, together with the relationships of her everyday life. This happened in conjunction with an increased interest in metaphorical use of music, especially linked to the activities of listening and improvisation. Music as an analogy and a contrast to her everyday life would increasingly become a topic of conversation. My field notes from session 28 illuminate this: The session started with dialogue on the dilemma she experienced concerning balancing care for others and care for herself. She then said that she was afraid that I would throw her out of music therapy and close the door. As in many sessions previously, the theme of not trusting that she deserved what was good for her

was prominent. After a while, she wanted to play, and she picked out some new instruments in the music therapy room. First, she played softly on pipe chimes and then she wanted to try the ocean drum. She had never played that instrument before, and it fascinated her. I improvised on the piano and the music lasted almost 30-minutes. While playing I was enthralled by the musical interaction, which was sensitive, creative, and collaborative. The contrast to how she communicated musically earlier in the therapy process was striking. There was much more mutual trust now. After the improvisation she did not comment upon this, however, but shared a metaphoric experience she had had while playing: “I’m just like one of those small hailstones in the ocean drum, I move automatically.” The paradox of this statement, expressed after an improvisation where she had taken considerable responsibility and many initiatives, did not escape her. The theme of being in charge was existentially significant for Ramona, given the history she had of being abused and suppressed by men. Gradually, she started to trust that she could share that she was terrified by the idea of relating to me emotionally, since she was then afraid that I would exploit her, as men usually did. She added that maybe I was different, but she was not sure. The way she worked with this theme reveals how she gradually took responsibility in using the possibilities that being in charge of the music therapy agenda offered her. She started to use music therapy in tandem with the support that she increasingly was able to muster in other contexts. For instance, after two years of music therapy, she decided to join a summer camp arranged by an indemnity group by and for abused women. When she came back, something had changed. She told me that she felt empowered by the sisterhood and that the courage of the other women who insisted upon the right to “take their bodies back” had really been important for her. She declared that she now wanted to use music therapy in a new way. “I almost want to dance a waltz with you. Well, that would be too much, but I’d like to move to music.” We agreed about various ways of doing this, starting with me improvising on the piano with my eyes closed, so that she did not need to worry about being watched. Gradually she trusted me to open my eyes, and after a few weeks, we ended up doing movement improvisation together, mirroring, leading, and following each other. I was moved and astonished. The memory of how misplaced the idea of movement had been two years ago was still vivid. This would not be the only thing that surprised me this autumn. Ramona was now able to make many changes in her life, and she was both determined and energetic. Some months previously she had divorced her husband. Now she had met a man who she felt was good for her. And this was not the only change. She started to sing in a choir in the community, which is something the feeling of “not being worthy” had stopped her from doing previously. Also, and this was especially important, she started to attend high school classes. As a young woman, she had been forced to drop out of high school when she had her first child. Now, as a middle-aged woman, she felt that she had a new beginning. This was also the beginning of the end of her music therapy process. Ramona started to air that she was now so occupied with school, the choir and her new personal relationship that maybe she would soon be ready to conclude our music therapy collaboration. We agreed upon a period of closure, where we looked back at what she had achieved and worked through many of the activities that she had enjoyed. In one of the last sessions, we did a long piano improvisation together. Before we started playing I asked if she

wanted any givens or rules for the improvisation. She said “No, I can play here or I can play there. I can play in my own space or move toward your space, and you can do the same. That’s fine.” We started to improvise, first in a sequence with no established tonality. Then we moved into a succession of fifths and ended up in the B flat Dorian mode. After a transition in C minor, we moved to C major and the rhythm of the music gradually changed. After a while Ramona stopped playing, smiled, and asked: “That was triple time, wasn’t it?” I responded positively, and she said: “Hmm, so finally there was a waltz for me in music therapy…That was a good rhythm for me; it gave me this feeling of space.” It was time for closure. Ramona summed up her experience of music therapy and shared that she had been thinking about her depression lately. Some doctors would call it a disease, but she felt it was a struggle, a struggle for survival. If she only could manage to maintain the space she had created for herself, in her inner dialogues as well as in her everyday life, then she felt she could have a chance in this struggle. Music was a part of this now, she said. She had started to enjoy daring combinations in music and she related this to her life situation, which she described as a struggle requiring courage. “Music therapy has been a workshop for me…, no, more than that, it has been a holy space where I could do things I never thought I would be able to do.” When ending the therapeutic relationship we agreed upon meeting a few more times, for interviews where she could look back at the therapy process. I met her some months later, and we talked for an hour, but not in the format of a research interview. At this point, she was so overwhelmed by the complexity of her life situation that I suggested that we just talked about whatever was important for her to talk about. She told me that one of her kids was in serious trouble with the law and that this was very upsetting for her. Also, going to school was stimulating but also quite stressful. She had top grades in mathematics and history, but was toiling with the Norwegian literature. Previously she had not felt that she had the permission to read novels, so this was new territory again. The total life situation was quite overwhelming, she told me. As an addition to and possibly also a symptom of all this, she had just crashed her car in an accident that could have been very dangerous. “And now I’m going to marry again in a few months,” she then added, in a tone that reflected both despair and hope. I interviewed her again 17 months later, almost two years after the closure of the therapy process. Things were now much calmer in her life. She had moved to a different part of the country and felt that her new environment was much better for her. She enjoyed being married to a more respectful man, her children were doing reasonably well, and she herself was doing fine in high school and was even considering going to college. Within this context, she felt she was ready to look back and think about how she had experienced and used music therapy. I think I can say that I experienced the music-therapy-corner that we had together as kind of the “interspace” that I needed in order to find courage to open up, from the heart of my inner life.3 The expressions, the moods…to create a space for myself, to hear my voice, to hear all the sounds whether from the instruments or from my voice, or…to feel the movements of my body, and then--to find the courage to join a choir…and to hear my own voice together with the others. To have that experience; “This is fun.” So that was something; from just being afraid and wanting to hide [and then] to

