Case Examples of Music Therapy for Musicians [1 ed.] 9781937440312

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

Case Examples of Music Therapy for Musicians 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: 978-1-937440-31-2 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 The Meta-Musical Experiences of a Professional String Quartet in Music-Centered Psychotherapy Heidi Ahonen Colin Andrew Lee CASE TWO The Use of Elemental Music Alignment in the Journey from Singer to Healer/Therapist Frank Bosco CASE THREE Rehabilitation of Piano Performance Skills Following a Left Cerebral Vascular Accident Denise Erdonmez CASE FOUR The Case of Paula: Music Psychotherapy with a Musician Joanne Loewy Stephan Quentzel CASE FIVE Protect This Child: Psychodynamic Music Therapy with a Gifted Musician Louise Montello CASE SIX Music and the Listeners Mary Priestley CASE SEVEN Jacob: Reviving Prayer through Song Chava Sekeles

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 musicians with occupationally related problems. It has been compiled not only to provide practical information to students and professionals in music therapy and related fields, but also to inform musicians about the potential benefits of music therapy. About Musicians In addition to being susceptible to the usual health threats, musicians are often challenged by medical and psychological problems that are unique to their profession. (For a comprehensive overview of these problems, see Habboushe & Dileo [1991]). For example, singing or playing an instrument can lead to overuse or abuse of certain parts of the body, which may necessitate surgery, medication, or various forms of physical rehabilitation. Performing in public, or making a recording can cause serious and debilitating bouts of anxiety, which necessitate psychotherapeutic intervention. Making music with other musicians over an extended period of time, as in chamber music ensembles, orchestras, and solo-accompanist pairs involves an intimacy and closeness that can be easily threatened by the personal and interpersonal issues that each musician brings to the relationship. This in turn can have very adverse effects on the musical cohesion and intimacy required to perform or record at the highest standards. And finally, musicians can have medical or psychological problems that are not a result of their musical activities but prevent them from continuing in them. For example, if a musician has a stroke or is physically injured in some way, his or her musical skills can be lost or seriously impaired. Or if a musician suffers a bout of depression, his or her motivation to make or listen to music may be lost. Inasmuch as the problems of musicians arise from and/or affect their music-making or music listening, it makes sense to use music in their amelioration. In fact, music therapy has been found to be very well-suited to help musicians who have music-related problems. The case examples in this book provide myriad perspectives not only in how the medical, psychological, and interpersonal problems are manifested differently by each musician, both within and outside of a musical context, but also how these problems can be addressed through carefully designed music experiences. About Music Therapy (Based on Bruscia, 1993) Definition and Applications

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

In those therapy sessions that involve re-creating music, the client sings or plays precomposed music. This may include learning how to produce sounds, imitating musical phrases, learning how to sing, learning to read notation, participating in group sing-along’s, performing a song or piece, participating in a musical show or drama, and so forth. Re-creative experiences are most appropriate for clients who need to develop sensorimotor skills, learn adaptive behaviors, maintain reality orientation, master different role behaviors, identify with the feelings and ideas of others, work with others cooperatively, or merely share in the joy of making music—as these are the main aspects of singing or playing pre-composed music that have therapeutic implications. In those therapy sessions that involve improvising, the client makes up his or her own music extemporaneously, singing or playing whatever arises in the moment. The client may improvise freely and spontaneously or according to the musical or verbal guidance of the therapist. Sometimes the client is asked to improvise sound portraits of feelings, events, persons, or situations that are being explored in therapy. The client may improvise with the therapist, with other clients in a group, or alone, depending on the therapeutic objective. Improvising music is most appropriate for clients who need to develop spontaneity, creativity, freedom of expression, self-awareness, communication, and interpersonal skills—as these are the basic components of improvising. In those sessions that involve composing, the therapist helps the client to write songs, lyrics, or instrumental pieces, or to create any kind of musical product, such as music videos or audiotape programs. Usually the therapist simplifies the process by engaging the client in aspects of the task within their capability (e.g., generating a melody, or writing the lyrics of a song) and by taking responsibility for more technical aspects (e.g., harmonization, notation). Activities involving composing music are used with clients who need to learn how to make decisions and commitments, or find ways of working in an organized way toward a goal. Most often, clients create compositions (especially songs) around significant events, people, or relationships in their lives, or to express thoughts and feelings that they are exploring in therapy. In addition to strictly music experiences, music therapists often engage clients in verbal discussions. Clients may be encouraged to talk about the music, their reactions to it, or any thoughts, images, or feelings that were evoked during the experience. Clients may also be encouraged to express themselves through the other arts, such as drawing, painting, dance, drama, or poetry. Music therapy sessions for children often include various games or play activities which involve music. The case examples that follow highlight the goals of music therapy for musicians, 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 a musician, 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 the unique problems of musicians are as interested in this question as scientists and researchers. Their interest is in whether musicians in their own lives can derive the same benefits of music therapy as the client in this case did. Scientists or researchers can also glean other very important information from case studies. Because clinical cases provide rich descriptions of the therapy process, they usually provide myriad ideas for what needs to be studied scientifically. By describing what seemed to work and or not work for a particular client, a clinical case reveals to the researcher which clinical protocols and therapeutic outcomes warrant further research, while also suggesting specific hypotheses that might be tested. Moreover, because events unfold naturally in a clinical case as they do in real life, and because variables cannot be controlled as in laboratory research, the clinical case gives very important information on what specific variables must be

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

A clinical perspective is concerned primarily with methodological questions that are most often posed by other clinicians. Clinicians want to know what does and does not work when working with a client in music therapy. Practically speaking then, they are most interested in the following kinds of questions: 1) Based on this case, what should I be looking for in clients? What client needs and resources do I have to address more in my own work? How can I assess these facets of the client in music therapy? 2) Based on this case, what kind of therapist-client relationship is best for this kind of client, and what is the best way of forming such a relationship? 3) What is the role of music in working with this clientele? What types of music experiences are most therapeutically relevant and effective? What styles of music are most appropriate? 4) Based on this case, what are the best ways of responding to the client when he or she is acting out, abreacting, resisting, or not progressing? 5) Based on this case, what clinical criteria should be used in evaluating the client’s therapeutic progress? Other Writings on Music Therapy for Musicians 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 musicians. Additional case examples have been written, which further elaborate how musicians can derive therapeutic benefits from music. Here is a list of other published case examples along with other writings on the topic. Appel, S. (1976). Modifying solo performance anxiety in adult patients. Journal of Music Therapy, 13(1), 2-16. Brodsky, W., & Sloboda, J. A. (1997). Clinical trial of a music generated vibrotactile therapeutic environment for musicians: Main effects and outcome differences between therapy subgroups. Journal of Music Therapy, 34(1), 2-32. Brotons, M. (1994). Effects of performing conditions on music performance anxiety and performance quality. Journal of Music Therapy, 31(1), 63-81. Coons, E., Montello, L., & Perez, J. (1995). Confidence and denial factors affect musicians' postperformance immune response. International Journal of Arts Medicine, 4(1), 4-14. Erdonmez, D. (1982). Case report of preservation of music performance skills in a right-handed man presenting with expressive dysphasia. The Australian Music Therapy Association Bulletin, 5(1), 3-11. Fischer-Williams, M. (1993). Selected musicians treated with EMG feedback. International Journal of Arts Medicine, 2(1), 1993. Fry, H. J. H. (1991). Treatment of medical problems of performing musicians: Overuse syndrome. In C. D. Maranto (Ed.), Applications of music in medicine (pp.223-229). Washington, D.C.: National Association for Music Therapy (NAMT), Inc.

Habboushe, F., & Maranto, C. D. (1991). Medical and psychological problems of musicians: An overview. In C. D. Maranto (Ed.), Applications of music in medicine (pp. 201-221). Washington, D.C.: NAMT, Inc. Kim, Y. (2008). The effect of improvisation-assisted desensitization, and music-assisted progressive muscle relaxation and imagery on reducing pianists' music performance anxiety. Journal of Music Therapy, 45(2), 165–191. Lee, C. A. (2003). Reflections on working with a string quartet in aesthetic music therapy. Voices: A World Forum for Music Therapy, 3(3) Madsen, C. K., Standley, J. M., & Gregory, D. (1991). The effect of a vibrotactile device, somatron(TM), on physiological and psychological responses: Musicians versus nonmusicians. Journal of Music Therapy, 28(1), 14-22. Maranto, C. D. (1992). Music therapy in the treatment of performance anxiety in musicians. In R. Spintge, & R. Droh (Eds.), MusicMedicine (pp. 273-283). St. Louis, MO: MMB Music. Massey, R. A. (1996). A psychophysiological profile related to overuse injuries in university musicians. In R. R. Pratt, & R. Spingte (Eds.), MusicMedicine (pp. 275-291). St. Louis, MO: MMB Music. Montello, Louise. (1990). Utilizing music therapy as a mode of treatment for the performance stress of professional musicians. Dissertation Abstracts International, 50(10-A), 31753176. Montello, Louise. (1995). Music therapy for musicians: Reducing stress and enhancing immunity. International Journal of Arts Medicine, 4(2), 14-20 Montello, Louise. (2010). The performance wellness seminar: An integrative music therapy approach to preventing performance-related disorders in college-age musicians. Music and Medicine, 2, 109-116. Niemann, B. K., Pratt, R. R., & Maughan, M. L. (1993). Biofeedback training, selected coping strategies, and music relaxation interventions to reduce debilitative musical performance anxiety. International Journal of Arts Medicine, 2(2), 7-15. Norris, R. (1993). The musician's survival manual: A guide to preventing and treating injuries in instrumentalists. St. Louis, MO: MMB Music, Inc. Orman, E. K. (2004). Effect of virtual reality graded exposure on anxiety levels of performing musicians: A case study. Journal of Music Therapy, 41(1), 70-78. Quentzel, Stephan & Loewy, Joanne. (2010). An integrative bio-psycho-musical assessment model for the treatment of musicians: Part I-A continuum of support. Music and Medicine, 2, 117-120. Quentzel, Stephan & Loewy, Joanne. (2010). An integrative bio-psycho-musical assessment model for the treatment of musicians: Part II-Intake and assessment. Music and Medicine, 2, 121-125. Reitman, A. D. (1999). Performing arts medicine: Music therapy to treat anxiety in musicians. In C. Dileo (Ed.), Music therapy and medicine: Theoretical and clinical applications (pp. 5368). Silver Spring, MD: The American Music Therapy Association, Inc. Rider, M. S. (1987). Music therapy: Therapy for debilitated musicians. Music Therapy Perspectives, 4, 40-43. Tomaino, Concetta M. (2010). Recovery of fluent speech through a musician's use of prelearned song repertoire: A case study. Music and Medicine, 2, 85-88.

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. Habboushe, F., & Maranto, C. D. (1991). Medical and psychological problems of musicians: An overview. In C. D. Maranto (Ed.), Applications of music in medicine (pp. 201-221). Washington, D.C.: NAMT, Inc.

Case Examples of Music Therapy for Musicians

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

CASE ONE The Meta-Musical Experiences of a Professional String Quartet in MusicCentered Psychotherapy Heidi Ahonen Colin Andrew Lee Introduction This chapter focuses on music-centered group psychotherapy with professional musicians, drawing together two models of music therapy: Group Analytic Music Therapy (GAMT) (Ahonen-Eerikäinen, 2007) and Aesthetic Music Therapy (AeMT) (Lee, 2003). We will describe a series of four sessions consisting of open improvisations alongside group analytic discussions. The practice of music-centered psychotherapy with musicians is a new field, focusing on the psychological and physiological stressors they encounter. Foundational Concepts Music Therapy with Musicians Performing as a professional musician can be an emotional and motivating experience. The truth, however, is that classical music is one of the five high-risk occupations among mental health threatening professions (Brodsky, 1996; Gabrielsson, 1999). Professional musicians rarely consider changing their career path even though their lives are often stressful and demanding. From early childhood through university and professional life, schedules are filled with never ending practice, competition in recitals, auditions, job opportunities, and various interpersonal conflicts or tensions among colleagues, conductor/managers, and others who have power over the individual musician. Because musicians often identify with their occupation (Spahn, et al., 2004), this makes them vulnerable emotionally: if their performance fails, they fail as human beings. Perfectionism is a common psychological problem. Irregular working schedules and frequent traveling can affect one’s relationships. It is no wonder that musicians experience both occupational and performance-related stress; they may suffer performance anxiety and also various physical injuries (e.g., hearing difficulties or lower back problems). Some develop severe health conditions such as burn-out, depression, anxiety, sleep disorders, substance abuse, and various somatic problems such as stomachache, headache and even heart disorders (Fishbein, et al., 1988; Brodsky, 1996; Gabrielsson, 1999; Panasuraman &

Purohit, 2000; Steptoe, 1989; Steptoe & Fidler, 1987; Jokimaki & Kivinen, 1994; Chesky & Hipple, 1997; Butler, 1995; Giga, et. al., 2002; Harper, 2002; Dews & Williams, 1989; Brandfonbrener, 1997; Hagglund, 1996; Fetter, 1993; Hamilton, et al., 1995; Lehmann, et al., 2007). In light of the above, it seems that musicians can benefit from music therapy (Montello, 2002) equally to any other client group. Aesthetic Music Therapy (AeMT) Aesthetic Music Therapy (AeMT) (Lee, 2003) came from a need to define my developing clinical work. AeMT considers music therapy from a musicological and compositional perspective. Looking to theories of music to inform theories of therapy, AeMT can be defined as a primarily improvisational approach that views musical dialogue as its core. Interpretation of this process comes from an understanding of musical structure and how this structure is balanced within the relationship between client and therapist. The therapist must therefore be first and foremost a clinical musician. Clinical musicianship is comprised of the following components: 1) Clinical Listening: It is important that the therapist is able to hear and articulate, without bias, the sounds and music created in clinical music making through both assessment and supervision (Lee & Khare, 2001). To listen clinically is to listen analytically and dispassionately, as well as listening to the emotional and interpretive elements of the music. 2) Applications of Aesthetics, Music Analysis and Musicology: The therapist should have knowledge and understanding of musical theories and musicology and then know how to apply this knowledge in their clinical practice. If known and understood from this angle, musicological literature can relate directly to clinical practice and our understanding of the music therapy relationship. 3) Musical Form and Clinical Form: The therapist should know how musical form affects and is affected by clinical form. Looking to the musical structures of composition and improvisation and then relating them to therapeutic structures will enlighten the link between therapeutic intent and musical representation. 4) Understanding of Seminal Works: Western musical history provides us with a repertoire of musical greatness. By analyzing and understanding the music of seminal composers, we can add not only to the richness of our musical palette, but also to our knowledge of the human need to express through music. 5) Therapeutic Relationship and Aesthetics: All human beings have an aesthetic content regardless of disability, pathology, or illness. AeMT believes this phenomenon is central. All clients have the ability to be great composers, and all clients have the ability to develop within a music therapy relationship that is aesthetically informed, be it beautiful or ugly. 6) Clinical Analysis from a Composer’s Perspective: To enter improvisation with a client as a composer and therapist is an ever-shifting balance between music and therapy

that is at the heart of AeMT. If the composer music therapist allows his/her knowledge of creative musical form and how musical ideas develop when composing, he/she will be able to offer clients the experience of being in a complete musical process that is both musical and therapeutically directed. Group Analytic Music Therapy (GAMT) “Individuals speak for the group and the group for individuals” (Brown, 1987, p. 214, cited in Ettin, 1999, p. 172). Group Analytic Music Therapy is an eclectic approach combining group analysis, interpersonal theories and inter-subjectivity (Ahonen-Eerikäinen, 2007). As a group analytic music therapist, I am intrigued by the idea that the group can be understood from three different perspectives (Salminen, 1997; Foulkes, 1964; Ashbach & Schermer, 1994): 1) The individual in the group (the intersubjective window). 2) The group members with one another (the interpersonal window). 3) The group-as-a-whole (the group matrix window). In real therapy situations, individual, interpersonal, and group-as-a-whole processes are closely related. According to the principle of isomorphism, all group-as-a-whole processes mirror individual-level processes, and individual processes are reflected in group-as-a-whole phenomena (Ettin, 1999). An intersubjective window focuses on clients’ psychodynamic processes. The process is like any “practice of face-to-face therapy in the group circle” (Pines, 1998, p. 26). When I conduct GAMT, I am as interested in each group members’ inner processes as when I practice individual therapy. I respect each group members’ subjectivity, and I am interested in hearing everyone’s voices. The interpersonal window focuses on the interaction between group members and how each individual affects other members. As therapist, I observe who speaks with whom and when and what kinds of roles are present. How pairing, counteracting, splitting, or joining recreates real and imagined problems in relating in and outside the group. What kinds of power struggles are there and what kinds of nonverbal communication are occurring? Each individual has a repertoire of ‘member roles’ that have been given to him or her by other group members, and have also been received by them (Agazarian & Peters, 1981). Whenever a new person enters a group, they must find a role from the repertoire available. That role, however, must fit them and the needs of the other members. After a while, the group-acceptable role will become a role that belongs to the individual while also being shaped to meet the needs of the group (Thompson, 1999). While observing each individual and their reactions to each other, I also observe and treat the group-as-a-whole. I try to sense the group members’ needs and the ‘matrix’ that

develops from the web of interrelationships occurring in the group (Pines, 1998; Foulkes, 1999; Ettin, 1999). When group members share time, space and stories, their problems begin to transform into group dilemmas. After a while, these group dilemmas stimulate them to find more suitable personal solutions. As therapist, I maintain boundaries and search for meaning. This shapes the dynamics of communication for the individual group member. Every group member has a rich inner language and visions. Fantasies and images, metaphors and symbols are an important part of processing. Music is an audible image, and improvisation is a metaphorical expression of inner thoughts and feelings. Group members can be seen as instruments in an orchestra. The group matrix can be anything from freezing cold to blazing hot. It is interesting how different sessions have different atmospheres. The atmosphere is a dynamic process that mirrors the different atmospheres of past experiences and the therapeutic relationship. See Appendix A for a detailed description of these concepts. Music-Centered Psychotherapy in Group Work: AeMT and GAMT Combined While GAMT is concerned more with the representation of musical experience through to verbal, conscious thought, AeMT is concerned with the musical qualities and how our understanding of the musical make-up affects the therapeutic process and/or outcome. Thus psychodynamic and music-centered therapies combine to produce a way of working that is potentially crucial when working with musicians. Within this context, GAMT/AeMT with musicians is nondirective. Musical images take place during non-referential improvisations and are discussed. The therapy focuses on either the manifest content of the group members’ music (improvisations or music itself) or the latent content (associations, feelings, images, body sensations). Music improvised in GAMT/AeMT may stay at the surface social interaction level if the therapist is not skilled in clinical musicianship (Lee, 2003). Verbal discussion may stay at the surface social interaction level if the therapist is not skilled in verbal psychotherapy. Similarly, musical dialogue may stay at the surface level if the therapist is not skilled in clinical musicianship. To integrate both skills, the therapist must guide clients to create music that is aesthetically valid and also has clear psychotherapeutic boundaries. The therapist also needs to help clients in articulating their feelings, images, or other latent meanings of improvisation. Discussion itself is not essential. It is important only if it integrates the unconscious ground and elevates these topics from the unconscious group matrix level to the conscious social interaction level. If the discussion is integrative, it can help the clients to gain an understanding of the connection between their improvised music and their current life issues, past experiences, or here-and-now situations (Ahonen-Eerikäinen, 2007). GAMT and AeMT are two sides of the same coin. Each represents its own particular themes, both being integral to the survival of each other. It is this marriage of two similar yet disparate theories/approaches that forms the music-centered psychotherapeutic approach that is at the core of this work with professional musicians. The Clients