be able to experience that there are good things with being with others; and to sing--to express myself in the presence of others. She continued by talking about how she gradually had understood that she had the freedom to participate in various public situations: “…today my platform is much more solid. That is, I have a much better understanding of my rights,” she said and continued by elaborating some of the metaphors she had used in describing music therapy. Do you know where I would have placed music therapy today? …Eh, you know…that place where the women put on their make-up, a place of preparation before one goes out. Or, to be with the hairdresser; that is, it’s like a private corner where you…make yourself ready and aware of who you are…and that you shall express yourself in a way or another. We elaborated upon this image of music therapy as a dressing room, which she explained as a place in between a private and public space: Not the therapy process in itself…but the products become public. It’s a place where things are created, and what comes out of it is yourself as a new product, and this becomes public…But my music therapy in itself was to meet you as a therapist…and I think that you affected my music therapy…Well, maybe I should not say that you have been dominating in my inner world, but I think you have been an invisible factor there. I don’t think that my music therapy would have been the same irrespective of what person was there…For me you represented safety, which helped me to cross my borders…I could come to the music therapy room with anxiety and fear, but – I could tell it to you, I could be open… In real life I have in fact no experience with using make-up, so it’s kind of funny that this is…what I find it natural to compare music therapy with, but, you know…maybe that’s the next step, that I start to use make-up? [chuckles] I can see myself in front of the mirror becoming conscious about who I am, and that I have several alternatives to choose among. And I can try them out. I guess that’s what I feel…and, there is another human being there, who helps me try things out…That’s why I also came up with the image of a hairdresser…There is another person there, with me, and I can say: “I’d like to try it a little bit shorter today.” “Should we put some color in it today?” You see? We are two persons in front of the mirror all the time…That mirror is important. I thanked her for the collaboration and expressed that I did appreciate that she could use music therapy and the relationship to me in this way. Summary Ramona experienced music therapy as an “interspace,” allowing for movements inward (contact with her emotions and her body) and outwards (participation in activities and relationships). The metaphor of music therapy as a “dressing room” captured much of this. The