The Professional String Quartet The quartet is comprised of three males (violin 1, 2 & cello) and one female (viola). The quartet has been performing internationally for over twenty years. The current group members are in their forties. They perform works from the romantic and contemporary periods. They are a lively and energetic group who feel passionately about their work. Therapeutic Aims The string quartet is one of the most intimate forms of music making. Members need to be open not only to their own musical growth, but to the quartet as a whole. The main therapeutic aims that developed from our work were as follows: 1. To understand the quartet’s relationships through music and how this could affect their playing on the concert platform. 2. To explore the links between, and elements of, inter-musical and inter-personal dynamics. 3. To explore individual personal dynamics and their relation to the group process. Structure of Therapy 1. Each session consisted of two parts, each lasting approximately 45 minutes. 2. AeMT improvisation with Lee as therapist and Ahonen as observer. 3. GAMT verbal discussion with Ahonen as group analyst and Lee as group member. Therapeutic Process The four sessions highlight the main discussion topics of the therapeutic process. Every session was full of expectancy and excitement as the work unfolded. The transcriptions only present a part of the musical richness and dialogue as the therapeutic process danced between words and music. Session One Musical Description (35 minutes). Slow dissonant intervals without pulse. Randomly placed tones create a sense of ambivalence and openness. Animated sounds appear: Tension builds as the tempo becomes faster. Tonal, melodic lines. Slower and romantic in style. Floating sounds become faster. The music accelerates. Romantic music, consonant and precise. Rapid, atonal sounds. Intense listening that is not crowded and carefully placed. Col legno until Violin I begins a simple melody. The music then becomes tonal developing into a hoedown. The music becomes slower, ending with a slow romantic coda. Someone is Missing in this Room. After the improvisation, the discussion starts on a social, interactional level, exploring various musical elements and inter-musical and

interpersonal interactions. As typical in the early phase of group therapy, the members search for structure, safety, and boundaries. How should they be in this new group situation? How and what should they discuss and play? The projective level activates when one of the group members says after the improvisation: “There’s somebody missing in this room….” It is a new experience to play without a composer. How do they go about defining various roles? What about having a pianist (Colin) in the string quartet: Was it stimulating or disturbing? The group also explores searching for connection, hearing, the musical atmosphere and the roles impacting the music. From a musical perspective, the improvisation was stunning. It was obvious that the quartet had connected deeply to the music, evoking an experience of the collective unconsciousness (Ahonen-Eerikäinen, 2007), in which primordial images and metaphors were activated (Jung, 1969). During the discussion, members processed these shared feelings and compared the musical experience with spirituality. Session Two Musical Description (7 minutes). Cello begins with a grinding low note (D). This becomes the musical base. The tone is raw and builds in intensity, with the rest of the quartet taking the musical lead from the cello. The music builds. A slower more delicate section based on the intervals of a major 7th (D and C #) and a perfect 5th (E and A) (Piano). The music is slow and transparent. The 2nd Violin initiates a syncopated dance-like section in the style of Bartok. A short return to Section II, leading to a quiet and delicate ending. I’ve Seen Burnout on Everybody’s Faces. The discussion began on the social interaction level, investigating the musical elements. Members also investigated interpersonal connections, especially moments of synchronicity. The group discussion then begins to deepen; as the group members reflect on their busy schedules and work-related issues, they connect with feelings related to burnout. Viola - We were talking about burnout before. I was burnt out about four years ago. I spent time thinking “how am I am going to get out of this?” I thought about other issues that impact my life: regarding sleep. It wears you down and can be depressing. I thought about ways to take care of myself. You have to do the best from where you are, to bring yourself whole to the group, to find a way to make that happen; saying “no” to negative things and “yes” to healthy things. All of us go through moments of “I’m just hanging on.” I experienced that in a dramatic way. There are still periods where I am just barely hanging on. Heidi - Yes. Violin II - For different reasons and solutions. Feeling burnout, coming from different sides. Cello - Being able to re-generate yourself is something personal. You have to find it.

Doing other things with other people, then you find out … you have to know what it is and then you learn. Heidi - Learning to hear the warning signs is important. Sometimes we don’t hear them. You (to Viola) said you had burnout. How did you recover? What was the key for your recovery? Viola - At the end of the season we had a break and I regenerated. Realizing there is space in every day--there is space between. When there’s too much on my plate…I see this as a group too…you feel like you’re barely getting from one thing to the next. A signal to create more spaciousness…I sit at home alone. It’s not meditation--it’s different, but all of a sudden things start to click and settle. Part of the reason I don’t sleep well is because I need time to let life be…thinking about how things are affecting me. Time to let life soak in…Realizing there are few opportunities, even if it’s five minutes…not be in my office going like a crazy person. I try to be a little less crazy. It’s been helpful to see the space between things. Heidi - That makes sense. Viola - I’ve seen burnout on everybody’s faces. Cello - I thought by joining a quartet it would be one way of eliminating the burnout from before (in an orchestra), but it proved to be a different burnout altogether. Colin - You swapped it for a different kind of burnout? Cello - It was supposed to be good. Violin I - It’s like there’s no end to what you could be doing, because we’re running our own business basically. We have help but…I’m always aware that we could be doing more things. We have opportunities; which is fantastic: making CD’s. There are always limitations…but I’ve also learned to just let it happen. Violin II - It’s the nature of music. It’s never satisfactory to me, so I go home after a heavy day and I think I should practice. It never stops…It can always be better. You can’t say, “I’m ready.” Well, I can’t myself. It’s sometimes an issue but I never feel like it…The pieces we have played hundreds of times on stage…I just still feel there’s more to do. Cello - That also contributes to the feeling of being overwhelmed. It doesn’t matter how long you spend in the practice room, you’re always going to feel dissatisfied. Even if you reach the next concert and you think “That really worked well.” Then you go back in the practice room and start thinking about more things that you could do…things you could change.

Violin II - That’s why being a musician is so challenging. Heidi - It’s like you’re always climbing a mountain. Four People Yielding to One Another. The quartet members end the group by investigating each other’s relationships. As the quartet developed, their roles became ever more complex. Maturing within a professional musical context is essential if the group is to be elevated onto the international stage. Viola - I remember when the quartet was younger, before Sam became the cellist. The frenetic energy we had. What Sam taught me was that I don’t really need to understand everything. At times I didn’t understand when Yuli [violin I] was asking; “let’s explore the concept about re-birth and re-generation.” I didn’t understand what he was saying but then realized that in due time I would. Violin I – We have also simplified our rehearsals. We know how to get somewhere with a piece quicker. When I first joined the group, I didn’t know how to rehearse; I made a lot of mistakes. There were many irritations in those first years…it was just immaturity …mostly my fault but…on the other hand…what were you saying? Viola - Yuli [violin I] never listens to me is what I was saying (laughs). Violin I - It’s like letting the musical identity of the quartet be simply four people yielding to one another…rather than shellacking a conviction and trying very hard to make everyone be convinced of that idea. I feel really strongly about this. What happens if we just play and listen to each other? What evolves from that? Does that make any sense, then to have a discussion about it? Violin II - I feel that’s the only way to do it…but we know that. Violin I -But it’s not quite as intense, is it? I remember in graduate school playing chamber music with people who were strong-minded and it’s just impossible. You have to be flexible to be able to feel. Viola - That boils down to the respect that grows. We are four strong-minded people and sometimes you do sublimate…sometimes you squelch what you think. And then it might just make you pause for a moment and say, “yes, we could do it that way” and “it’s possible.” If somebody feels strongly and they think “it’s got to be this way” or “its here.” There’s a great deal of subjectivity. I like that. We play and let it have a sound and there’s openness. I like it that way. We have our off days…it’s not fixed. For me the last five years have been a real revelation. Heidi - Exactly.

Viola - I’ve played in chamber groups for 25 years and I’m still learning. This session helped the quartet to understand the importance of cohesion and their roles with one another. Trusting their fellow members as their relationships matured helped them to appreciate their uniqueness and the fact that they indeed function as a family. Session Three Musical description (26 minutes). (Note: a range of percussion instruments are now made available for the quartet to play) The improvisation begins with a theme in E minor. The direction becomes more formed. The music is free and syncopated. A sense of rhythmic and harmonic structure becomes clear. The therapist provides a four-chord theme that acts as anchor. The quartet begins to play percussion instruments also, using mainly drums and the cymbal. The architectural tonic is D. In contrast the music takes on a quieter nature. There is a sense of sorrow and searching. It is based on minor modes that provide a sense of openness. This is balanced with a slow, lyrical section in E major. The music grows in intensity. There are sections of wild abandon balanced with more formed musical inventions. All styles are contained within a clear and expressive/energetic form. A long slow lyrical section ends the improvisation in E major. I Felt Like Crying. After a period of playfulness explored through the improvisation, the group began talking about the emotions expressed. Viola - There was tension. It was cathartic. Cello - I endured the pain. Cello - There was an elevated experience when you reached a certain point. Viola - Yes. Cello - Which part was that? Cello - The drumming. I am not sure who was playing because I don’t often look. Violin I - Clara [Viola player] was the only one whacking the life out of the drum skin. Viola - It was odd, because I also felt like crying about six times, which is weird. Heidi - Mmmm. Viola - I don’t know why.

Musical Euphoria. The improvisation was cathartic, and after this experience, the group members began to discuss if they had ever had similar experiences during their concerts. They then reflect this back to their improvisation, describing the improvisational experience as euphoric. Violin I - I think what I liked, with Xavier (violin II), is the idea of euphoria, too. I think what we love about our profession is those euphoric moments that are purely musical and physical. Your reflexes are very connected to immediate signals. C - I felt we touched on it. During the E major section especially, it felt quite euphoric, very heightened. Musical euphoria in music therapy is at the core of the process and can affect therapeutic outcome. To be in a heightened sense of musical dialogue is beyond empirical logic and refers to the intensely creative and spiritual nature of our field. In improvisation, euphoria can take on an ever more heightened level of expression and union within a group setting. When all players become a collective musical expression, the individual voices of the group merge to find a balance that is bigger than the sum of the parts. It is this musical euphoric dialogue and union that is at the heart of music-centered practice. The musical components and pieces within the symphonic understanding of an AeMT improvisation merge with the psychotherapeutic understanding and interpretation of GAMT. Together, they allow euphoria to be experienced and understood as part of the music-centered psychotherapeutic process. Session Four Musical Description (17 minutes). The music floats with the quartet exploring string configurations producing music that is nebulous and free. The music becomes tonal and overtly romantic. Quiet delicate searching. Intense listening. Faster more rhythmic music. Separate musical ideas. Faster, and more rhythmically consonant. The cymbal creates a new texture. The intervallic theme from the improvisation in session II, section two is re-introduced by the therapist as the main musical form. The improvisation takes on a feeling of the Blues leading into the Middle-Eastern mode, which concludes the improvisation quietly. Competition. After a vivid discussion about touching music, emptiness, freedom and need of “just wanting to hear something different,” the group ends up with a long dialogue about competition. Heidi - Is there competition between the quartet members? (Silence - awkward laughing) Violin I - In this situation of improvising? Heidi - No, I mean as a string quartet, and as musicians.

Violin II - Certainly within the confines of the quartet, there’s definitely competition, because we all have our own ideas, and we want our ideas to come out; on every level-from administration, to business, to music. Violin I - I don’t feel it’s all competitive. Violin II - I’m not saying it’s necessarily a competition. I just mean there is competition. It’s all About Family. The interpersonal perspective opens up after an intervention from Heidi that compares the dynamics of the quartet with the dynamics of the family unit. Is the quartet nearer to the family dynamic than other chamber groups? The quartet, just like any family unit, will include competition. This may be promoted musically. The quartet, just like any family, contains roles that are given and received. Playing in the quartet includes “important” roles and “not so important” roles, along with sub-groupings, akin to sibling dynamics. Violinists are always together, while the cellist and viola player are always alone. Violin I - We think that the viola and cello are always alone. Colin - I think of the violinists as like brothers. Violin II - …we’re used to each other, that energy. Colin - Because you swap roles as well? Violin I - There are always two of us, but these guys [cello and viola] are always alone. Viola - Primo cellist and primo violist. Violin II - For them that’s it. …I’m the cellist …I’m the violist …I’m the pianist too. Colin’s comment takes the group into an in-depth discussion of their relationships with one another. Through Heidi’s interventions, they come to see how their past relationships and experiences influence the ways they interact verbally and musically in the group (AhonenEerikainen, 2007), and this leads to an important question: How do the quartet members deal with each other? Colin - In my family, I can criticize my sister or brother, but from the outside, no one is allowed to say anything bad. I felt that here. You don’t want Heidi and I to think that there are problems…but inside… it must be like that? You can be mad with each other, but you won’t let anybody from the outside know. Because that’s the front you put on…we are a ‘together’ string quartet. Heidi - Like in any family.

Viola - I think over the years, there have been a lot of inherent problems, especially with you guys. Like teaching and playing…who plays first? It seems like from the outside, that our relationships have become healthier over the years. When I first joined the group, understanding how each of you talk. You are all very different players. Essentially we’re all each other’s teachers. I look at it that way. I want to be open to what people have to say. My first instinct is: “No, it’s like this” but there’s a voice that says, “It could also be like that.” I want to always keep that option; except when I’m not in the right mood. I think that you guys have really developed a lot. Violin I - It’s like a family. You’re alone, and then you have a sibling, and you adjust. There’s a time, but you learn how to be with one another. Conflicts. The following intervention from Colin and Heidi helps the group recognize their conflicts. The discussion opens the door for the other group members to grasp the real topic: Colin - At times I really get a sense you are a family, and other times you say things, or things happen, and I realize that as our discussions continue, you’re still evaluating who you are as individuals. Sometimes you really surprise me with the things you say. I think it’s more in the talk. At times, I really get a sense of a close family, and other times, a family in transition. Viola - A family with conflicts. Colin - Yes, thank you, I didn’t like to say that, but yes. Viola - I think we have our conflicts. Some difficult situations sometimes are not really resolved. They either resolve or we let them fade…then little things become touchy, or they can be…at least for me. So it can be tricky. Violin I - It doesn’t help that it works with families in our lives. Colin - You have been very open, I don’t think the conflicts are always negative conflicts, but they’re there, aren’t they? Heidi - (Helping the group to go deeper into the issue) Do you want to speak more about that? Viola - About conflicts? Heidi - Yes, whatever you started to speak on… The group explores their issues and how they have resolved their conflicts in the past.