subsequent elaboration of the metaphor highlighted the interplay between private, interpersonal, and public aspects of the music therapy process. In spite of the conventional format of individual music therapy, Ramona strongly focused upon public aspects of the music therapy process. This did not make her downplay the private and interpersonal aspects. She worked with her own capacities for emotion and expression and at the same time she was concerned about how she presented herself to others. She did this not only through use of the activities and relationships offered in the music therapy sessions but through creative use of the possibilities and challenges of her everyday life. The dressing room that she was using had mirrors but also doors and windows. This relates to the idea of health as participation and mutual care, described in the beginning of the chapter. The connotations that the phrase dressing room may give to the backstage of a theatre were not commented upon by Ramona but are of relevance for our understanding of the metaphor, if we take Goffman’s (1959/1990) dramaturgical approach to the understanding of everyday life into consideration. Music therapy sessions seem to have the potential of representing an intermediary arena, bridging private explorations of self (“backstage performances”) with more public presentations of self (“front stage performances”). In musicmaking, we may integrate the biologically given capacity for non-verbal communication that we all share with our own personal narratives as well as the available sociocultural resources for participation in a given context (Stige, 2002). Music, therefore, is a powerful medium for a client-directed yet relational and contextual approach to therapy. Music therapy, according to this way of thinking, is a collaborative and interactive search for health-promoting connections. References Anderson, H. & Goolishian, H. (1992). The client is the expert: A not-knowing approach to therapy. In S. McNamee and K. Gergen (Eds.), Therapy as Social Construction. London, United Kingdom: Sage Publications. Austin, D. (1999). Vocal improvisation in analytically oriented music therapy with adults. In T. Wigram & J. De Backer (Eds.), Clinical Applications of Music Therapy in Psychiatry. London: Jessica Kingsley Publishers. Duncan, B. L., Miller, S. D. & Sparks, J. A. (2004). The Heroic Client. A Revolutionary Way to Improve Effectiveness through Client-Directed Outcome-Informed Therapy. San Francisco, CA: Jossey-Bass. Goffman, E. (1959/1990). The Presentation of Self in Everyday Life. London: Penguin Books Ltd. May, R. (1969/1977). Kjærlighet og vilje [Original title: Love and Will (Translated to Norwegian by Daisy Schjelderup and Hilde Andresen)]. Oslo: Dreyers Forlag. McLeod, J. (1997). Narrative and Psychotherapy. London: Sage Publications. Moe, T. (1998). Musikterapiforløb med en skizotypisk patient udfra en modifikation af metoden [A Schizotypical patient’s music therapy process through use of a modified version of Guided Imagery and Music]. Nordic Journal of Music Therapy, 7(1), 14–23. Nordoff, P. & Robbins, C. (1977). Creative Music Therapy. New York: John Day. Priestley, M. (1994). Essays on Analytical Music Therapy. Phoenixville, PA: Barcelona Publishers. Rogers, C. (1951/1999). Client-Centered Therapy. London: Constable.

Rolvsjord, R. (2007). “Blackbirds Singing:” Explorations of Resource-Oriented Music Therapy in Mental Health Care. (Unpublished doctoral thesis). Aalborg Universitet. Rolvsjord, R. (2010). Resource-Oriented Music Therapy in Mental Health Care. Gilsum, NH: Barcelona Publishers. Stige, B. (1998). Qualitative research interviews as a part of the music therapy process. Musiikkiterapia 2. (Finnish Journal of Music Therapy). Stige, B. (2001). The fostering of not-knowing barefoot supervisors. In M. Forinash (Ed.), Music Therapy Supervision. Gilsum, NH: Barcelona Publishers. Stige, B. (2002). Culture-Centered Music Therapy. Gilsum, NH: Barcelona Publishers. Stige, B. (2003). Elaborations toward a notion of Community Music Therapy. (Doctoral thesis). University of Oslo. Stige, B. (2008). Implications of various perspectives on evidence for music therapy assessment, treatment, and outcomes. Invited paper for the Mid-Atlantic Region Chapter of the American Music Therapy Association, Cherry Hills, New Jersey. Stige, B. (in press). Health musicing – A perspective on music and health as action and performance. In R. MacDonald, G. Kreutz and L. Mitchell (Eds.), Music, Health and Wellbeing. New York: Oxford University Press. Summer, L. (1988). Guided Imagery and Music in the Institutional Setting. St. Louis, MO: MagnaMusic Baton. Ulvestad, A.K., Henriksen, A.K., Tuseth, A.G., & Fjeldstad, T. (2007). Klienten – den glemte terapeut. Brukerstyring i psykisk helsearbeid [The Client – The Forgotten Therapist. Userdirected Mental Health Work]. Oslo, Norway: Gyldendal akademisk. Vetlesen, A. J. (2004). Det frie mennesket? Et sosialfilosofisk blikk på patologiene i opsjonssamfunnet. [Are humans free? A view from social philosophy on the pathologies of the option society]. In H. Nafstad (Ed.), Det omsorgsfulle mennesket. Et psykologisk alternativ [The Caring Human. A Psychological Alternative]. Oslo, Norway: Gyldendal Akademisk. White, M. & Epston, E. (1990). Narrative Means to Therapeutic Ends. New York: W.W. Norton. ___________________________________ 1 I have discussed aspects of Ramona’s story in order to illuminate the relevance of culturecentered perspectives for music psychotherapy (Stige, 2002 pp. 155–177). I have also discussed her story in a chapter of my dissertation on community music therapy (Stige, 2003 pp. 285– 343.) 2 For discussion of relationships between qualitative research and therapy process, see Stige (1998). For explication of the specific research methods used in this case, see Stige (2003 pp. 289–306). 3 In translating her statement I use the neologism “interspace” even though Ramona used an established Norwegian compound. The word she uses – “mellomrom” – literally means “interspace” but usually refers to a crevice or interval and not to a “space in between” which could be used, but this seems to be how Ramona uses the word here.

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

CASE ELEVEN Music Therapy and Depression: Uncovering Resources in Music and Imagery Lisa Summer Introduction This case study illustrates how I adapted the Bonny Method of Guided Imagery and Music (Bonny, 1978, 1980) to address my client Kyle’s depressive symptoms. Initially, GIM with its emphasis upon inner exploration and reconstruction exacerbated his symptoms. But through trial and error, I learned to rework the basic components of GIM. This reworking, over time, led to the discovery of the supportive and re-educative levels of practice in music and imagery. Each level of practice--supportive, re-educative and reconstructive--is concerned with transcending the emotional limitations that brought the client into therapy, yet each uses a different approach to this end. Supportive music and imagery uses positive inductions with simple, repetitive music with little harmonic tension. The re-educative approach uses symptomoriented inductions with repetitive music that matches the symptom with harmonic tension, but contains little structural development. In both levels of practice, the client is given a directed task during the music to hold him in a singular image. After the music, verbal processing techniques encourage the client’s in-depth relation to the image. Kyle’s sessions illustrate how the supportive approach circumvented his symptoms in order to connect him with positive resources lying dormant in his internal world. Subsequently, re-educative music and imagery brought Kyle new perspectives that enabled him to transcend his heavily ingrained and emotionally limiting symptoms. Foundational Concepts In the early 1970’s at the Maryland Psychiatric Research Center and the Institute for Consciousness and Music, Helen Bonny created specific procedures for an in-depth, humanistic music listening session and called it Guided Imagery and Music (GIM, also called the Bonny Method of GIM) (Bonny & Pahnke, 1972/2002; Bonny, 1995/2002). Bonny’s goal was a broadbased, free exploration of the unconscious. To achieve this, GIM utilized an altered state of consciousness and an exploratory, open-ended induction, paired with a 30-minute program of evocative classical music (Bonny, 1980/2002). Bonny created a series of 18 music programs, each with a different therapeutic contour (Bonny, 1978/2002). The musical selections used in the Bonny programs can be classified into three different categories (Summer, 2009). Supportive classical pieces, such as the Warlock Pieds en l’air from

his Capriol Suite, have a simplistic use of all musical elements, a simple structure and little tension. Within a GIM session these serve a restful, or re-fueling, function for the client. Reeducative classical pieces contain significant tension yet have a simple, straightforward and repetitive structure (often an ABA structure). These are evocative, “working” pieces, such as the Barber Adagio for Strings, whose function in the session is to match and hold a client’s tension. Reconstructive classical pieces are those “working” pieces that are characterized by significant development sections in which the musical material is extended significantly beyond its original exposition, and beyond a simply stated ABA format. These stimulative pieces function to “work through” and transform the client’s symptom. Each GIM program links these three types of music together into a unique intensity contour that consists of supportive, re-educative and reconstructive pieces. The GIM client experiences the music program in a completely individual and subjective way, but usually follows the contour of the program, refueling with positive resources during the supportive selections, exploring conflictual areas during the re-educative selections, and ultimately traveling to unknown territory with the reconstructive selections. Since GIM was primarily designed for use with well adults, the case study of Kyle illustrates how I made changes in my practice of GIM when I first encountered clients in a realworld practice. In essence, when working with a depressed client, I found the need to slow down and separate the GIM process into its three constituent parts: refueling, working, and transforming. Many sessions, especially at the beginning of a therapeutic process, consisted of only one of these aspects. My approach and terminology came to be basically aligned with Wheeler’s levels of music therapy practice (1983): supportive, re-educative, and reconstructive (taken from Wolberg, 1977), which actually represent a flexible continuum of clinical practice in music and imagery. All levels of this continuum have the same ultimate goal as derived from Bonny’s (2002) foundational goals for GIM: transcendence--transcendence of the external reality in which we are all immersed, with its practical limitations, in favor of the internal world which has no limitations but that of the individual’s imagination. The central assumption of the use of music and imagery is that the freedom we possess in our imagination transcends the limitations imposed upon us by external forces (parents, society, the expectations of peers and the like). The supportive level addresses the development of positive internal resources, the re-educative level directly addresses the client’s specific symptoms and the reconstructive level goes to the root of the resources and symptoms within the unconscious (Summer, 2002). The Setting The setting for this case study was within a private practice in the U.S. Virgin Islands. The practice consisted of a family physician, two verbal psychotherapists and me. Most of our clients were diagnosed with drug addiction, anxiety or mood disorders; about a third of the clients were on medication (they saw a psychiatrist to monitor their medication), and the majority were in recovery from alcohol or drug addiction. The verbal therapists took a psychodynamic approach and referred clients to me when they were “stuck” — having gained cognitive insights or symptom relief, yet without enough life change. When clients were referred to me for music and imagery, I consulted frequently with their verbal therapist, sometimes having co-therapy to integrate the music and verbal therapy. Kyle, one of my first