Strengths and Weaknesses. This leads to another discussion in which the group compares the dynamics of a quartet and an orchestra; their roles, power struggles and games. If string quartet dynamics refers to a family unit, the orchestra dynamics refers to an extended family: no need to get along, you’re playing great music, but often under horrible circumstances. Viola - Ultimately what the four of us should do is bring our strengths, to what we have, and we also know each other’s weaknesses. Violin I - That was one thing I was hoping for in string quartet, that it would be an environment that was interested in each other’s strengths. This is a very different environment [than an orchestra]. It has the capacity to be infinitely more supportive. Violin II - What do you mean, praise on weakness in the orchestra? Violin I - I mean, just the way you play, people in orchestras…the games that people play when you’re actually making the music, are power struggles all the time, about who gets it right and who doesn’t get it right. Who got the shift and who didn’t. Just little games that people constantly play to prey on each other’s weakness. Heidi - It’s like extended family. Violin I - But it’s very dysfunctional. The audition process is a prime example. All the audition process does is tests your nerves. If you’ve got nerves of steel, you’ll win the audition, and you’ll get into the band, and you might be able to deal with that dynamic of constant fighting. Viola - Being in an orchestra, you are just a cog in a wheel, and there’s something dehumanizing that sucks out my love for making music. Violin II - That’s something…there’s plenty of jobs in companies you’d be in the exact same situation. You’re asked to do a task, this is the task, show up to work, and do your job. The nice thing about the orchestra is there’s some nice music to play at the same time. Violin I - Part of the problem is, when music becomes, starts to feel like office work, it becomes upsetting. Sometimes there’s friction, but most of the time it’s a good bunch of people. If the contractor’s careful, he wants a band that plays together, who gets along. At the end of the day, you make some money. It’s a simple transaction. A brutal exchange of funds, it’s not like a program, that’s always the same people. No need to get along, you’re playing great music, but often under horrible circumstances. Conclusion

This work demonstrates the vital nature and connection between the aesthetic, clinical and psychodynamic processes in clinical improvisation with musicians. Words have a musical content and music can seamlessly move into the verbal dialogue. AeMT and GAMT move between each other and dance back and forth like poetic communication that is truly representative of our initial vision of combining our two voices in the ensuing work with the quartet. Metaphoric symbolic language was at the heart of this combination of music and words that we describe as the ‘meta-musical.’ Every session was a process in itself while also connected to, and a part of, the previous and following improvisations and dialogue. The potency of the process culminated in discussions mostly related to the potential for burnout and conflicts among group members. Conflict and the ability to recognize when this becomes unhealthy, are normal in any family unit. In the beginning, discussions revolved around exterior concepts, such as risk-taking and the fact that the composer was not present. The difference when working with musicians is that they need to experience skills in risk-taking and recklessness. These experiences could, in turn, influence directly their work on the concert platform. This kind of exterior outcome is specific to work with musicians. Also dealing with the conflicts within the group and their sense of family is crucial for their ongoing process and professional work. Acknowledging burn out and how they can cope with this dynamic is another essential element in working with musicians. This therapeutic fundamental is at the core of how a music-centered psychodynamic process can help professional musicians manage the difficulties they encounter as performers. These issues were explored through the improvisations, which allowed the group to look more closely and deeply at their problems. Playing (AeMT) and interpretation (GAMT) combined to produce a process that allowed them to see and reflect on the group’s dynamics and develop new ways of experiencing their roles and performing skills. Transferring these concepts discussed outside the therapy situation enabled them to continue their work as professional musicians as well as explore their individual and collective responses to music. References Agazarian, Y. & Peters, R. (1981). The Visible and Invisible Group. London: Routledge. Ahonen-Eerikäinen, H. (2007). Group Analytic Music Therapy. Gilsum, NH: Barcelona Publishers. Ashbach, C. & Schermer, V. (1994). Object Relations, the Self, and the Group: A Conceptual Paradigm. London: Routledge. Brandfonbrener, A.G. (1997). Pathogenesis of medical problems of performing artists: general considerations. Medical Problems of Performing Artists 12, 45–50. Brodsky, W. (1996). Music performance anxiety reconceptualized: A critique of current research practices and findings. Medical Problems of Performing Artists, 11(3), 96–116. Butler, C. (1995). Investigating the effects of stress on the success and failure of music conservatory students. Medical problems of Performing Artists, 10, 24–31. Dews, C. L. & Williams, M. S. (1989). Student musician’s personality styles, stresses, and coping patterns. Psychology of Music, 7, 137–47.

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Appendix A

The above circle (Figure 1) introduces the conscious and unconscious levels of the group matrix (Foulkes, 1964; Fiumara, 1983; Kreeger, 1991; Salminen, 1997; Zinkin, 2000; Ettin, 1999). This conscious or unconscious communication relates to everything that happens in the group. These levels imply that the group can be discussed and understood at different levels of consciousness: both conscious and unconscious. The outer circle is the conscious level. It includes the conscious level of social interactions (Salminen, 1997; Kutter, 1982, 1983; Foulkes, 1964; Zinkin, 2000). The three inner circles are all unconscious. They include the transference level (Foulkes, 1964; Kutter, 1992; Salminen, 1997; Fiumara, 1983), the level of projection (Fiumara, 1983; Salminen, 1997; Foulkes, 1964; Fiumara, 1983, 1991; Zinkin, 2000) and the collective-unconscious level (Salminen, 1997; Zinkin, 2000; Foulkes, 1964). The levels of the group matrix and levels of consciousness become visible in different musical images and dreams that clients experience during GAMT (Ahonen-Eerikäinen, 2007). Musical images during group matrix levels have certain characteristics. Figure 2 and Table 1 illustrate these characteristics in the form of descriptive categories.

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

CASE TWO The Use of Elemental Music Alignment in the Journey from Singer to Healer/Therapist Frank Bosco Introduction This chapter describes the clinical application of Elemental Music Alignment (EMA) with a middle-aged woman challenged by traumas and issues of insecurity. EMA combines music with touch (bodywork) in order to address issues that clients initially find too difficult or disconcerting to talk about. When focused on touch, the principles and practices of Polarity Therapy serve as a foundation in understanding this aspect of the EMA process. Once the client encounters and begins to process these experiences verbally, Gestalt Therapy theory serves to frame and contextualize verbal exchange. Aspects of the early stages of Clara’s work will be described, along with updates from our nearly 12 years of work together. Foundational Concepts Elemental Music Alignment (EMA) is a unique approach that I designed to combine the power of two therapeutic modalities that bring about change and growth for adults in individual therapy (Bosco, 1992). As I discuss this case, I will attempt to describe how these two therapeutic modalities--bodywork (massage) and music--are combined to enhance the power of music and broaden the experience of therapy. EMA involves making specific connections between music and touch that are determined by the client’s particular needs, and then both sound and touch are altered or adjusted by the therapist in accordance with the client’s moment-to-moment responses. Musical qualities and events are matched with the specific nature of the bodywork, which can include for example, the degree of pressure, the speed of movements, the pressing, holding, rocking, shaking, and/or lifting of body parts and contacting the specific areas of the body with respect to how they relate structurally and theoretically to Polarity Therapy theory (Stone, 1986). The verbal processing in this case, surrounding and supporting the EMA work, was primarily based in Gestalt Therapy theory (Perls, et al., 1994). While Polarity Therapy recognizes the importance of establishing emotional balance as part of the overall healing process, it offers no specific techniques or unified approach to verbal processing. It does, however, address how emotions relate to the body, and in that regard, become a spawning ground for Gestalt experiments (Perls, et al., 1994). Such experiments are suggested by a therapist and/or client to explore and experience novelty through an expanded awareness of the present, given the real

or imagined circumstances of the experiment. Generally, we might opt for doing an EMA session as a form of Gestalt experiment to deal with issues that arise in a verbal process. Conversely, an EMA session would tend to bring to light topics to discuss and further process verbally. Since some of the issues in this case interrupted the client’s ability to engage in verbal processing, EMA became instrumental in taking the process further, and then allowed movement back into verbal work. Elemental Assessment In order to associate music with a person’s current condition and needs, I feel it is most helpful to make an assessment in a language that is consistent with both human nature and the nature of music. Music, from a purely scientific perspective, is a function of vibration or wave forms that we experience in nature as the movement (compression and decompression) of air molecules within a space; and yet, as an art form, we might agree that it somehow expresses or adequately represents our human nature (Kahn, 1983). Therefore, it seems a logical fit to utilize a theory of the human condition that is based on understanding nature by breaking it down into its most basic structural categories or elements; earth, water, fire, air and space. Element theories come from ancient traditions of which the most widely considered is probably the Oriental five element system that serves as the basis for acupuncture (Kaptchuck, 1983). Many indigenous cultures have taken on this idea which, in essence, was an attempt to arrive at organizing principles by which to better understand human life. In other words, five element theories are a form of ancient science. The element theory that I mainly utilize is from Ayurveda (Lad, 1984), developed in India in alignment with yogic traditions. This theory became the basis for much of the work of Stone (1986) in the development of what he called Polarity Therapy (Sills, 1989; Stone, 1986). Stone was a doctor of osteopathy who challenged himself to find out why his patients would not maintain the adjustments he would give them. His search for answers led him to discover and incorporate element theories as they attempt to address the notion of life energy. In 1981, I began to study Polarity Therapy as a system for understanding the connection between the innate structure of music and the innate structure of human beings. After studying the application of five element theory to the quality and expression of the human voice (Beaulieu, 1987), I extended this work to include polyphony so that any and all musical expression could be understood in terms of the Ayurvedic five elements: earth, water, fire, air and ether (i.e., “space”). I devised a system for analyzing music in detail for specific applications in this approach that I call EMA, to bring about balance as needed in the human condition. From this point on I will make references to these elements using parentheses--earth (E), water (W), fire (F), air (A) and ether (e)--as they relate to certain descriptive words or concepts in this case. One way that I have used to come to understand the idea of balance in the human condition, that is consistent with element theory, is to compare our needs to the needs of a plant. Starting with the notion that growth only happens under certain conditions that will then yield varying results, ranging from dismal to optimal, depending on the nature of those conditions, we can visualize a working elemental metaphor for therapy. We are like the seed that needs enough water and warmth (F) to germinate (i.e., to begin a growth process; for

example, conception). Next, we open to the earth’s nutrients, but can only get enough if we break through to the air (e.g., the birth process) in order to siphon up the water that will carry those nutrients through to where they are needed. Indeed, as this process continues, it is bound to ultimately repeat as the plant bears fruit and the life cycle continues. It is this kind of thinking that informs me in a way that I feel is both simple and profound. Applications of these elemental metaphors provide understandings of the therapy process at any level from the moment-to-moment minutiae of the client/therapist interaction to the over-all stages of the therapy process. I would encourage the reader to be open to such references as I have used them to outline the case that follows. The Client Not a “Diva” Clara was 52 when she came to see me. In her 20’s, she achieved some notoriety in a performance that caught the eye of some prominent people in and around the New York opera scene. To many, she showed promise. She was an attractive young talent with a huge “Wagnerian” soprano voice, but there was a crack in her foundation (E). Clara was not exactly “Diva” material. She had a great voice and the necessary intellectual fortitude to “fit the bill,” but at the core, her self-confidence faltered, resulting in some unpredictable performance disasters. She encountered issues like losing her voice just before or after a performance, or freezing in fear (E) on stage. She had no sense of what was causing the interruption, which she described as “having the rug pulled out from under me.” This was clearly an earth element issue since it relates to the polarities of structure, support and security. She needed a solid foundation of fertile ground to grow confidence in her vocal expression. Fertile ground supports growth through a balanced infusion of all the elements. Many of Clara’s problems seemed to be related to her father. He was a powerfully assertive man who realized the American dream as he developed a major manufacturing company. All through her childhood, Clara would engage in “battles of the will” (F) trying to resist her father’s patriarchal rule, often in support of her mother or siblings. As she would win some of these fights, she would eventually learn to expect the unexpected in a surprise attack her father would launch to get back at her by embarrassing her in the presence of other people. It wasn’t until she was well into her teens that Clara learned to sometimes counterattack by getting others to see what he was doing to her. Unfortunately, by that time the damage was already done. She learned to be very careful about leaving herself open (e) and vulnerable to attack. With any situation that required intimacy or personal exposure, she would tend to be on guard or go into a reactive mode of behavior. She became overly defensive and even reclusive later in her 20’s as she managed bouts of anorexia and bulimia on her own in a constant struggle with embarrassment due to her poor body image. Out of fear (E) of being seen as “fat” she even resorted to constantly donning a raincoat to hide her body. Elementally, this represented a kind of earthen regression back to a sense of safety that might come with being inside a womb, like a pod, or a shell provided for a seed. The Therapeutic Process

One of Clara’s original reasons for beginning therapy was that she wanted to gain more comfort (E) with her “big” voice. She was aware of how it felt cut off or stifled in her throat (e) and solar plexus(F). It was a bit like a static charge needing grounding (E) or discharge. It would build up in her body and then, when she could release her voice, the sound (e) would feel out of control like she was somehow not producing it. In fear (E), Clara would lift her chest up to get more air into her body as would be needed for a “fight or flight” situation. But, without a clear threat to respond to, she would not be able to release this energy. Consequently, she would not be able to take in much air on her next inhalation and would then start to panic, having closed off the physical gates for her expression. Excessive tension in the thoracic region--particularly the intercostals and scalene muscles--would effectively flatten the domelike shape of the diaphragm, and leave her with a confounding feeling of discomfort and disconnection with her body. She was, as it became quite clear later on, describing a pattern of dissociation that began in childhood and would for now become the central focus of our work together. In terms of elements, balance supports life. Clara’s lack of emotional support (E) gave her a quality of frozen (E) ground with muscular tensions that made her body too rigid for the powerful voice within her to flow (W) freely out into the world around her. She could not claim the necessary space (e) she needed for her “big” voice, and so her expression (e) was stifled much like a plant that has out-grown its pot and become root-bound. Stage 1: Thawing and Tilling the Soil, Sowing the Seed For roughly the first three years of our work, the challenge was to deconstruct the shaky ground that Clara had become accustomed to and reconstruct a more solid and consistently secure ground/Earth for her to stand on. This involved a kind of re-forging of the configuration of her elements so that her desires (A) could be willfully (F) expressed with a clear sense of her Self/identity (E). Her early struggles with her father left her in a predicament where he, in essence, rather than supporting her to express herself, took up the space she needed for her voice to come forward by constantly asserting his authority over her. While her ability to defend herself was compromised by this lack of a consistent support, she learned to fight with her father and became a valiant defender of others. In harnessing this ability, we did many sessions where she learned to defend herself against oppressors and perpetrators of the past. We enacted many experiments based on reviewing challenging events both from her past and from current relationships using Gestalt techniques (Perls, et al., 1994) and Somatic Experiencing (Levine, 1997) to support aspects of her expression that she was not originally able to access because of earlier trauma. At this point, she was not yet ready to try an experiment where she would confront her (deceased) father directly for his offensive behaviors. In fact, she would tend to defend him at the suggestion that he was not a good father, even after discussing these offenses. She needed to feel a good, strong connection to him and to the part of herself that felt proud of him. She could feel a sense of having inherited some of his strengths during these experiments as she was experiencing a greater sense of personal power. It was our third session when she brought up the “raincoat” and described how it gave her a sense of security--like a shell that protected her from the embarrassment of being fat. She

showed me the fearful posture that she imagined she held under the coat. As this moved into a spontaneous experiment, I picked up a drum and started to pound in a sporadic manner to emphasize and represent the external world as I repeated back to her the negative thoughts about herself (introjects) that she had just expressed to me. She held herself in fear and hiding with her head tucked down into her arms held tightly across her chest. I supported this posture with drumming that was sharp and strong (F), irregular and syncopated (A), to represent the ceramic quality (E: dried = no water and, compressed = no e) of her shell-like containment (E). Next, seeing her in what I believe Keleman (1985) might describe as a posture of “rigidity, aversion [and] fear” (p. 69), I asked her if she could move from this internal experience to begin feeling her arms as a self-loving embrace. To support this musically, I needed to introduce some water to be warmed by the available fire and moved by this combination with air. I did this by establishing a moderate, regular beat with predictable accents and a flowing wavelike quality. Her head began to rise up as she appeared to embody a proud, serene and noble looking posture. I asked her to hear and relax into the rhythm like it was water all around her. Soon I began slowing down (E) and simplifying the rhythm, relating it to a gentle heartbeat, and gradually fading the volume lower (E) down to silence (e), giving her time and space (e) to return to the present. When she came back from this experience, she had an awareness that her main issue in life was, just as with her voice, her difficulty in maintaining a consistent and self-replenishing output of energy. She acknowledged how great she was at supporting others, referring to a song she sang entitled “As long as he needs me” (Bart, 1960), to indicate that the only thing she would need in return for her efforts was external validation. She was beginning to realize that she needed to learn how to be there for herself in the spirit of the embrace she had just experienced. We continued working on this theme with bodywork and EMA sessions on my sound table--a massage table with built-in speakers to enhance the physical experience of recorded sound or music. Breathwork became the most compelling focus for us at this point as the tensions she experienced while performing also disturbed her ability to speak freely. She would often not finish sentences in a way that seemed to correlate with her tendency to not finish her exhalations. Issues associated with these tensions constantly created hesitations in her speaking when she would attempt to communicate and make contact in a meaningful way. This was a clear example of a common understanding in Gestalt therapy theory of how holding back physically and emotionally can be linked (Perls, et al., 1994). Typically, I would use music to provide a sense of safety in these moments when Clara would tend to freeze up in reaction to some memory that caused involuntary shaking, as her body attempted to manage or discharge this bound energy. Depending on the circumstances of the moments, I might either attempt to quell this reaction, perhaps with more soothing elemental qualities, or encourage the symptom toward fuller expression and release. In one such session, I was playing a recording of a shakuhachi (bamboo flute) and koto composition (Somei Satoh) which presented ether of Air, as long stretched-out tones were surrounded by silences (e). With Clara lying face up, I began pressing gently but firmly into her neck region to release her tightly held scalene muscles (these emanate from the mid-to-lower cervical vertebra and insert or attach into the first two ribs). The music had a direct elemental correlation to the body area I was working in as this is precisely where the heart chakra (A) and the throat chakra (e) meet. Both the music and the bodywork helped her to release emotions

that she held deep in the realm of her body. We were contacting a physical boundary that gave her a needed layer of protection similar to what the “raincoat” once provided. But softening this inner shell required a more tactful approach. The air and ether of this music presented a rather cold, barren and isolated atmosphere, much like a frozen (E of W) Arctic tundra. Grief (e) was apparent, but her deep sadness was not being released, as fear (E) was overwhelming her ability to feel it and let it go. Her earth element needed some warmth to thaw so that insecure frozen ground could shift into a secure and fertile ground where emotions could flow and growth could be experienced through proper nurturing. So, keeping one hand on her shoulder so as not to let her feel abandoned, I reached over to my CD player controls and faded out the somewhat stark flute sounds and quickly switched to the Adagio for Strings by Samuel Barber. The slow and steady process of this piece provided the necessary elements to support Clara through an expression of profound grief. The nature of this piece is such that it builds gradually on a connected, flowing and stepwise (W,W,W) string (F) theme through the entire range of elements from a quiet (E) pool to a gentle, slow boil (F of W and A). Using principles and techniques from Polarity Therapy, I worked contact points in coordination with this music. I was constantly working to integrate at least two different elements as they were represented in the music and in accordance with Polarity bodywork. For instance, in the beginning of this piece I shifted my right hand from her shoulder (A) to her neck (E) and placed my left hand just under her navel, contacting the second (W) chakra. With gentle rocking and firm full hand contacts, I soon moved down to her left foot (W) and knee (E). From there I worked upward again by matching contacts with the changing elements in the music. Clara seemed to be almost crying when, near the climax of the piece, I found myself again gently pressing into her diaphragm up under the ribs with one hand and down under the clavicle (collar bone) into the anterior scalene muscle with the other. Suddenly, she let out a deep howl, releasing her chest and exhaling completely as she broke into a sobbing that she later described as being “not as much about feeling her pain, but rather finding release from it.” Clara cried through the pause in this piece, which comes after the building of a dynamic melodic pinnacle. During this silence, Clara seemed to make some connection (e) to what she needed to feel and by the end of the piece she was in fact feeling peace. She briefly made eye contact with me and with an acknowledgement of where we had just gone. In the verbal processing that followed, Clara told me this session was all about her learning to be less dependent on others to help her feel safe. She was feeling this infantile place like a child who grieves a loved toy that is somehow broken beyond repair. She was shedding a false sense of protection that she had wished was truly provided by her father but that she could never really count on. Facing this sad reality, she felt the loss of a dream and at the same time a new awareness that she could take care of herself. Stage 2: Breaking through the Soil The raincoat was off. The shell had broken open naturally, and the process of germination had begun. Like a child taking its first breath, Clara could now get the air needed to fan her own fire; and there was much to do with that fire. We entered into a phase that focused on her ability to express her anger in an empowered way. About eight months into our

work, she had a recovered memory while driving home from a voice lesson where her male teacher was touching her neck to assist in a new technique for vocal production. She recalled a date she had during a trip to Italy when she was 22 years old and suddenly moved into the memory that she was raped. She pulled the car over immediately and called me after releasing what reportedly, and to her credit, was some “very loud sounds.” I supported her to recoup and get home safely, and we scheduled an extra session to revisit this event. Two days later, as she was sitting in my office recounting the scene with a man in Italy, she started to collapse, almost losing consciousness. I encouraged her to stand up and feel what was happening in the moment. She had a hard time accessing her anger, but eventually I got her to mobilize some emotional energy by pounding on a big cushion. However, she could not yet make any sounds with the pounding. I tried to keep her moving through this, but she fell into a kind of posttraumatic reaction, shaking and crying. I helped her to the table and played a soft and slow, watery clarinet piece called Begin Sweet World by Richard Stoltzman, holding contacts on her body to match its nurturing mix of elements--warm, moist and aerated earth. As she settled into her body again she was able to tell me that she had never really dated before this event, which happened just after losing a lot of weight. Indeed, feeling more attractive made her feel more vulnerable to an overpowering sneak attack just like she had suffered many times before with her father. The same feelings of embarrassment and entrapment came up for her with the addition of some guilt over feeling some degree of sexual arousal before she realized this young man was taking advantage of her and acting against her will (F). Two days later, as we were again working on her ability to stand up and defend herself from attack, it became clear how Clara was caught in a traumatic re-enactment pattern stemming from these issues with her father. She told me that she had successfully deterred sexual advances from some football player who also tried to force himself on her when she was just twenty years old. The problem was that she felt subsequently that she failed somehow because she let this guy down and upset him. It was the same old demoralizing feeling that she would get when she won an argument with her dad. For, even if she got her father to apologize for something he did, she knew it was only a matter of time before he would stab her in the back with some insult that would reestablish his dominance. This also reinforced her feeling that it was not safe to win battles against people with whom she had a degree of intimacy. It was this pattern that made her actually apologize to the football player for messing up his play and perhaps, by beating him back, she was set up to lose against the surprise attack that would come two years later in Italy. Clara’s comfort with me at this point, and her ability to see how ludicrous it was to apologize to her rejected rapist, led us into what started as a light-hearted role play inspired by the fact that I had forgotten to turn off the ringer on my phone. Just as we were getting into the subject of saying “no!” as a means of setting a protective boundary, my phone rang. Playing with her, I went for the phone saying, “Oh, you won’t mind if I get that will you...?” Realizing that she was not about to use this opportunity to playfully respond to me by practicing, “No” I paused right before picking up and asked, “Clara, can you tell me what you are feeling right now?” We both realized her nervous system was activated, and she knew she should be protesting and angry but she could only feel frantic and shaky. We spent the next half hour working up her fire and earth until she could shout “no!” in various ways, coordinated with

rhythmic beating again, on the cushion and then sparring with me as we both played on conga drums. Most significantly, she did this with some real strength and without losing her intensity, anger or determination. Stage 3: Reaching for the Light In the next stage of her work, Clara came face-to-face with her inner demons. Standing up for herself and feeling safe in the world was no longer her main issue. Instead, she was in touch with feelings of depression connected to the fact that, with the exception of her mother, she had never had a deeply committed love relationship. At about a year and a half into our work, she told me that if her mother (whom she lived with and took care of) was to die now, she would want to die as well. Clara was managing her life but still seemed to need to support someone else to give her life meaning. Some sort of fear was limiting the joy of the connection she was having to her mother and also to her new-found sense of self. I was inspired by some toning (Keyes, 1973) work that we had recently done to do some EMA work to Steve Reich’s Tehillim. I often combine toning with EMA to stimulate energy for creative expression, and this particular piece has a buoyant and stimulating quality that I thought might get her in touch with the joy of having this precious time with her mother. We started working on the table, and as she seemed to become activated by fear in her body, I could see her back away from it and suppress it rather than release it. I intuitively thought this music would support her and provide some ground for opening up her heart chakra/area (A) for expression. I felt that the energy of the voices (A), warmed by the gentle syncopated (A) accents (F) combined with a steady rhythmic background (E), could persuade her frozen earth to melt and move. Following the music with some very active jostling of her shoulders (A) helped to release some formidable knots, but when I reached her abdominal (E) area I could feel her defenses and I kept a gentle pressure there so that she could remain aware of her fear and internal holding. At some point in the piece I did sense a deep relaxation throughout her body, but we did not speak until the piece ended. In the ensuing silence I briefly checked in verbally to see how she was doing. Clara was not ready to talk, but she gave a subtle nod indicating that she was in a good place and did not want to move or speak. I put on Om nama shiva ya, a quiet (E) and peaceful Hindu chant that offers a mix of voices (A) with a slow (E), flowing (W) texture like elongated (e) breathing patterns quite devoid of accents (F). I let Clara bask in this peace as I stood at her feet, gently holding her ankles (e contacts). She soon began to tell me about her experience. She said she had never heard music in this way before and that she felt pain, but all of the sudden it just lifted and she went into the music. She said that it filled her body and, as the different overlapping voices entered, she was aware of feeling them in her back and running through her limbs. It was the most amazing sensation of connectedness that she had ever had--an experience of healing, she said. Stage 4: Choosing Life--Braving the Elements and Receiving the Sun’s Light With Clara’s increasing strength and independence, she took on many new challenges as many traumas from her past continued to emerge over the next couple of years. She began to study several health and healing approaches, and incorporated other self-help tools and

techniques she had learned previously. Opening herself to others, she soon had a budding private therapy practice. However, the more she learned in the interest of helping others, the more she had to grapple with her own issues. She was growing fast and making many important life adjustments, such as changing what she would tolerate in friendships and family relations, dealing with authority issues with new teachers, and learning to let go of her ailing mother. However, feeling isolated and unable to focus on creating new, loving relationships, she was still suffering bouts of depression. We first addressed this theme just nine months into our work when she experienced it as something of a distant memory of an old despair. Using the first part of Bruch’s Concerto No. 1, we did an EMA session that she reported had a transformational effect on her mood. Three years later, when I thought she was feeling strong enough to embrace the tumultuous musical conflicts inherent in the compositions of Gustav Mahler, we did an EMA session using Mahler’s Second Symphony (The Resurrection) to revisit Clara’s looming death theme. Indeed, this music lived up to its name. The elements at play in this piece took her through an extraordinary journey, and while she shared some words during the process, I encouraged her to speak minimally so as to stay in her body sensations relative to the imagery she was actively experiencing. Given that there was not much time left in the session to talk after the music, and the fact that talking immediately after an EMA session can interrupt the necessary digestion and assimilation of the experience, I asked her to consider writing about what had happened so we could discuss it later. The following is taken from what she wrote: …I didn’t want to die but the desire to live was only a thread and the opportunity to go out of my body was there for me...So many times I could feel the music giving me the choice to die and ascend and go into ether (she understood this from my talk of Polarity) as I felt a sweet sinking, but then the desire to live would present itself and I would fight. I was fighting for my survival. I wanted to live. I had a life with promise and I wanted to live it. All my energy, every bit of me was focusing on my next breath…The music penetrated my soul and carried me along when I felt too weak. In retrospect I can say this session was life changing. I have for so long questioned my passion and desire to live this life. This session tapped into my passion, my desire, my love of life, my need to survive, and my strength and power. I didn’t want to leave this life without completing. Completing is a big issue for me. I have things to do and a life to live. I felt this whole session had to do with giving up or fighting to survive. I was supported through this whole process. Conclusion Indeed Clara’s life did change after this. Naturally, she continued to struggle in her life, but she never again questioned the point or purpose of her life. She continued to take on more challenging studies with various teachers and trainings so that she could better herself as a health and healing practitioner. As her work developed, we naturally blended personal therapy with supervision by addressing issues related to counter-transference as they became apparent.

In these years of working with Clara, I have witnessed her overcoming huge obstacles. To summarize these elementally, the process involved fanning Clara’s fire (A&F) to get it hot enough to melt the faulty and insecure aspects of her familial foundation (E) and then utilize the creative (W) movement provided by music (hearing = e) and touch (A) to mold a new form of support from a ground (E) substance that was now more purely hers--free of infiltration and unwanted introjects. Going forward, such a profound transformation has enabled Clara to have the sense of space and clarity (e) for herself to express the presence and solidity needed to take other people through the same kinds of troubled waters that she has now successfully navigated. Recordings “Om nama shiva ya” Sidda Foundation “Symphony No. 2” Gustov Mahler “Begin Sweet World” by Richard Stoltzman “Tehillim” by Steve Reich “Adagio for Strings” by Samuel Barber “Kougetsu” by Somei Satoh References Bart, L. (1960). Oliver. Musical Beaulieu, J. (1987). Music and Sound in the Healing Arts. New York: Station Hill Press. Bonny, H. (1978). Facilitating Guided Imagery and Music Sessions. Salina, KS: Bonny Foundation. Bosco, F. (1992). Elemental Music Alignment. (Unpublished master’s thesis). New York University. New York, NY. Bosco, F. (1997). Sensing and resonating with pain: A process-oriented approach to focusing the body/mind using music therapy. In J. Loewy (Ed.), Music Therapy and Pediatric Pain. Cherry Hill, New Jersey: Jeffrey Books. Bosco, F. (2002). Daring, dread, discharge, and delight. In J. Loewy and A. Frisch-Hara (Eds.), Caring for the Caregiver: The Use of Music and Music Therapy in Grief and Trauma. Silver Spring, MD: American Music Therapy Association, Inc. Kahn, H. I. (1983). The music of life. New Lebanon, NY: Omega Press. Kaptchuk, T.J. (1983). The Web that has no Weaver. New York, NY: Congdon & Weed, Inc. Keleman, S. (1985). Emotional Anatomy. Berkeley, California: Center Press. Keyes, E.L. (1973). Toning: The Creative Power of the Voice. California: DeVorss. Lad, V. (1984). Ayurveda: The Science of Self-Healing. Santa Fe: Lotus Press. Levine, P. (1997) Waking the Tiger. Berkeley, California: North Atlantic Books. Loewy, J.V. & Frisch-Hara, A. (2002). Caring for the Caregiver: The Use of Music and Music Therapy in Grief and Trauma. Silver Spring, MD: American Music Therapy Association, Inc. Lowen, A. (1976). Bioenergetics. New York, NY: Penguin Books. Perls, F., Hefferline, R. & Goodman, P. (1994). Gestalt Therapy: Excitement and Growth in the Human Personality. Highland, NY: The Gestalt Journal Press, Inc.

Sills, F. (1989). The Polarity Process: Life as a Healing Art. Longmead, Shaftesbury, Dorset: Element Books Limited. Stone, R. (1986). Polarity Therapy: The Complete Collected Works (Vol. I & II). Sebastopol, CA.: CRCS Publications. (Reprint of works originally published 1954–1957).

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

CASE THREE Rehabilitation of Piano Performance Skills Following a Left Cerebral Vascular Accident Denise Erdonmez Abstract This case describes the rehabilitation of piano performance skills in a 54-year old man following a left cerebral vascular accident (CVA). The CVA rendered the client expressively dysphasic and dyslexic, although his ability to play from music notation was unimpaired. Due to paralysis of the right hand, rehabilitation was restricted to performance skills in the left hand only. Weekly music therapy sessions were provided over a 3 year period. Assessments taken at 18 month intervals showed improvement in rhythmic short-term memory, keyboard dexterity, and the ability to play music of increased complexity in key and rhythm. These results support current knowledge that the brain compensates for areas of impairment through involvement of new pathways and strategies. Background Information John suffered a Cerebral Vascular Accident (CVA) infarct at the age of 54 years. A Computerised Axial Tomography (or CAT scan) confirmed the massive extent of damage to the left temporal and parietal lobes of the brain. John was rendered aphasic (expressive type) and hemiplegic on the right side of his body. John’s pre-morbid talents were quite impressive. He was a General Medical Practitioner with a busy practice; he spoke three foreign languages fluently (Latin, Italian, German); and he was a talented pianist and organist with a broad classical repertoire. Ten months after suffering the CVA, John was referred for individual music therapy. Tests had been carried out by several professionals, and the results made available to the author. The neurological tests revealed paralysis of the right arm and hand. This was his dominant side in that previously, John used his right hand for writing and all manual tasks. He had residual spasticity of the right leg which severely restricted his mobility. John also had leftright disorientation, and had lost half of the visual field in both eyes. The speech pathology tests indicated an expressive dysphasia, as some speech had been regained. John could speak short phrases, characterised by literal and verbal paraphasias (incorrect substitution of consonant sounds in different words). He had lost knowledge of all three foreign languages. On processing auditory information, he could cope with only 3 units.

He could read single words of several syllables, but not words of 3-4 letters such as “the” or “for.” Neuropsychological tests indicated that his I.Q. on the Wechsler scale was 117. He was well orientated in time and place and could count backwards from 20 to 1. His short-term memory was tested on digit recall (reproducing a series of random numbers), and John showed a memory span of only 3 units (consistent with the speech pathology tests). Music Therapy Assessment Upon referral, the author administered the Botez-Wertheim (1959) tests for amusia. Although no normative data are available, the tests are classified according to the subject’s musical training. There are 45 tests in the battery grouped under several sub-categories. Melodic And Harmonic Elements: John could vocally reproduce a series of individual notes with accurate pitch. He was also able to continue singing a known melody in AABA form when only part A was given, and recognise musical errors when played intentionally. He had difficulty differentiating major from minor chords and discerning the number of notes in a chord. He had considerable difficulty when asked to name notes in a music score, but could easily pick out the same notes on the keyboard. He also had difficulty playing a note when asked to do so by letter name. Recognition of intervals was totally beyond him: he could neither identify an interval, nor choose an answer if several options were put to him, e.g., “Is this a 3rd or a 5th?”. Rhythmic Elements: John had great difficulties with rhythmic tasks. He could identify the meter of a piece as duple or triple, but was unable to reproduce a rhythm either presented on a single note of the piano or as a melody—unless the pattern was less than 3 or 4 units in length. This finding was consistent with both the speech pathology and neuropsychology tests indicating a 3-unit memory span. Lexic Elements: When asked to play at sight a 12-bar melody in the key of G major with his left hand, John played with near accuracy, and made mistakes at a modulation point. Upon finishing the melody, he was able to identify the mistakes he made. He correctly translated the Italian terms (i.e., moderato, allegro) but said that the symbol “mf” meant “slow but loud and soft...then hit big!”. He could not name the one sharp in the key signature, but correctly played it throughout the piece. Singing And Whistling Tests: John was able to sing a well-known melody from memory without cuing. He was unable however, to sing from memory a melody of 8 notes played once by the therapist. He could sing scales accurately from a given note, and was careful to differentiate the characteristic intervals of the scale. Summary: John was unable to name notes in a score or when played; he was also unable to play notes when given their letter names; he could, however, correctly interpret these symbols and play the correct notes on the keyboard when reading directly from the score. This is not a musical dyslexia as such since there is no impairment in his ability to read, but rather in his ability to associate a letter name with a note. This is similar to a nominal aphasia where the person experiences difficulty in finding a target word. In the music context, we could term this impaired skill an expressive nominal amusia. (See Glossary for other categories of amusia).