clients, illustrates the development of the music and imagery continuum of practice as it unfolded in my music psychotherapy practice. The Client Kyle, a physician, came to our first session in an expensive and stylish suit and tie, a starched white and monogrammed shirt. Referred to me by his primary therapist as depressed and obsessive-compulsive, he seemed so articulate, healthy, aware of himself and in control, so that even when he talked about being depressed and obsessive, I wondered whether he was simply confabulating. Despite that, he was working obsessively--at least ten hours a day, six days per week--and he could not rid himself of the feeling that his work was inadequate. Married, with two children, the 50-year-old professional was on medication for obsessivecompulsive disorder and major depression. He had been in verbal therapy for about two years. Verbal therapy and medication had improved many of his depressive symptoms, but his primary therapist had reached an impasse in her work with him to lessen his hours at work, to slow down his pace while he was at work and to deal with his feelings of inadequacy. Kyle spoke with celerity and perspicacity, changing topics faster than the island’s chameleons changed color. In an early session, I played for Kyle a Bonny program containing chatoyant impressionistic music with a great deal of musical tension, my goal being to match his demeanor. In a GIM session, when you can match a client’s in-the-moment state with music, they feel “understood” and “heard” on an emotional level. Having matched his state, the music stimulated an experience, as Kyle told me once the music concluded, exactly analogous to how he viewed his life. As Kyle listened, he reported fleeting and disturbing images: I see swirls, they are coming at me very quickly...now there are sketches, like black and white drawings of birds...it is very dark...Everything is coming and going so fast, I can hardly recognize anything; I am trying to slow things down, but they won’t listen to me...I am in a tomb--a grave, it is so dark and empty, I think I am in the tomb; I am trying to get out but I can’t. I tried several different pieces of music to see if the change in music would elicit a change in the nature or pace of his experience. No change in the music resulted in significant changes in his imagery. These unvarying images, Kyle told me, were akin to “symptoms” that afflicted him in his everyday life, a life he described as unconnected and distant. Nothing, he insisted, had real meaning to him, and he felt powerless to make any changes, as if he were simply an ineffectual observer of a life consisting of a series of mostly unpleasant events. Work, relationships, and events were all remote from him emotionally; and the prosperity, success and intellectual achievements that he had obtained were without meaning. Kyle worked obsessively to feel accomplished, bringing him fleeting positive thoughts, but kept himself emotionally distant from the fruits of his labor. Intellectually, he justified his disengagement as a necessity, paradoxically denying himself the joy of the rewards he worked so hard to accomplish. The momentary positive feelings generated by his accomplishments were destroyed by what was underneath, in the unconscious: an internalized (introjected) version of his mother (a depressed, needy perfectionist who was emotionally abusive to Kyle

and whose behavior was highly inconsistent in his childhood) and his father (who was highly critical, emotionally abusive, and paid little attention to Kyle). The internalized figures of his parents continued the abuse and criticism of his childhood and thus denied him any lasting feelings of self-worth. Instead, as revealed in his imagery, his inner world consisted of shells of defensiveness, nested in further shells of defensiveness. Feelings of sadness, helplessness, powerlessness, anger, despair, vulnerability--all the responses he had had as a child to his parent’s emotional abuse--were, by this time, chronically patterned in his unconscious. His imagery also uncovered the dark roots beneath his depressive defenses: a deep existential fear of death. When younger, he had periods of intense nightmares and night terrors that his parents had not addressed in any way. Using GIM had yielded, for Kyle, imagery that was fragmentary, fleeting and out of control, but I believed that this session would be helpful to him; that it would help him face his difficulties and bring him a new understanding of himself. Experiencing how out of control his life was, I thought, should bring him motivation to change--to work less, slow down, to become more engaged and thereby live life more fully. But when Kyle returned for his next session, it was clear that his condition had seriously worsened due to the GIM session. He reported to me that in the previous session he had realized how out of control his life was and that during the previous week, he had felt an increased sense of hopelessness about himself. Instead of relief and reinvigoration, he was despondent. He had become acutely aware of his wife and children’s complaints about his emotional distance from them, and yet he could not respond. He was pale, could not look me in the eye, seemed totally miserable, and his manner of speaking was more fragmented than in his previous session. Though most people have had some injurious parenting in their childhood, there are nearly always aspects of positive nurturance as well. When imagery is conflictual, one can expect some evidence of ego strength (positive resources, positive adaptations to tension and abuse), and even when such is not evident in a client’s imagery, there is likely to be evidence in the client’s positive response to the images. Kyle had no positive feelings whatsoever. If there was any ego strength, it was completely obscured by his unremitting depression. Though I did not expect to be able to remedy every client’s symptoms, it seemed here that I had actually made the situation worse. I wanted to rescue Kyle from himself, to give him some relief from his horrible and fragmented world, but I was at a loss as to how to proceed. The Therapeutic Process Supportive Music and Imagery It was clear to me that GIM would not help Kyle address and improve his symptoms. I had not yet worked with a client whose positive internal resources were so unavailable to him-even with the help of psychiatric medication. There had to be a positive experience upon which to rebuild his ego: a positive, innocent Kyle that existed prior to his abuse. But I did not know how far back in the past this true positive self remained, nor how deeply buried it was within his unconscious. As a beginning therapist, I was determined to help him find this positive kernel, but I did not have the technique or skills to locate it. I needed an approach to music and imagery that