John has the ability to sing in tune and sight-read music notation remarkably well, given his dyslexia for written prose. Rhythmic skills show the greatest impairment: he cannot reproduce rhythms or melodic rhythms of more than 3 notes (units), or sing from memory short examples of more than 3 notes (units). Method Following the initial assessment of music skills, John commenced weekly individual music therapy sessions. The aims of the sessions were: to rehabilitate John’s piano playing skills in his left hand; to extend his short term memory span for rhythmic and melodic phrases; to improve the rhythmic accuracy of his playing; and to extend the dexterity of his playing to include pieces of increasing difficulty. Each music therapy session lasted 45 minutes. A central activity was to have John play the treble line of piano pieces with his left (unimpaired) hand, while the music therapist played the bass line with her left hand. Opportunities were also provided for practising rhythmic patterns, singing familiar songs, and for relearning music terminology. During the week, John practised 1-2 hours per day of his own volition. He often selected new piano pieces, and therefore determined the pace of his own rehabilitation. Given John’s level of intelligence, and his pre-morbid professional orientation, it was essential that his rehabilitation provide as many opportunities as possible for decision making, initiative and selfdirection. Thus, each music therapy session commenced with work John had prepared, and ended with rhythmic exercises and other tasks planned by the music therapist. Treatment Process Music therapy sessions were carried out over a three year period with a re-assessment after 18 months. The First Eighteen Months At the beginning of the first 18-month period, John played pieces in the simple keys of C and G major. The pieces were elementary, with simple melodic lines which he played with his left hand, and chordal accompaniment played by the therapist. While it is customary to mark piano scores with fingering, this numbering system could not be used with John because he became confused by the association of the numbers with the fingers of his hand. In addition, John played the treble line (which is written for the right hand) with his left hand. Frequently, the line of the music followed the natural line of the right hand over the keyboard, and playing this part in the left hand created additional problems of hand positioning. Despite the inappropriateness of conventional learning aides, the therapist devised a number of ways to assist John in mastering the pieces. For example, an ‘X’ was used to denote the thumb, so that in learning new fingering patterns the thumb was placed correctly and the other fingers fell into correct sequence. Dotted rhythms in the melodic line frequently had to be practised in a range of ways to assist the internalising of the pattern. John would be encouraged to tap out the rhythm on a single note of the piano, or clap it on his knee, or sing the rhythm to on a “la.” It

was essential to introduce new methods of practising the same material as John had very high expectations of himself and became discouraged very easily. After 12 months of music therapy, John began to study the Bach two- and three-part inventions, playing as much of each piece as possible with his left hand. These pieces were more difficult than the previous pieces in several ways: the melodic line often had unpredictable changes in pattern; the melodic contour was frequently interwoven and linear in concept, whereas the simple pieces had been more vertical in concept; there were more accidentals and modulation points; and there was greater demand for finger dexterity, particularly when scale passages written for the right hand were transferred to the left hand. John showed remarkable perseverance in learning these pieces and his dexterity improved because of their contrapuntal nature. While the two-part inventions require playing one linear melody in the treble, the three-part inventions require the interweaving of two linear melodies, and consequently much greater finger independence, for the left hand. It should be noted that John had learnt some of the inventions at a younger age, however, for all practical purposes, each piece had to be mastered anew since his left hand was learning the right hand part. About this time, John took an interest in the art songs of Schubert and Schumann. He played the treble part of the accompaniment with his left hand, while the therapist filled in the bass part. The songs also provided an opportunity to sing the vocal line while playing the piano accompaniment. Often, singing these songs allowed John to ventilate some of his emotions, and afterwards he often tried to explain how frustrated he felt in coming to terms with his speech and motor impairments. At times, John showed liability in mood (as is characteristic of CVA clients), and he would weep during the playing of pieces and songs that were meaningful to him. Re-assessment after 18 months John was re-assessed on the Botez-Wertheim battery of tests after 18 months. On the rhythmic sub-tests (which are graded from 3-unit examples to 7-units), all examples except one, were reproduced accurately. A simple test of digit recall was also given, and John succeeded only on those patterns of 3-4 digits. His rhythmic memory had improved from a 3-unit span to a 7-unit span, however his memory recall for digits remained at 3 units. The advances made in rhythmic short-term memory did not generalise to digit recall, however it should be noted that rhythmic skills were consistently practised within the music therapy sessions, and digit recall was not. Progress in Third Year of Program John’s motivation for practice and increased self-confidence became apparent in the third year of music therapy sessions. His interest in art songs developed further, and we studied song cycles in their entirety. He found books on the composer’s life and wanted these read to him during music therapy sessions. He took an increasing interest in the development of certain motifs in one song, which he found in another song by the same composer in a later period.

His piano repertoire increased rapidly and he re-learnt the Beethoven Piano Sonata in G Major (Opus 79), and several of the Bach Preludes and Fugues. The span of his left hand developed to cover 10 notes, and this enabled him to play both treble and bass parts of some pieces with his one hand (e.g., Satie’s “Gymnopedies”). At the end of the third year, we were playing contemporary pieces of complex rhythms and complex key signatures, including Scriabin’s Etude in C# Minor (Opus 2 #1), and Hindemith’s “1922 Suite for Klavier” (Opus 26). His practice schedule remained at 1-2 hours practice each day. Discussion and Conclusions Each of the aims of the music therapy program was achieved. The first aim was to rehabilitate John’s piano performance skills in his left hand. At the commencement of the program he was playing simple pieces in uncomplicated keys. At the end of the program his confidence had increased markedly, and he was playing pieces written in difficult keys involving many accidentals. The second aim of the music therapy program, to develop short term memory for rhythmic skills, was also met. The initial assessment indicated a 3-unit memory span for rhythmic tasks. The follow-up assessment 18 months later indicated an improvement to a 7unit memory span, which is within acceptable or normal memory limits. The reason for this improvement may have been the consistent practise of rhythmic patterns within the music therapy session. Alternatively John may have developed or rehabilitated the ability to process rhythmic patterns in “chunks.” Sloboda (1978) in a study of sight reading strategies in musicians suggests that patterns of more than 7 notes may be processed as gestalt patterns rather than separate units of information. The fact that John improved on rhythmic tasks (which were practised) but not on recall of digits (which were not practised) suggests that consistency of repetition is a major factor in successful rehabilitation of short-term memory skills. The third aim of the music therapy program was to develop rhythmic accuracy in his piano-playing. At first, John experienced great difficulty with dotted or complex rhythms, but with creative approaches to learning and practicing them, John successfully regained the ability to accurately play complex rhythms, as was clearly demonstrated in the contemporary works of Hindemith that he mastered. Several factors contributed to the success of the music therapy program. First, John was highly motivated. Moreover, his high level of intelligence and commitment to practice enabled him to succeed in mastering pieces of increasing difficulty. Second, given the massive extent of damage to the left hemisphere, particularly the parietal and temporal lobes, it is evident that John’s brain effectively compensated for areas of damage, enabling him to learn new material accurately, which ordinarily requires analytical skills and logical thinking generally ascribed to intact left hemisphere function. This achievement is all the more remarkable because John was playing right handed parts with the left hand. This required the anatomical design of the right hand to be accommodated by a left hand of reverse anatomical design. The changed fingering patterns necessitated considerable practice and therefore contributed to the rehabilitation of several motoric skills.

This case study has similarities to a study by Luria, Tsvetkova and Futer (1965) of a composer and professor at the Moscow Conservatory, who suffered a CVA which caused damage to the left temporal and parietal areas of the brain. He suffered aphasia and sensorimotor deficits of the right side of the body, however he continued to compose and many of his later works are in keys requiring excessive use of accidentals. Other studies of musicians who have suffered brain impairment are sparsely reported in the literature, yet they provide valuable evidence for understanding how the brain processes music information. Different strategies are required for music tasks according to the musical ability and experience of the subjects, the processing strategy and the nature of the task. It is evident in this case study that new pathways for memorising short rhythmic phrases can be developed, and that short term memory spans can be increased. New motoric skills can also be acquired (e.g., playing right-handed music with the left hand), and improvements can be made in speed and dexterity of performance. It is also possible to devise new strategies for deciphering music and for coping with the complexities of key signatures, accidentals and rhythms in contemporary music. In terms of theoretical orientation, this case study describes a process of rehabilitation over a long period of time. The initial degree of impairment was severe and a music therapy approach was needed to encourage John in the slow advancement from simple pieces to complex. As John was highly self-critical, various approaches had to be taken to keep his selfesteem and confidence focussed on more positive aspects of the rehabilitative process. It was essential to stay “with him” when he skipped a measure, or a line of music, or if the rhythm was incorrect. Creative and spontaneous practice mechanisms needed to be offered by the therapist, so that inaccurate sections could be practised without a concomitant loss of confidence. On many occasions during the singing and playing of art songs, John became emotionally upset. CVA patients with language impairments have immense difficulty in adequately expressing feelings of frustration and depression. In John’s case, the lyrics of the various songs became clear projections of his feelings. One song cycle in particular (Schubert’s “Winterreise”) was particularly helpful in dealing with issues of blame for the CVA. The song cycle expresses many aspects of human suffering: coldness, rejection and despair. The depth of emotion in these songs often reflected John’s own suffering and enabled him to express it. The client’s wife expressed on many occasions how important the music therapy sessions were for his rehabilitation. Music became the focus of his life and gave him a purpose for his existence. Prior to the CVA, John had been a keen, amateur landscape painter. Following the paralysis of his right (dominant) hand, he taught himself to paint with his left hand, submitting his paintings to local competitions and winning prizes. The success and extent of John’s rehabilitation is attributable as much to his indomitable spirit to overcome adversity as to the efficacy of music as therapy. Glossary Amusia: the loss of, or impairment to music function. Henschen (1920) identifies sub-categories of amusia as follows (Also see Benton, 1977): 1. Motor Impairment - Expressive Amusia

a. Loss of the ability to sing (oral-expressive amusia) b. Loss of the ability to write musical notation (musical agraphia) c. Loss of the ability to play an instrument (instrumental amusia or musical apraxia) 2. Sensory Impairment - Receptive Amusia a. Loss of recognition of familiar melodies (amnesic amusia) b. Loss of the ability to read musical notation (musical alexia) 3. Musical deafness, including loss of recognition of familiar melodies. 4. Loss of ability to read musical notation. Aphasia: A disorder of communication in which there is a complete loss of the ability to speak (expressive type) and/or comprehend speech (receptive type). Cerebro-Vascular Accident (CVA): Commonly known as a “stroke,” CVA occurs when there is a blockage of blood supply to the brain which causes damage to tissues of those areas deprived of oxygen. It may be caused by an embolus, hemmorhage or thrombus. Effects on the sufferer are determined both by the site of the blockage and the extent of the area involved” (Bright, 1989). Computerised Axial Tomography (CAT scan): A method of imaging brain anatomy using different planes (vertical, horizontal) to detect damage. Dysphasia: A disorder of communication in which there is impairment (but not complete loss of) the ability to speak (expressive type) or comprehend speech (receptive type). Dyslexia: Impairment in the ability to read. Infarct: Dead tissue as a result of lack of blood supply. Hemiplegia: Paralysis or weakness of one side of the body. Following a CVA, the contralateral side of the body is affected. Paraphasia: There are two types: (1) literal paraphasia, which is the transposition of consonant sounds from beginning or ending of words; and (2) verbal paraphasia - substitution of an inappropriate word when attempting to say a target word. Pre-morbid: Before the onset of illness, disease or symptoms. References Botez, M.I. & Wertheim, N. (1959). Expressive aphasia and amusia. Brain, 82, 186-202. Bright, R (1989). Why Does That Happen? Discussions on Geriatric Care. Wahroonga, NSW: Music Therapy Enterprises. Henschen, S. (1920). Klinische und anatomische Beitrage zur Pathologie des Gehirns (5): Ueber Aphasie, Amusie und Akalkulie. Stockholm: Nordiska Bokhandlen. Benton, A. (1977). The amusias. In M. Critchley and R. Henson (Eds.), Music and the Brain Studies in the Neurology of Music. London: William Heinemann Medical Books Limited. Luria, A., Tsvetkova, L., & Futer, D. (1965). Aphasia in a composer. Journal of Neurological Science, 2, 288-292. Sloboda, J. (1978). The psychology of music reading. Psychology of Music, 6 (2), 3-20.

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

CASE FOUR The Case of Paula: Music Psychotherapy with a Musician Joanne Loewy Stephan Quentzel Introduction This chapter is based on music psychotherapy sessions that took place at an outpatient center for musicians. This center is part of a large medical institution in New York. Paula was a musical prodigy who was referred to our center by a fellow musician and friend. She was involved in 44 individual sessions over a period of approximately 14 months. Central to this treatment were aspects of self-care, musical intimacy, awareness, and trust. This included using music for self-care, which often was in contrast to the music Paula might have played in performance. One important philosophy of our work with musicians, illustrated in this chapter, is the desire to recover creativity and aspects of health and spontaneity, which eventually lead to integration of the ‘true self’ with the ‘performer self.’ Specifically, musical play was addressed as a forum for repartee - an expansion of the ability to seek an authenticity of self through discovery of music used in the context of its application to the self. Foundational Concepts The Center for Music and Medicine, from which this chapter is drawn, treats musicians and performing artists who have specific medical and health needs related to the unique physical, mental, and emotional demands of their profession. This includes treating musicians whose performance may be stifled by overuse injuries, psychiatric challenges, anxiety, chronic fatigue, focusing difficulties, and/or the various side effects of medications (e.g., tendon inflammation). Performers often report a high incidence of depression and chemical dependency (Cuyjet & Tolson, 2007), and this has been reported in the literature for jazz musicians as early as the 1960’s (Winick, 1960). The mission of the Center is to provide musicians and performing artists with health services tailored to their unique needs. Each musician and performing artist can receive low-cost medical treatment in conjunction with select, specialized music therapy services. Our clinic’s medical director specializes in integrative medicine and psychiatry, while the music therapists specialize in music psychotherapy. The Center’s integrative-bio-psycho musical approach (Quentzel & Loewy, 2010) addresses the unique ailments specific to performing artists and musicians. The Center’s interdisciplinary

team of medical professionals and music therapists provide traditional medicine with complementary mind-body approaches. Each musician, upon intake, receives both medical and music therapy consultations, which include a comprehensive history and physical exam, review and evaluation of his/her chief complaint, and proposals for treatment modalities. The music therapy assessment (Quentzel & Loewy, 2010) includes a full music history, music psychotherapy evaluation, and a performance history along with an assessment of future music therapy interventions that might address the patient’s symptoms and potential. In follow-up medical treatment, referrals to our team of consulting physicians cover a wide range of specialties that include neurology, acupuncture, pulmonology, pain medicine and palliative care, neuromuscular and electromyography neurology, rehabilitation and internal medicine. Follow-up music therapy services may include treatments by our team of consulting music therapists in the following areas: 1) Music ergonomic-posturing, which focuses upon adjusting and/or altering the way music is played and the musical environment in which one plays, to assist in the avoidance of overuse that contributes to repetitive strain injury, 2) Music visualization, which focuses on relaxing mind and body to alter one’s perception of tension and/or to evoke the potential of healthy inner resources, 3) Sound vibration, in which vibratory instruments are used to address and alter the client’s perception of pain and/or anxiety, 4) Music and breath entrainment, which uses the inherent structure and shape of music to create flow and enhance the patient’s feeling of space, in order to ease the fear and constraints of breathing, 5) Tonal intervallic synthesis, (Loewy, 2011) in which tones and sounds are used to create consonance within the body, and 6) Rhythmic release, where repetitive rhythms, drumming and triplet metered holding (in both structured and non-structured musical motifs) can provide a physical/emotional/spiritual release. Music Psychotherapy Since music is often a musician’s means of livelihood, and is strongly associated with feelings of self-worth and/or self-hate, it can often be a source of problems for a musician. Being inside the music experience with the musician client can address these issues in a unique yet delicate way. Using the ‘Tour of the Room’ assessment approach (Loewy, 2000) presents opportunities to explore the musician’s musical and performance history. The ‘Tour of the Room’ also includes demonstrations of all the sounds/instruments in the room and provides a means for the client to make associations with each of these sounds. Playing music of choice for and with the therapist may further elicit memories or expand current experiences. This might include stories related to the experience of performance. The outcomes may include identifying problems related to pain from overuse, chronic fatigue, anxiety and/or a host of other situations that are accompanied by fears, anxiety, loss of confidence, or renewed feelings of success that shape the musician’s identity. Central to the Center for Music and Medicine’s approach to clinical care is music psychotherapy, which utilizes music and the context of a musical relationship, to provide opportunity for self-growth and insight. Clinical music improvisation is vital to this approach and involves creating spontaneous live music by oneself or with a music therapist on an

instrument (or instruments) that is either familiar or unknown. The created music can provide a spontaneous forum that uncovers intra-psychic tendencies. Clinical improvisation may give insight into unconscious issues and into the interpersonal tendencies that are often encapsulated by the role one tends to assign to the music. Analyzing and making conscious one’s relationship with music, musical others and the subtle referential role that music and musicians tend to play in everyday living can be life-changing. The musical relationship that develops in the treatment of musicians is complicated in the sense that the music therapist is constantly seeking to understand the transference, and counter transference, not only in the relationship between client and therapist, but also between the client and the music, and in doing so, providing insight into the problems and resources of the client. The Client Reflections on Treating a Music Prodigy Paula was a renowned jazz musician who was referred by a friend who was concerned that the client had not been able to leave her apartment for several years. He was worried that her medical condition was worsening, though he could not say exactly what it was she was suffering from. Nevertheless, he believed that our Center was using what he referred to as “music-based healing” and upon arranging an appointment, promised that her nurse would be able to accompany her to come see us, if we could arrange car service. Two weeks later, Paula was rolled into our clinic on a stretcher. The transport medics lifted her from the stretcher to a special large padded electronic wheelchair that we borrowed from the day surgery department. This is only important to know because the transport team and the process of lifting Paula from the stretcher to the modified gurney each week became a ritual, and as such, there were notable transitional elements. Paula was a large woman. This, combined with her rapid-fire nervous joking, her disarming though somewhat gruff and unfailing ability to say the right thing to the transport medics, and her uncanny ability to use flirtation coupled with her dramatic cries if not touched exactly the right way, made for a prolonged transition from stretcher to chair. It was a memorable weekly experience. This is not to imply that physical motion was not a true hardship for her, or that we were not empathic to her continuous apparent discomfort in moving. There was, however, an undeniable ease yet simultaneous sense of entitlement in the way she treated the five people assisting her in the weekly transition that seemed to be indicative of her many years of concert touring. She was the quintessential diva! Memorable were Paula’s familiarity with the entourage and her grace in entertaining everyone involved as she demanded as much as possible from every person around her during transitions in and out of her music therapy sessions. Her grace, however, taken one step further, resembled manipulation more than it did charm. This giant of the jazz world was insecure and rejectionsensitive enough to feel drawn to test how far she could push our loyalty and responsiveness. Today, approximately seven months after her death, we find ourselves still feeling compelled to review and rediscover the extremely sensitive aspects of treatment that emerged, especially in the cross transferences between music prodigy and music psychotherapist. We are grateful to have recorded a pivotal mid-point music therapy session on DVD, which we analyzed

as part of this chapter. This case highlights a few of the significant and delicate issues, nuances and treatment perspectives that can arise when treating performers. Paula’s History Paula was an African American woman, one of two sisters from a large family. She studied classical piano as a young girl in the 1930s. In her music therapy sessions, she often remembered playing the piano for governor’s events in his mansion at the age of two. Paula was a frequent music contest winner as a child and her early interest in jazz as a teen afforded her an invitation to play in neighborhood bars. Eventually, as a very young woman, she earned opportunities to play music abroad with several well-known big band leaders. Paula studied at a mid-Western university and worked with local west coast bands in the late 1940s, well before graduating. She relocated to New York City in the mid 1950s, playing cocktail lounges and developing her own style as a singer and performer. At the same time, she accompanied a variety of well known jazz vocalists. Her compositions include several recognized jazz tunes. Her big band recordings number in the hundreds. Paula was chosen to perform at the Kennedy Center in the late 1990s and at the Apollo Theater at a national jazz event several months before her death. The Therapeutic Process The First Meeting We distinctly recall approaching Paula in the hallway outside our clinic in preparation for our first session. She was screaming, complaining of pain, and refusing to move off the stretcher onto the wheelchair in order to enter our clinic. The transport team was in need of the stretcher Paula was lying on in order to go to their next job. They seemed frustrated and were concerned about being late for their next pick-up, but our wheelchair was standard and not perceived as comfortable by Paula. As she caused this great commotion, Dr. Quentzel, knowing of an oversized padded electric wheelchair in the surgery recovery room, went to retrieve it for Paula. Early in the transportation process, upon hearing her moaning and the commotion outside our clinic, and not quite knowing what to expect, I grabbed my guitar and met Paula with music outside in the hall. My hands fell into a bass line vamp that was grounded in the key of her screams. Amidst her delight and quieted moans, I worked myself into an “I Can’t Give You Anything But Love” improvisation with lyrics of “…soon we’ll go on in the music room…P-au-l-a (spelling out her name). This delighted Paula and she sang back to me and the medics as we waited for Dr. Quentzel to retrieve the recovery room chair. She also improvised to strangers passing by the hallway--patients and families going to other clinics. She was receptive to me and called me “darling.” In two bars, she had the medics smiling and dancing, seemingly forgetting about their other routes. She had mustered a small crowd around her and appeared to be slowly rising to a ‘sit-up’ position on the stretcher. My bass line kept flowing effortlessly, and we were scatting in harmony. Before Paula had ever appeared inside our clinic, she had our medical director serving as a transport aide and her new music therapist holding a walking bass on guitar. At the

final cadence of I Can’t Give you Anything But Love we glided into Oh What a Beautiful Morning, Ray Charles-style, in 3… “I played for him (Charles)…” she announced. We were all listening, as my bass line shifted into chords. I thought to myself: how did she know I liked to play in three quarter time? We were all in the ‘music sphere’ - a manager from another clinic whom we rarely saw outside of her office, the director of phlebotomy, and the chief pediatrician from another clinic. Everyone was watching and some were even singing. This was a like a gig, I thought to myself, and we were all musically infatuated. Treating Paula Infatuation soon led to heavy reflection and several consultations with our team prior to her second session. We prepared in advance for the padded electric wheel chair to be ready so as to generate an easier transition for the medical transport team that was bringing Paula to session two. We learned from session one much of Paula’s medical and psychosocial history. She was 75 years old and the youngest of eight children. She had been bedridden for years due to her legs being crushed by an auto hit-and-run accident some years earlier. Her medical problems were multiple: diabetes mellitus, cataracts, hypertension, multiple motor vehicle accidents, gross atrophy of lower limbs, peripheral neuropathy, peripheral vascular disease, degenerative disease of the lumbar spine, vision problems, and moderate anxiety. Her husband had died 25 years ago. Her only son died in a shooting in his late 20s. Paula was alone, with several friends and home health aide, but “mostly alone,” as she explained. The First Six Months The first stage of treatment usually involves listening. In a music psychotherapy context, this entails building trust. Though tempting to come quickly and directly into musical play, the building of a dynamic emerges most naturally when the therapist hears from the musician and listens openly: “What does the musician come in with, and what is s/he choosing to play in the first moments of our musical meeting?” These are essential questions to ask early in the music psychotherapy relationship. The first month of Paula’s sessions was spent listening: listening to her music, listening to her stories about musicians, and to the litany of ups and downs she had experienced in playing with many prominent jazz musicians. Notably, as I eased my way into playing with Paula, there were recognizable resistances. She would typically speed up her tempo and transpose us into a key a half step higher than the one we had begun in. At first this seemed to be a natural elevation, but at other times, this would not occur at a cadence or bridge, but seemingly would occur ‘out of nowhere.’ It felt as if it was a challenge, or more specifically a test: Could I follow? It was a challenge I rather enjoyed! Paula’s greatest acceptance of me musically was when I would harmonize with her. She remained on the melody and would smile with delight when I decorated her melodies. This happened in the latter parts of our work together. She also enjoyed medleys of her own design, which occurred as part of the musical soliloquies she would share. Paula had countless stories of traveling on the road through her relationships with jazz greats and movie stars. I worked

hard to discern what was important and applicable to Paula’s issues and what was merely ‘sensational’ and seductive to our musical and personal relationship. A Turning Point Paula’s favorite tunes to sing and play included “Tomorrow” (jazzy arrangement), “Feliz Navidad” (jazz style) and “Lush Life” (slow and heart-felt). She was a personal friend of Billy Strayhorn, and the story I heard her repeat more often than any other was the day he happened to step into a bar in which she was practicing piano. She had not seen nor heard anyone enter and was unaware that her practice was being evaluated. Evidently, Strayhorn (the composer of “Lush Life”) was taken by Paula’s interpretation of “Lush Life” and relayed that her rendition was the way he had “meant it to be played,” and the finest he had heard. For Paula, the rest was history. One of Paula’s favorites to play was “Lush Life.” This story reminds me of how the musician often builds a significant repertoire based on the feedback of others, rather than the inclusion of repertoire based on the performer him/herself. How one gauges one’s own creative process often takes a back seat in repertoire building. This inner nurturance can be replaced by an outer image, which is built upon the feedback and approval of others. In a way, this takes away our own feeling about our music and how we play it, and in so doing, we may be diminishing an authentic level of self growth and discovery. This aspect of ‘art,’ as representative of the ‘self,’ involves a critical self-evaluative process that many musicians and performers find is worth investigating because it not only influences how they play, but can permeate into themes of self-fulfillment outside of music. For Paula, there were often instances where she would recall stories of jazz greats, people with whom she had enjoyed playing, which included those who had appreciated her genius. At the same time, there was a marked separation in what she had identified as her own process versus what others had demanded of her. There were feelings related to stories of being “burned” or mistreated, and these often involved the ideas and egos of other musicians, whom she did not feel appreciated her enough. There was a part of Paula and her music that she saw as being taken advantage of. Session 24 was particularly important in Paula’s therapy, providing insight into several dimensions of the therapeutic process: the sequence of the session, the main issue(s), the treatment strategy, the music and our musical relationship (Table 1). At this juncture, we were reflecting on the session prior, where Paula had ended with a poignant rendition of “Little Girl Blue:” Sit there and count the raindrops, falling down on you. Old girl, you’re through. All you can do is count the raindrops. Unlucky, little girl blue. This session was unusual in that she had trusted my song selection, and then worked with my tempo and arrangement. At this point she had been going through a particularly difficult time. She shared that her home health aide had hit her and taken her wallet. Evidently the police had taken their time in responding to her call. She reflected that most of her home health aides had been inattentive and that several had robbed her. Playing “Little Girl Blue”

toward the end of our session seemed to reflect a point of tenderness and hopelessness for Paula. Once she had been transferred to her chair and the keyboard placed on top of it, I brought up the last session and how her rendition of “Little Girl Blue” had stayed with me.

Paula continues, “That’s the problem with them [famous musicians]…the magic is tragic. We had a great day when we first played together. It’s sad because the stars see themselves doing what they were doing, before when all the lights were on, and when the lights were dimming, they can’t face it.” Realizing that she has not only disclosed about the “Happy Talk” star, but perhaps also about herself, she reflects on her own struggles with her sister growing up. “My older sister was sent to a conservatory while I always traveled with people who saw themselves in ‘lights.’ I’m not really needing to know how to take care of myself, I can do that….” I respond, “I know you can do that, I see you can do that…this film will show you directing with lots of song themes of how to make yourself happy…and…you know how you say you always trust ME, well I trust YOU…especially the things that come for YOU when you play, very important themes….” Paula then reflects “I need to get away from people that are trying to hurt me…” (referring to aides and nurses). Joanne directs Paula back to music improvisation based on a good-bye theme. Paula speaks about her upcoming gig, the first in ten years. We discuss resourcing options for a wheelchair and transportation.

Session Reflection For the first time, Paula allowed me to play with her for an extended period, and furthermore, she allowed me to lead. Much of my work in previous sessions had been listening to her play and talk. This was critical to our relationship, but also seemed to reflect her general sense of isolation. Listening to her in earlier sessions led us to this point of improvisatory play. In so doing, it helped her to admit her depression and lead her to find resources to cope. The more she sang and played, the more she was able to recognize her deep need to perform again. Paula became more collaborative in future sessions, especially once we had watched the film of the session. She reflected that “we had good musical ideas” and she also claimed to understand music therapy and was impressed by how it visibly influenced her mood and sense of self, especially in our improvisatory moments. After this session, Paula complained less and seemed to be excited about getting back on the stage. Her desire to perform and to become more physically independent reflected greater risk-taking and increased coping skills. Throughout her turbulent final years of life, several themes emerged and crystallized in the course of her music therapy treatment at our center. The strongest, ironically, was her deep desire to walk. This grossly unrealistic desire came alongside her weekly resistance to discuss the use of a wheelchair. She adamantly claimed that using a wheelchair would limit her and would keep her from her ultimate goal of walking. This belief did not seem to foster resilience, but rather built unreasonable expectations, which ultimately would seem to defeat her ability to recover her own ability to be mobile. Her unstated goal, of freezing herself in the ‘sick’ role, worked like a charm.”I will walk again--wait and see” she would say, accepting little discussion that “any wheelchair” would be a first step to sitting up and gaining independence. It was believed by the team that the only reason she used the oversized wheelchair to come into the music therapy center was because the stretcher would not fit through the door. Incidentally, she also used this type of wheelchair in her last public performance at a jazz event that occurred at the Apollo Theatre a few months before her death. She told us that at that performance, she had reconnected with a podiatrist who promised her he would treat her personally and would have her walking again in several months. The first step to this process was to admit her to a nursing care facility near to his office, which he did several months before her death. We received several calls from Paula from that facility. The first two were shortly after her admission. She was seemingly positive, yet there were no details about how her ambulation challenges were being treated. She avoided the topic altogether. It seemed she mostly wanted a personal connection with me. “I miss you girl…and how is Quentzel?” she said a few times. A month later, she called and spoke of being in “hell” and that she was “trying to get out.” We had no access or phone number for the nursing home, and the podiatrist’s number was disconnected. Paula promised to be back at our Center soon. Three months later, Paula passed away, but we did not hear for several months until her referring friend called to invite us to her memorial service, which would be attended by an international mix of jazz greats.

Conclusion We have appreciated the opportunity to study, research, present and share this work. In an important way, Paula’s brilliance and our learning of how to treat issues delicate to music and musicians remain significant for us. Music resistances as well as the vulnerabilities of what genius musicians can tweak in the music psychotherapist provide a deep learning and perhaps a path for Paula’s legacy to live on through the understanding of focal themes within this treatment context. References Cuyjet, M. & Tolson, G. (2007). Jazz and substance abuse: Road to creative genius or pathway to premature death. International Journal of Law and Psychiatry, 30(6), 530-538. Loewy, J. (2011). Tonal intervallic synthesis as integration in medical music therapy. In F. Baker & S. Uhlig (Eds.), Voicework in Music Therapy (pp. 253-266). London: Jessica Kingsley Press. Loewy, J. (2000). Music psychotherapy assessment. Music Therapy Perspectives, 18(1), 47-58. Quentzel, S. & Loewy, J. (2010). An integrative bio-psycho-musical assessment model for the treatment of musicians: Part I-A continuum of support, Music and Medicine, 2 (2), 117120. Quentzel, S. & Loewy, J. (2010). An integrative bio-psycho-musical assessment model for the treatment of musicians: Part II—Intake and assessment, Music and Medicine, 2(2), 121125. Winick, C. (1959/1960) The use of drugs by jazz musicians. Social Problems, 7, 420-253. Appendix of Songs “I Can’t Give You Anything But Love, Baby” (1921) by McHugh and Fields, Columbia Records. “Oh What A Beautiful Morning” (1943) by Rodgers and Hammerstein, Williamson Music. “Tomorrow” (1982) by Strouse and Charni, CBS. “Lush Life” (1949) by Billy Strayhorn, Verve “Little Girl Blue” (1957) by Rodgers and Hart, AMC “Make Someone Happy” (1935) by Styne, Comden and Green, DRG. “Happy Talk” (1947) by Rodgers and Hammerstein, Columbia.

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

CASE FIVE Protect This Child: Psychodynamic Music Therapy with a Gifted Musician Louise Montello Abstract A gifted musician (former child prodigy) with a history of childhood abuse reconnects with her essential musical intelligence (EMI)--the innate capacity to use music as a selfreflecting transformational tool--during a four-year engagement with psychodynamic music therapy. The musician, plagued with a false-self personality constellation and symptoms of post-traumatic stress disorder, is guided in using her own music (instrumental and vocal improvisation and songwriting) to facilitate the expression of her authentic self and to discover her true purpose in life. Introduction Gifted musicians usually work until they break down. Witness the growing number of well-known musicians who end up in rehabilitation centers with psychological and/or physical maladies. It is obvious to me that show business is not for the faint of heart. However, it is this very personality--the fragile artist--who is often thrust into the spotlight by power and moneyhungry parents, teachers, managers, etc. to become, as one client described, a “dancing clown,” competing with other “dancing clowns” under the strictest media imposed rules and regulations for achieving success. It is hard enough for normal talents to play this fame game. Prodigies, however, have several strikes against them to begin with: Often they grow up too fast, having been given demanding adult responsibilities at a time when they should be exploring their inner and outer selves through that remarkable invention called play. This inappropriate “fast lane” orientation to life results in a productoriented, often perfectionistic individual who is unable to relax and smell the roses. Prodigies are typically used by narcissistic adults, who project their own frustrated desires onto their young charges. In this way, the young gifted musician develops a “false self” and lives an “as if” life, relegating their true self/destiny to the back burner. By nature, many prodigies live on the razor’s edge between fantasy and reality, and more than anything, need compassionate and wise mentors to help them in navigating their journey through life. Many prodigies do not receive this kind of nurturance and care and are instead robbed of their innocence and childhood.