was lighter, more structured and more directive than GIM. For several sessions I explored different approaches: relaxation techniques, music without imagery, imagery without music, though I was anxious myself about whether I was doing any good. At least, I thought, let me do no more harm. A breakthrough came in the eighth session. I asked Kyle to tell me if he had had even one positive, quiet moment by himself within the last few years. He had not, but he had had a vacation with his wife, and they had risen at dawn to see a sunrise, a thought which Kyle found pleasant. Nervous as I was to introduce drawing to a man dressed in an Armani suit, I suggested (in an induction prior to the first movement of the Dvorak String Serenade, Opus 22) that Kyle recall the memory of watching the sunrise, and that he draw the experience on the page in front of him. As the music started, I could see he was self-conscious about the idea of drawing a picture. After about a minute of hectic illustrating, Kyle relaxed. With the pace of his drawing slowed down, his arms began moving every once in a while with the rhythm of the music. Listening deeply, he allowed the beauty of the music to shape what he was drawing. I played the piece over and over again. Rolling up his starched, monogrammed white shirt Kyle proceeded to get it filthy with all the colors of the chalk he used — without any concern to his previously immaculate garb. He used pastel colors, putting them on the page and then using his hands to blend them together. When he had covered the entire page, and it seemed that he was finished, I stopped the music. After all the layering of pastels, his drawing appeared to be softly green, blue and purple inside the circle: with soft yellows and reds, respectively on the left and right side of the page outside the circle.

He was transformed, totally at ease and comfortable, the music and the drawing having created some kind of idyllic, positive experience. I did not really know how to verbally process what had just occurred, but, speaking slowly, I asked him to describe his experience. Kyle expressed that he had felt “focused,” “involved” and “creative” while he was drawing. He had tried, he confessed, to draw the sunrise in a literal way, but let go of that goal in favor of just expressing the feelings of the sunrise. He expressed gratitude that there were “no

interruptions,” unlike the interruptions that flooded his daily life (by which he meant his obsessive, depressive, fleeting thoughts). He was truly able to relax and enjoy the music. For the first time, Kyle had made contact with positive feelings in a session. He did so by initially recalling the memory of a sunrise as a visual image. Then, the music helped to focus him on the memory, and the simplicity and aesthetic beauty of the Dvorak Serenade held him in the image and called forth, into the present, the true and positive feelings contained within that image. The repetition of the movement (which I played four times) allowed the positive feelings that had emerged to gain strength. Kyle’s state of consciousness had totally transformed from the beginning of the session, when he entered feeling “pressured, left over from work,” to “content.” This change held throughout our discussion and continued until the end of the session. He titled his drawing “Contentment.”Kyle was pleased with the results of this session and came back to the next session with a positive attitude about the therapy. I continued to use the same format in all of Kyle’s supportive sessions: a positive induction tied to the task of drawing, with classical music. These sessions resulted in the following drawings: “Trying to blend chaos and pleasantness,” “Father and son dolphins, frolicking,” and “In touch.” Within two months of our work together, Kyle found that he was capable of establishing contact with positive resources (positive feelings) within himself. He described himself changing in his everyday life, finding focus, presence, openness, acceptance, hope, availability, relaxation, and contentment. In addition, he reported that he experienced--for the first time in his life that he ever remembered--really feeling what he knew were normal feelings of compassion for another person. This occurred at work when a client told him about her impending divorce, and for the first time, rather than offering the professional, artificial compassion that he employed only as a tool in his trade, he felt able to emotionally empathize with a patient. The supportive music and imagery sessions in which Kyle was in touch with positive feelings had crossed over into the real world and had already begun to take hold. He was developing a constant positive internal object, the beginnings of a healthy ego, previously absent due to his parents’ abusive and inconsistent nurturance. The repetition of internal visits to his positive core with classical music had taught his psyche about positive feelings, and was beginning to take root outside the session, even with people outside his immediate family. For the first time, he reported, he had been able to make a truly human connection with a patient, an amazing confession--coming as it did--from a physician. Over a period of approximately two months, the supportive music and imagery sessions allowed Kyle to discover a state of consciousness that was unattached to his usual psychological patterns. During the music, he was able to free himself from the omnipresent levels of defenses that otherwise plagued his every waking hour: the negative parental introjects, his depressive feelings and his existential fear of death. Kyle’s weekly “immersion” in a positive, healthy state with music began to free his psyche from psychologically debilitating defenses. Though these symptoms would always return, little by little Kyle generalized parts of this healthy state of consciousness into his daily life. The Process Deepens: Re-educative Music and Imagery

Although supportive music and imagery was changing the quality of Kyle’s daily life, it had not adequately or directly addressed his general anxiety or work-related problems. That required a deepening of his inner experiences that I have called re-educative music and imagery. In order to directly address Kyle’s symptoms, I kept the basic structure of using drawing with a piece of classical music. Yet I began to directly introduce his symptoms as an entrance point, an induction into the music, and I utilized evocative music that could match the tension of his identified symptom. Kyle’s therapy sessions were scheduled after work, and he arrived at sessions with a long list of complaints from the day. In one re-educative music and imagery session, Kyle initiated the session with his usual complaints about his day’s work. Although it was evident that he wanted to unburden himself with each successive complaint he stated, I asked him to close his eyes and rather than think about the frustration or talk about it, to allow himself to feel it. He described: “It’s a trapped feeling, a pressure, a tension in my chest. It wants to get out but I feel it’s trapped there.” As he described these internal sensations, I could better choose a piece of music to match his experience. I felt that the Passacaglia and Fugue in C by Bach, orchestrated by Stokowski, would match Kyle’s tension. With the suggestion that he let the music help him express his internal experience in drawing, Kyle began to draw a road on his page. With the music, he depicted a winding road, colored in black and dark blue with patches of mustard yellow. It wound around the page with several large curves in it. After the road was complete, he added, at different points outside the path, seven round figures. Each figure had a strong center and several small, bright fluorescent pink arms extended, touching the outside of the path. After the music had ended, we began to discuss the drawing, which he titled “No Exit.” Kyle described the feeling he had as one akin to being trapped on the road. “It meanders, it goes no place; it has nothing to offer.” As he described the drawing, the feelings became stronger. We went back and forth, referring to his feeling, referring to the image. He identified the feeling as frustration. Furthermore, he explained that the seven figures were people in his office who were ready to help him. However, he felt these figures--not as potential helpers, but rather--as a burden. They only served to cement his frustration with feelings of inadequacy. I continued to work with the image and his feelings until I saw that he had more fully accepted the two feelings: frustration and inadequacy. After this, Kyle’s perspective about the seven figures shifted. His expressions of inadequacy were replaced with a new feeling of desire to ask a secretary in his office for help. This is the hallmark of re-educative music and imagery. The therapist brings matching pieces of music to bear on a problem. But rather than becoming stuck in the problem as a client is wont to do, the client is “re-educated,” by which I mean that he/she gains a new perspective. In reeducative music and imagery, the image does not change; the client changes his relation to the image. Kyle’s perspective on the “no exit” drawing changed from frustration to inadequacy to acceptance and, finally, he arrived at a desire to ask for help.

In Kyle’s session, the strong, constant repetition in the music--Bach’s Passacaglia and Fugue--paired with the focus (induction) had held him in the internal feeling of frustration. The drawing had allowed him a full, yet contained, expression of feeling trapped, frustrated and inadequate, in an aesthetic image. The verbal processing of the “no exit” image further held Kyle in a here-and-now experience of the symptoms he had been experiencing on a daily basis at work. Each of these components contributed to Kyle’s “re-education.” The first step of Kyle’s re-education occurred when he was able to separate and identify the specific symptoms, frustration and inadequacy, that were keeping him trapped in his depression and unable to ask for help. The second re-educative step occurred when he was willing to accept, on a new level, the reality of his feelings. On the surface, it may appear odd to suggest that it was a positive result for Kyle to deepen the feeling and acceptance of being trapped since the goal of our therapy was to alleviate his symptoms. But this is a prerequisite to the amelioration of symptoms and a prerequisite to new insights and perspectives. Re-educative music and imagery sessions usually end with the verbal processing of the client’s new perspective, and I could have ended Kyle’s session after the first or second reeducative step had been achieved. But I sensed Kyle’s readiness to solidify his new perspective with another music experience. Therefore, I asked Kyle not to think about what just happened, but to embrace this new perspective in a second drawing as he listened deeply to another piece of music. I chose the second movement from Beethoven’s Piano Concerto #5, a supportive piece. He drew three concentric circles growing progressively larger from the center. Beginning in the center, the circles were bright yellow, light blue and fluorescent pink. Three green curving lines flowed through the center, and one green line circled around the center. Kyle reflected: I just need to do it. I have an opportunity to do it. It’s safe to do it here. I need to make the effort [at work] — it may not work out, but I think I have it within me now. I can take some time out and then ask someone to help me. He called the drawing “Opportunity,” and our discussion centered upon his feeling that there was a way out for him.