The musical prodigies with all three of the above strikes are the ones who eventually break down and disappear from public view, only to reappear in some new improved version after a quick fix and a new manager appears--that is, if they are lucky--or are they? What follows is a case study of my work with an accomplished musician whose prodigious talent was both a gift and a curse. She was drawn to music therapy because of her ambivalence around her relationship with music. Through psychodynamic music therapy, she was able to connect with what was real about music and to use it to transform her life. Background Information Jennifer, a gifted thirty-two-year-old professional jazz pianist, was referred to me by a physician who worked with injured musicians. She was suffering with severe tendonitis in her left forearm, along with extreme performance anxiety. Both disorders had reached the stage where they were beginning to interfere with Jennifer’s performing obligations. Jennifer originally came to see me for a series of stress-management sessions to deal with her anxiety. One of the first techniques that I usually teach musicians for stress reduction is breath awareness and diaphragmatic breathing. While practicing these breathing exercises during our second session, Jennifer became aware of her tendency to hold her breath. I also noticed that her diaphragm was rigid and that she was physically unable to take a full breath. As she began, with some coaching from me, to let go and allow her to breathe into her belly, Jennifer experienced what she described as waves of anxiety and terror, coupled with flashbacks of being chased and physically abused by her mother when she was a child. These feelings/ flashbacks motivated Jennifer to begin individual psychodynamic music therapy with me (once a week) during the periods of time that she was not touring. Jennifer was the only child of parents who were both gifted artistically, but at the same time frustrated and unfulfilled. Her mother had been a successful opera singer who was now teaching singing full-time at a neighborhood music school. Jennifer’s father, a gifted painter, was, in Jennifer’s words, forced to teach in the public school system to provide for the family. She described her father as being severely depressed for most of her young life. Jennifer characterized her mother as being angry all the time. She never knew when her mother would fly into a rage and become verbally and physically violent. Jennifer was not allowed to be angry or act out herself because, according to her mother, it might cause her father to have a heart attack and die. Jennifer was a musical prodigy who excelled not only in singing, but also on clarinet and piano. Her father delighted in her talent, while her mother was controlling and, at times, envious and abusive. She was primed from a young age to be a diva--taking lessons from her mother and other distinguished teachers, going to the opera almost every weekend, etc. Although she loved to sing pop music (i.e., Joni Mitchell, Steely Dan) her mother discouraged her from pursuing it. She had disdain for the “natural” voice. Jennifer’s earliest memory of music was of being the center of attention while making up her own little songs with her father. Another fond memory was of her toy opera theater. As a young girl, Jennifer would regularly retreat to her room and create her own musical dramas for hours with paper dolls, as a way of coping with difficult feelings and desires. Her most traumatic memory as a young child involved the destruction of her beloved transitional object

by her mother. Jennifer described this scenario to me as being a significant loss that left her feeling completely betrayed and alone. When I was around three years old, I had a favorite stuffed animal, “Tony the Tiger” that I carried around with me everywhere I went. He was so worn and dirty and smelly and I loved him more than anything. One day, my mother was cleaning the house in her usual frenzy. I was playing in the kitchen with Tony as usual. Mother was in a foul mood and told me that Tony was disgusting. She grabbed him out of my hands and tossed him into the incinerator. I just remember screaming and shouting until I passed out. When I came to, I realized that Tony was gone forever. I was devastated for days and felt like I just couldn’t go on living. Mother didn’t understand. She said it was just a smelly old toy and wanted to buy me a new one. I don’t think I was ever able to trust anybody in my life since then. From that point on, Jennifer reported that she was repeatedly abused, both emotionally and physically, by her mother--a large, rageful woman. She remembered a particularly shocking experience that occurred when she was approaching puberty. Her mother was a fan of romance novels and devoured them one after another. When she discovered Jennifer masturbating one day, she shamed her mercilessly and then proceeded, in Jennifer’s words, “to instill the fear of God” in her with regard to sex. Jennifer was confused--she was aware of how much her mother enjoyed her romance novels, and yet she [Jennifer] was not even allowed to entertain the thought that sex could be pleasurable. Her mother had also disclosed to her around that time that she and her father did not have sex. This was similarly perplexing for Jennifer, particularly when she was often placed in the role of “surrogate spouse” to her father. All through school, Jennifer was a brilliant student who was easily bored by her teachers, both academic and musical. According to Jennifer, teachers started to resent her precocity and arrogance from an early age. Her first piano teacher was abusive and mean. Her band teacher humiliated her in front of her classmates. In response, she began to develop a “false self”--a compliant, yet arrogant, “holier than thou” persona--and relegated her true self to the back burner. Her goal was to impress people as opposed to expressing her truth. In Jennifer’s words, “I was like a dancing clown.” She resented the fact that she had been deprived of having a real childhood. At the same time, she also felt an overwhelming sense of entitlement. Around this time she developed a perfectionistic attitude where she would have to be the best in order to win her teachers’/parents’/friends’ approval. This desire to be perfect occasionally backfired, creating more and more tension in the young prodigy. Her final blow came from a famous opera singer who mildly criticized her singing when she was 14 years old. Jennifer immediately decided to give up singing and to pursue something where she could be the absolute best and become famous. She was convinced that this would free her from the abuse and abandonment that permeated her world. In order to separate completely from the world of opera (and her mother), Jennifer decided that she would become a famous jazz pianist. She thought this would be easy and it was--up to a point. At age sixteen, she attended a noted jazz summer program where she excelled as usual. She became the center of attention and, finally, began to achieve a sense of self-worth. At the same time, however, she repeatedly experienced frustration and humiliation in her teenage sexual encounters. She explained that boys looked up to her as a role model, but did not desire her. She grappled with feelings of guilt, shame, loneliness, and grief associated with rejection. She dealt with her depression by working harder, again feeling that if only she

was the best she would finally be loved. She also saw herself as the rescuer of her family. If she could become famous, then maybe her parents would finally have money and esteem. All during her years at a famous conservatory, Jennifer excelled. She spent eight to twelve hours a day practicing and was very competitive with other students. Her self-esteem came only from her achievements. Her sexual life continued to be skewed in early adulthood. She connected with men who were needy and less talented than she was which eventually led to envy, conflict, and then abandonment, mirroring her relationship with her mother and father. She had conflicts around her sexuality, and was unable to let go and enjoy sex. Jennifer could only have an orgasm when she thought about violent things in advance. Trauma literature (Davies & Frawley, 1994; van der Kolk, et. al., 1996) suggests that when a child is physically and/or sexually abused by a parent, she becomes sexually fused with that parent and tends to seek out similar relationships as an adult. Or, she may choose the extreme opposite-for example, a man who is not interested in sex and/or is impotent. Jennifer would grapple with this dynamic for years to come. After conservatory, Jennifer’s career as a jazz musician took off. When I asked her about her experience recording her first album, she replied, “I wrote music that sounded like someone great... something that people would think was intellectual.” She explained that it was all about getting the deal, not the music. At the age of twenty-five, Jennifer still maintained her student mentality: “I’m gonna die if I’m not the best. Everything I did was geared toward survival.” Jennifer came to New York from Chicago and got a tour with a successful smooth jazz artist. When his record went gold, it triggered in her the desire to become a star. She told me, “The only thing I’ve known is to scramble for gigs--but I hated them all--especially being on a tour bus with a bunch of guys.” She then joined a more mainstream jazz band. She enjoyed the fact that the music was more intellectual. This band felt like family. She explained that the leader and she had become competitive. She wanted it to be her band. She continued, “He beat me into submission and became an evil mentor like my piano teacher.” While she was playing with this band, Jennifer felt like she had to work harder because she was a girl. She practiced eight hours day. She started holding her breath. “I couldn’t relax,” she told me, “...it wasn’t safe... the drummer and the bassist wanted a guy pianist.” She continued, “Women in jazz are blown off constantly... I was so egotistical... I had no center. Being blown off was like being shot.” Music Therapy Assessment Before I began to see Jennifer for individual psychodynamic music therapy, she had asked me to hear her perform with her band at a local jazz club. While watching Jennifer play, it was clear to me that she was experiencing both physical and psychological tension. Jennifer was holding her breath much of the time while playing. She also held tension in her arms, hands, and jaw. I observed the group dynamics of the musicians on stage; there was an air of competitiveness among the players. Jennifer seemed to be playing defensively, pushing away the other musicians with her improvisations, as opposed to welcoming them in. The music was loud, driving, filled with tension. Jennifer seemed nervous, frightened, and angry at times on stage. She often pounded the piano throughout the set. Jennifer’s music displayed technical

prowess, but not much emotional expression. Her true expression seemed to be swallowed up by her defensiveness. In processing the assessment the following day, Jennifer described her feelings about the performance. “I was feeling a lot of anger and rage. I felt like I had to be better than everyone else in order to survive. I just deal with it [the tension]. I was thinking--you should be grateful you have a job.” In talking about the roots of these beliefs, Jennifer related them to early childhood experiences that were uncomfortable. “I had to be the best in order to gain my teachers’ favor and be deemed worthy. Physical abuse was not uncommon. I felt like I would have to take tough love in order to be worth anything. Musicians--like children--have no choice but to take it. It’s like the ‘be-bop’ mentality--shut up and take it, and get your training--you don’t know anything, so just shut up and pay your dues so you can play with pain and suffering, because there are so few crumbs to go around. Musicians need to work together to advance our artistry rather than keep self-esteem poor so just a few can benefit.” Although Jennifer was intrigued with the concept of using music as a healing modality within the therapeutic context, she was, at first, frightened of revealing herself through music. During our first few music therapy sessions, Jennifer had extremely mixed feelings about clinical improvisation. She resisted sitting at the grand piano, saying that she hated music--that it had destroyed her life. Still, when I asked her to just play what she was feeling inside, she complied. Her improvised music, however, was intellectually driven--elegant, with dark tonalities. She told me that she felt uncomfortable playing with me. Upon processing these feelings, Jennifer realized that she was seeing me as a music teacher who would possibly judge and abuse her. This brought up tremendous sadness and anger. As she began to trust that I was not her prototype of a music teacher, she began to relax a bit. I suggested that Jennifer simplify her improvisations and play more from a feeling level. At first, allowing herself to really feel what was going on inside was terrifying for Jennifer--it was as if all of her true feelings were dissociated and frozen deep inside. I was surprised that as a jazz musician, her improvisations lacked a bluesy, funky quality. Though beautiful and intriguing, her music was devoid of sensuality and joy. This seemed to confirm for me the aphorism--“as in life, so in music.” She soon caught on through our musical interactions, however, that she had to know what she was feeling in order to create a life that worked. She later told me, “Before therapy, it was just about being the best--being perfect, not feeling pleasure in living your life.” Clinical Diagnosis Jennifer was an extremely gifted young woman with a strong capacity for psychological insight. Narcissistically wounded from an early age, she developed a “false self” persona that kept her from acknowledging her real feelings and desires. She felt the need to rescue her parents through achieving her own fame and fortune through her musical career. Because she was separated from her real self, however, she allowed others (managers, agents, producers, etc.) to decide the course of her career. This left her feeling powerless and continually frustrated. She was living an “as if” life--at the top of her game, yet deeply depressed and anxious. Because of ongoing sexual and physical abuse throughout her childhood, Jennifer learned to dissociate her feelings and experienced fragmentation within her personality

development. The only feeling states that seemed acceptable to Jennifer were those of superiority and accomplishment. When she was not achieving, she was depressed. At the same time, she experienced entitlement rage when she did not get the recognition that she desired. Her sexuality was frozen. She engaged in codependent relationships with men whom she thought would rescue her. These short-lived relationships would inevitably end in fits of rage, violence, and heartbreak, leaving Jennifer in a suicidal state. Because of her extreme dissociation and proclivity to live an “as if” life, it was clear to me that connecting with her real self could bring up tremendous feelings of rage, grief, and loss. Finding true happiness would require a complete transformation of character. Was she strong enough to do this? Was I a good enough therapist to help her in achieving this psychological make-over? .

Methodology and Techniques My therapeutic approach is eclectic, drawing from my training as a musician/composer and music therapist, psychoanalyst, and practitioner of yoga therapy. I also have advanced training in working with victims of trauma. While the therapeutic relationship is key to facilitating change in patients with early abandonment and abuse issues, I believe that the most significant catalyst for transformation is actually the client’s relationship with the “self” through music. Early on in my work with “normal” adults, I discovered that, at the core of our beings, we each have a powerful source of healing that can be tapped, through our engagement with music. I call this source essential musical intelligence (EMI)--our innate capacity to use music and sound as self reflective, transformational tools in integrating spirit and matter--soul and personality - within the healing context. Although all human beings have access to EMI, most do not comprehend its value and, thus, do not use it as effectively as they could. EMI is our ability to perceive the voice of truth--the “will to be” (life force) that informs our beings through the archetypal language of spontaneous sound and music-making. This innate “will to be” is naturally perpetuated through the expression of human desires and emotions that must be acknowledged, processed, and integrated into the whole of our beings before total health can be achieved. Music is the most natural conduit for the expression of these desires and emotions, especially the ones that, for some reason, are hidden from ourselves, or repressed. From the perspective of EMI, music acts as a mirror of the inner life. By tuning in to the deeper meaning of music in our lives, we naturally begin to understand ourselves, and others, better. Thus, the music that we listen to and/or create can foster self-awareness, emotional intelligence, transformation, and, ultimately, deep healing of the body, mind, and spirit. The first step in accessing EMI is witnessing--to be able to step aside and become the observer of thoughts, feelings, desires, and actions as opposed to being caught up in and controlled by them. The following steps comprise the process of using EMI for selftransformation and healing: 1) Identify the problem through witnessing. 2) Remember your EMI (your innate ability to transform pain into power through engagement with music/sound), and trust that you are safe and secure no matter what the outcome.

3) 4) 5) 6)

Ask for help from your EMI. Connect with your center of creativity (throat chakra). Allow a solution to the problem to unfold through your engagement with music. Give thanks for the gift of your EMI.

Jennifer described EMI-based therapy as “a transformational twelve-step program that uses music to directly access the Higher Self.” Most renowned musicians/composers have naturally tapped the power of EMI to inform their creative process. These inspired individuals probably spent a lot of their time in the consciousness of the throat chakra (the energy center associated with receptivity/surrender to a Higher Power for inspiration/expression). Unfortunately, when looking at the numbers of creative/inspired musicians who have succumbed to serious pressures of the music industry, it is obvious that there is more to being healthy and whole than just being a channel for higher consciousness. All creative people need a safe, secure foundation upon which they can build their “castles” of light. This brings me to the next structure that informs my therapeutic stance. Drawing from yoga science and philosophy, I find that the system of understanding the different levels of consciousness and how they interact as described in the treatises on chakra psychology is quite useful. According to yoga science, the chakras represent seven levels of consciousness that are associated with the nerve plexus located along the spinal cord. Each chakra reflects certain developmental/archetypal realities that need to be experienced and integrated into the self in order for us to become whole and achieve the highest levels of human functioning. The following chart (Table 1) presents an overview of the chakras and the dramas that unfold at each level. The goal of yoga science is to assess which chakras are active and healthy in the client, where there are blockages and/or developmental delays/arrests, and to help the client to fill in and/or work through areas of weakness/dissociation/ trauma so that she can move up the ladder of consciousness toward more health and wholeness. The techniques of assessing the distribution of a client’s chakra energies are beyond the scope of this chapter. Please refer to my book, Essential Musical Intelligence: Using Music as Your Path to Healing, Creativity, and Radiant Wholeness (2002) or Anatomy of the Spirit (1996) by Carolyn Myss. From the perspective of chakra psychology, Jennifer’s core consciousness seemed to be centered at the level of the heart chakra. This was reflected in her desire to give service to humanity through her music and to rescue her parents from mediocrity/poverty. Most of her struggles in the beginning of therapy involved ego/power issues (third chakra) associated with perfectionism/identity. A developmental arrest at the level of the sexual chakra interfered with the natural flow of nurturing energy that is usually available at the throat chakra. This prevented Jennifer from enjoying pleasurable feelings and the experience of union--both physically and aesthetically. Jennifer was also arrested developmentally at the level of the root chakra. She was never able to integrate feelings of security and safety with respect to her relationship with her parents (a common issue in victims of abuse). Through her spiritual practice (Nisherin Shoshu Buddhism) and in her relationship with music, she experienced glimpses of insight and clairvoyance (sixth chakra--third eye). This would prove to be helpful to her in understanding and utilizing the symbolic material that emerged during the course of therapy.

TABLE 1 Chakras and Archetypal Themes Chakra Mode of Experience Ideal Polarities Experienced Representations 7– Unitary Consciousness No representations; None Crown beyond form 6Insight, witnessing The Sage Sage/fool; objective Thirdobserver/deluded participant Eye 5– Devotion, receiving nurturance The Child Object of devotion/devotee; Throat and unconditional love, mother/child; found/lost; surrender, trust, creativity, grace, trust/distrust majesty, romance 4– Compassion, generosity, selfless The Mother Rescuer/rescued; Heart loving, service liberator/liberated 3 - Solar Mastery, domination, conquest, The Hero Gain/loss; success/failure; Plex competition, inadequacy, dominance/submission; inferiority, pride blame/praise 2 – Sex Sensory pleasure The Hedonist Pleasure/pain; male/female 1 - Root Struggle for survival The Victim Predator/prey; life/death In my clinical approach, there is no particular therapeutic agenda. I am keenly aware of where the client’s energy is focused at the moment. From that place, I endeavor to provide a creative framework where the client can connect with her EMI and enter into corrective emotional/ somatic experiences which ultimately lead to self-awareness, insight, catharsis, and transformation. The following are the developmental stages of Jennifer’s psycho-spiritual transformation, with EMI as the central motivating force. Phase I Creativity/play. Jennifer began the process of uncovering her true self. From the time her original transitional object (Tony the Tiger) was destroyed by her mother when she was a young child, Jennifer’s capacity to play was thwarted. She became hyper vigilant, externallyoriented, and disconnected from her inner life. It took some time for Jennifer to let down her guard within the therapy context, to connect with her EMI, and to use her sessions to play and be nurtured by our interactions. During the first few sessions, Jennifer was terrified of sitting with me at the piano. She would cry and could not understand why. When we began to process her feelings, she realized that being with me at the piano brought up excruciating memories of her childhood piano lessons--subconsciously, a part of her was just waiting for me to criticize and abuse her.