This additional supportive music and imagery experience helped him to more firmly access the feeling of opportunity, and with it, the possibility of asking for the additional help he needed at work. In effective re-educative music and imagery, the therapist’s aim is to stimulate within the client a new perspective that can be made usable in daily life. In fact, after his music and imagery sessions, Kyle often utilized his imagery to help him confront issues in his life.

Conclusion Kyle’s internal and external world was filled with symptoms that were unmanageable and rigidly fixed. His distance from everyone had caused his relationships to be devoid of feeling, his character to be devoid of depth, and his life to be devoid of meaning. Since his inner life was so fragmented any time he had closed his eyes in therapy, he was inundated with negative images of death and hopelessness. Immersing Kyle in his symptoms, while playing music, had availed him nothing. In fact, it had exacerbated his distress. Neither had positive inductions with light repetitive music offered respite from the horror because he did not have the ego strength to utilize the positive imagery he generated, until I had added the external task of drawing to enable him to successfully hold the positive experience and assimilate it. Using positive inductions paired with simple, repetitive music, Kyle was able to develop compassionate responses within the therapy sessions that were then made useable in his real life-- both with his patients and family. Re-educative music and imagery using simple inductions focused upon his symptoms, paired with music that contained harmonic tension and little development, helped Kyle accept and gain new perspectives in his daily life. The re-educative sessions significantly improved Kyle’s life by reducing his symptoms and giving him an increased healthy repertoire of responses to life events. Kyle’s therapy progressed in a flexible way, moving between supportive and reeducative approaches for three years. Through supportive and re-educative music and imagery, instead of simply ameliorating his depressive symptoms through medication, Kyle transcended

the ingrained negative patterns that had limited his everyday life and supplanted these with his previously buried positive internal responses to life. References Bonny, H.L. (2002). Music and Consciousness: The Evolution of Guided Imagery and Music (L. Summer, Ed.). Gilsum, NH: Barcelona Publishers. Bonny, H.L. (1978/2002). The role of taped music programs in the guided imagery and music process. In L. Summer (Ed.), Music and Consciousness: The Evolution of Guided Imagery and Music (pp. 299–324). Gilsum, NH: Barcelona Publishers. Bonny, H.L. (1980/2002). The early development of guided imagery and music (GIM). In L. Summer (Ed.), Music and Consciousness: The Evolution of Guided Imagery and Music (pp. 54–68). Gilsum, NH: Barcelona Publishers. Bonny, H.L. (1995/2002). Guided imagery and music: The discovery of the method. In L. Summer (Ed.), Music and Consciousness: The Evolution of Guided Imagery and Music (pp. 43–52). Gilsum, NH: Barcelona Publishers. Bonny, H.L. & Pahnke, W. (1972/2002). The use of music in psychedelic (LSD) psychotherapy. In L. Summer (Ed.), Music and Consciousness: The Evolution of Guided Imagery and Music (pp. 20–41). Gilsum, NH: Barcelona Publishers. Summer, L. (1988). Guided Imagery and Music in the Institutional Setting. St. Louis, MO: MMB Music, Inc. Summer, L. (2002). Group music and imagery therapy: An emergent music therapy. In K. Bruscia & D. Grocke (Eds.), Guided Imagery and Music: The Bonny Method and Beyond (pp. 297– 306). Gilsum, NH: Barcelona Publishers. Summer, L. (2009). Client perspectives on the music in guided imagery and music (GIM). (Doctoral dissertation). Aalborg University, Denmark. Summer, L. & Chong, H. J. (2006). Music and imagery techniques with an emphasis on the Bonny method of guided imagery and music. In H.J. Chong (Ed.), Music Therapy: Techniques, Methods, and Models. (Korean language). Seoul, Korea: Hakjisa Publishing Company. Wheeler, B. (1983). A psychotherapeutic classification of music therapy practices: A continuum of procedures. Music Therapy Perspectives, 1(2), 8–12. Wolberg, L. R. (1977). The Technique of Psychotherapy (Third Edition, Part 1). New York: Grune & Stratton. Part of this case study was published in the Korean language in Summer, L. & Chong, H. (2006). Music and imagery techniques with an emphasis on the Bonny method of guided imagery and music. In H. Chong (Ed.), Music Therapy: Techniques, Methods and Models. Seoul, Korea: Hakjisa Publishing. With permission.

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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)