Although Jennifer was a consummate improviser, it was difficult for her to let go and allow deeper feelings to emerge through the music. A breakthrough happened about three months into therapy, when I asked her to improvise the “music” of her father at the piano. Breaking from her usual elegant improvisational style, the music at once sounded raw and filled with conflicting emotions. This was the first time that Jennifer had connected with her deeper self while improvising--her first conscious experience of her EMI. She later told me, “I realized that I had been playing patterns--what would sound good... it was the first time I actually heard what I was playing.” With regard to her own jazz playing, she continued, “I never thought--what is the feeling of the song, for example, “All the Things You Are.” I was just concerned with impressing people with my virtuosity.” During a series of free piano improvisations that followed, Jennifer also realized that finding her true voice was compromised by her codependency with narcissistic men. She called this her “love addiction.” Jennifer explained, “More women have love addictions than men--it’s related to perfectionism; we need to fill the emptiness inside us with another person.” Much of the work during our initial sessions focused on my mirroring and holding the feelings that came up for Jennifer both verbally and in the music. Because of the extreme splitting and dissociation related to early abuse and betrayal, Jennifer’s feelings seemed overwhelming and terrifying. This created a lot of resistance early on in the treatment. Jennifer explained, “It [the music] had to be pretty; I couldn’t let go and play from my body--it was either all rage, or all pretty.” Jennifer had created a wall built by perfectionism to protect her from the devastation of her true feelings--both her pain and her glory. Jennifer completed her second album, a musical tribute to powerful women through the ages, during her first stage of treatment. The album received four stars in a popular music magazine. It was touted as superior, intellectual music. After returning from her tour to promote the album with an all-woman band, she told me that she finally started to feel something in the music this time around. She became a little more connected to her inner life. She felt safer playing with women as opposed to men, and was feeling more physically connected due to the influence of a new supportive piano teacher who helped her to inhabit her body by making her count (rhythms) out loud while practicing. In summary, during Phase 1 of treatment, Jennifer learned to express dissociated feelings related to early trauma/abandonment through musical improvisation and worked toward achieving trust within the therapeutic relationship. Once Jennifer acknowledged, felt, processed, transformed, and integrated these feelings, she was able to give birth to her real self. “I had to first put down the drug: my rageful interactions with others and my addiction to power and fame” (first and third chakra issues). She learned to discriminate between her own personal needs and what others expected from her. Musical role-playing was the most effective way of learning how to discriminate between roles and behaviors that are true to the self, and others that were introjected from dysfunctional others. Jennifer and I engaged in what she called “struggle” exercises at the piano (role-playing--exploring the music of “what is you” and “what is introjected”) and finding the core of self within that struggle. Phase II

As Jennifer began to realize the split between her real self, feelings, and desires and the false reality she had created, she entered into the second phase of treatment--what she called her “dark night of the soul.” She realized that she was usually dissociated while performing and that she most often resented the audience. She used dissociation as a way of coping with overwhelming feelings of responsibility. “I wanted more from the audience than I was willing to give,” she explained, “I really hated what I was giving--my music wasn’t authentic. And because I didn’t want to give my music, I didn’t get much back in return” (heart chakra issues). During this phase of treatment, Jennifer was dealing with feelings of alienation from her body, heart, and soul. As a way of making contact with her deeper self, I encouraged Jennifer to engage in vocal improvisations with me at the piano. She was terrified of opening her mouth and singing. In a playful way, I demonstrated my own style of vocal improvisation. “Why are you having so much fun?” she asked me. She could not imagine just having fun with singing. She hated the sound of her voice, which, at first, had a strained and pinched quality. She did not find it at all expressive. With time, Jennifer realized that she could just play with singing…that she did not always have to be so serious. We imitated the likes of Aretha Franklin and James Brown together, often breaking down in laughter. Later we would explore difficult issues through a kind of call-and-response style of vocal improvisation that I call “musical dialogue.” At first, Jennifer was resistant and embarrassed to be so vulnerable and open in the music. But it seemed to me that the “child” in her was awakening, and this child part truly enjoyed our vocal interactions. I asked her to continue creating musical dialogues at home. Jennifer took this very seriously and proceeded to “sing her truth” at the piano daily. She recorded every session. “After freely singing at the piano,” she shared, “I heard my true voice for the first time. I didn’t realize how much tension I held around my throat, neck, and jaw. I spent a lot of time every night singing and then listening back. I was amazed at what came out--it was frightening at times--but I was speaking my truth.” At first, most of her improvisations focused on exploring her feelings about her addictive relationship with a narcissistic, emotionally unavailable lover (second chakra issues). She tried to create some distance in her dependency on this man by developing a more intimate relationship with her own creative process. She worked on her music every day and by the end of a month, her at-home improvisation sessions turned into 14 new songs. In addition, during this phase of music therapy, Jennifer started to listen to music that truly moved her, music that appealed to the adolescent in her who had never had a chance to thrive: Joni Mitchell, Alanis Morissette, Tori Amos, Smashing Pumpkins. A transformation was occurring where Jennifer was now alive in her adolescence for the first time. She had unleashed a hidden desire to become a rock-oriented singer/songwriter--to simplify her music and finally express her heart (true self). As Jennifer progressed in therapy, she became aware of her inner emptiness. She was prone to addictive behavior--bulimia and codependency. I encouraged her to use toning to “fill her up” energetically. She particularly liked chanting the chakra sounds on a daily basis. She told me that she used the sounds to get Gordon (her narcissistic lover) out of her body, and to help her to remember that she exists as a separate whole person without him. Right around that time Jennifer wrote a song about saying a prayer that she could stand alone, without her codependent relationship. She later told me that the song, along with weekly twelve-step meetings for people with “love addictions,” had truly freed her from her codependency. (The whole process of using vocal improvisation within and outside the music therapy context and

attending recovery groups took about a year.) Her recovery plan included the following goals: “To be a rock singer/songwriter and create the true music of my spiritual path.” In moving into this new genre of music--and a new professional identity--Jennifer explained that she had to defend the music all the time, “...this made it [the music] more real, more precious.” Jennifer was using the therapeutic relationship, along with her relationship to her own music (EMI) to separate from her dependency on her introjected mother and from her parasitic producers and managers, who, up until now had dictated the course of her career. She was rebelling like a teenager, belatedly entering the stage of separation and individuation. Opening the throat chakra. Jennifer experienced tremendous resistance related to singing during this phase of treatment. “I had issues with protecting that voice,” she told me. She typically experienced tightness/tension in her throat. When we began to explore the underlying causes, Jennifer began to have flashbacks of her mother hitting her on the back of the neck. The pain was overwhelming. It was difficult for me to witness the heartbreak associated with Jennifer’s resistance to singing. Yet I proceeded to focus on her relationship with her voice and singing during these sessions. Occasionally I was cast in the role of the abusive mother. In working with the transference, Jennifer was finally able to express threatening feelings that were previously disowned (murderous rage, shame, guilt) lest she summon additional abuse from her out-of-control mother. With time and patience, she was able to work through some of the pain. (See Jennifer’s Therapeutic Song Cycle.) One day, after 20 years of estrangement from the opera world, she was compelled to sing again. She brought in one of her favorite arias to her session and sang for me. Immediately after singing the last note, Jennifer broke down and sobbed from the depths of her being. I, too, mesmerized by the intensity of her musical gift, began to cry. After some time passed, I asked Jennifer if she could talk about her feelings. She told me that she realized that this (her voice) was a gift from God and that she had rejected it. She felt that the gift had required too much responsibility. Jennifer was overcome with grief. For me, these feelings signaled the opening of her throat chakra--the realization of her connection with divinity through her creative gift, and, finally, her willingness to receive and cherish this gift and be nurtured by it. Jennifer had never integrated the experience of being truly nurtured. Because of this, she had to rely only on herself and felt either omnipotent or powerless, nothing in between. “If I really did sing well,” she told me, “my mother/Harold (her producer) would be jealous.” This was a difficult, heavily charged period for Jennifer--full of pain and confusion. I encouraged her to integrate EMI into her life on a daily basis. In Jennifer’s words, “Music therapy was the only sane place; it provided proof that I am insane. It’s the only place in the world where I am doing something that is real--so it can’t be real.... You (Louise) were very persistent.” It was difficult for Jennifer to hold the gift (her intense spirituality) and her very real pain/ suffering (due to past abuse/false self) together at the same time. Engaging with her EMI was the only way that she was finally able to do that. As she called upon her EMI more often in times of need, she was able to disengage with the “false self,” illusory world that she had created and take baby steps toward manifesting her true purpose in life. Tools of EMI

The following EMI techniques were used to help Jennifer to release the shackles of perfectionism; transform her love addiction; and find her “true self.” Spontaneous song writing as a mode of problem solving. Jennifer explained, “I wrote 14 songs to break through the love addiction. You (Louise) asked me to sit at the piano and to sing how I felt. I had never done that before.” Jennifer was asked to do daily vocal improvisations to tell her life story through music. She was also asked to sing about what was going on in the moment. She recorded these sessions and used a lot of the improvisational material in her compositions. Her treatment also included yoga breathing techniques for anxiety reduction; chakra tuning for emotional balancing; and, Guided Imagery and Music (GIM) (Bonny & Savary, 1973)--a way for Jennifer to explore her inner world through recorded music and then externalize the images/symbols found there through mandala drawing. According to Jennifer, “GIM helped to melt frozen feelings.” I encouraged Jennifer to take voice lessons. This gave her more confidence as she began to create a new rock-oriented band where she would be the lead singer. She took a hiatus from her own jazz work, and to make money, became a sideman with what seemed to me to be one sadistic band leader after another. Here she was reenacting the past trauma of her early family dynamics (emotional abuse). Jennifer was working twelve-hour days; her defenses were down and her “shadow” side was escalating. In her very real pain and suffering, Jennifer started to get in touch with a formerly dissociated, destructive child part who was wreaking havoc in both her professional and personal relationships. “She (the six-year-old) was really pissed,” Jennifer told me. “She didn’t want to be suppressed any longer” (third chakra: identity/power issues). Jennifer was also manifesting her inner conflicts in the therapy room. She had deeprooted issues around giving and receiving, and was occasionally hostile and arrogant. It was my guess that this issue was popping up in her sidemen gigs as well. For example, Jennifer had been running up a huge therapy bill, promising to pay, but consistently forgetting her checkbook. Up until this point, analyzing her resistance to pay had not been effective. During one particular session, she had again forgotten her checkbook. At the same time she was boasting about how much money she had just invested in the stock market. I had been roleplaying her mother in a particularly intense vocal improvisation that day, and as she was leaving the session, I succumbed to my own countertransference and teased, “You better pay me soon or I’ll get the goons out after you.” (When I processed my feelings later on, I realized that I was really annoyed and angry with her. I felt that she was devaluing me but I was not able to analyze this with her because the session had already ended.) Immediately, Jennifer cast me in the role as her abusive mother. She experienced this as a reenactment of past abuse. She immediately sent me a check and notified me that she wanted to take a break from therapy. I apologized over the phone and encouraged her to come back to talk about the painful interaction. Jennifer made a tentative comeback. She told me that she did not know if she could trust me. After this interaction, Jennifer began to become aware of how much she hated the “little girl” part (sub-personality) who was so needy, angry, and destructive. I suggested that Jennifer get to know the “little girl” instead of pushing her away. The “little girl” began writing angry letters to Jennifer in her journal. Jennifer responded by saying, “You little bitch--shut up and die.” Jennifer had become the mother who ignored, rejected, and abused the innocent “divine child” who simply wanted to play--to love and be loved. We engaged in musical roleplaying to explore this dynamic. I played her out-of-control mom and she would defend herself.

It was helpful for her to have a chance to fight back. I was moved, however, to take care of the “little girl.” During one session when Jennifer was loathe to listen to her “little girl” part, I played her role and during a vocal improvisation, sang, “You’re using me, and you never let me have any fun....” Jennifer was touched by my words. As the “little girl” sub-personality was slowly welcomed into Jennifer’s life, she realized that she did not have to do things that she did not enjoy. She explored the masochistic statement: “You have to suffer and sacrifice in order to make it.” She realized that it was better to suffer to find truth as opposed to the suffering it took to climb the “show biz” ladder. This realization gave her the strength to leave her current abusive working situation. As she worked on making the transition from jazz to rock, Jennifer often lost her center when dealing with record companies, producers, etc. She realized that, because she had given all her power over to her producers/ managers, she felt like a slave. She harbored so much bitterness with respect to giving--her heart was closed. I encouraged her to take time to commune with her EMI. I knew that this is where her real self existed. Jennifer wrote a song for the “little girl” part. She called the song, “Protect This Child.” The lyrics were quite moving: She didn’t know why she was silent... show me the way to free myself to be myself... the diva dies, the scene is through, now it is I that must be true. Jennifer told me, “The music showed me how to heal the child--I was given an outlet and acknowledgment and I was able to forgive this child [for sabotaging her attempts to become famous].” She realized that this child part had been frozen early in life because it was not safe just to be a child and to create without feelings of responsibility. Essentially, the child had been bound and gagged for many years. It was time now to free her and allow her to enrich Jennifer’s world. Around the time that the child part was awakened, Jennifer also began to get in touch with her submerged spirituality. As a child, she had been deeply connected to the Catholic Church. She told me that when she had become increasingly dismayed due to parental/teacher abuse (at around age eleven), she turned to God for help. When none came, she felt betrayed. It was important for her to talk about these “irrational” beliefs/feelings within the therapy context. In my experience, many musicians (and creative people in general, for that matter) are deeply spiritual, but are apt to suppress this particular passion because it is not “cool.” I encouraged her to explore these feelings through her music. She wrote a new song for the child within where she worked through her “Catholic stuff.” She discovered that her inner child was split into two opposing self states: the part of her that she called the “demon child” (“...the presence that makes my life crazy”) and the other, the “divine child” (“...because I believe in the power of you”). In this song, she allowed the “demon child” (who had once been the innocent “divine child” before she was ravaged and suppressed) to creatively express her rage. This was the first time that Jennifer had used the full force of her voice in one of her songs. It was fascinating for me to watch that as the “demon child” was given a voice through the song, it actually transformed itself back into the “divine child.” They truly were one in the same energy (third eye chakra: dualities are melting--approaching unitary consciousness)! At this point, Jennifer became very aware of the inner conflict between these two sides of herself. She realized that she had a choice between succumbing to the negative spiral of the “demon child” (hopelessness, inability to trust, feeling unworthy/bad), and the upward moving spiral of the “divine child” (optimistic, able to receive and give love, trust). Jennifer used EMI as

an anchor in allowing her truth to unfold--trusting, as much as possible, that she was safe and secure in the lap of the creator within. As her relationship with me and with her own self became stronger and more committed (fourth year of therapy), Jennifer was compelled to nurture herself and to choose work that was nurturing (fifth chakra is opening). She no longer felt the need to resist facing herself in therapy. She now experienced therapy as a kind of creative partnership. She also described her new love relationship with a fellow rock musician as a creative partnership. Gone were the feelings of desperation for love that plagued her. She was now able to give and receive within this relationship and create healthy boundaries when appropriate. Jennifer’s Therapeutic Song Cycle. The following is a progression of songs that emerged as a result of Jennifer’s process of exploring and healing herself through EMI-based music therapy. 1) “Shelter Me”--a safe-place song 2) “Say a Little Prayer”--favorite line, “Pray for me to fly without you.” A powerful song that helped her to transform a long standing love addiction. 3) “Walking on Water”--favorite line, “Walking on the sea of love.” Led her away from dependency on narcissistic men, into dependency on the Christ mind. 4) “Protect this Child”--“I was able to admit that I was afraid and needed protection from abusive teachers and others to be able to sing again.” 5) “Take Your Hands off Me”--a song of fighting back. “I was able to confront past abusers through this song.” 6) “Grace and Pain”--two songs about exploring the possibility of standing alone, and the fear of being loved. 7) “These Things I Love”--“I finally had the courage to look at the good things that were happening in my life and give thanks.” Discussion and Conclusions Although Jennifer has made a lot of progress over the four years that she has been in psychodynamic music therapy, she still grapples with some fragmentation in her personality. She now uses vocal improvisation/musical dialogue as a way of identifying and giving voice to split-off parts of the self. We also regularly use what I call the “musical tantra” exercise as a way of resolving polarities within the psyche (through improvisational role-playing, the client will explore two sides of a polarity, i.e., fear vs. arrogance and, by bringing them together musically, find the center or meta-state between them). The musical tantra exercise has been wonderfully healing for Jennifer and has created a bridge between the superior/perfectionistic self-state and the inferior, hated/loser self-state. In that centered meta-state, Jennifer can find serenity and peace--the abode of her true self. And finally, at this point in her therapy, Jennifer has unpeeled another layer of the psychic onion and is grappling with opening herself more deeply to the experience of pleasure in her musical expression, performance, and love relationship (second chakra). For years she has been controlled by her introjected mother, feeling unworthy of enjoying her femininity and

sexuality--feeling that she will be shamed, or worse, physically abused, lest she relish pleasurable sensations in her body. I am currently working with Jennifer on this issue through clinical improvisation, encouraging her to explore the piano and her voice in a sensual way--to become aware of sensual/sexual impulses that emerge through the music and to embrace them instead of pushing them away or judging them harshly. This has been a frightening and painful process, as it is bringing up overwhelming feelings of remorse for the many years that she has lived repressing and inhibiting this delightful aspect of herself. My sense is that as she reclaims her innate feminine/sexual self, along with the power that she has been reclaiming through putting out her real self through her music, she will experience the wholeness that is her natural birthright and be able to fully give her unique gift and receive her just desserts in all dimensions of her life. References Bonny, H. L., & Savary, L. M. (1973). Music & Your Mind. New York: Station Hill Press. Davies, J. M., & Frawley, M. G. (1994). Treating the Adult Survivor of Childhood Sexual Abuse: A Psychoanalytic Perspective. New York: Basic Books. Montello, L. (2002). Essential Musical Intelligence: Using Music as Your Path to Healing, Creativity, and Radiant Wholeness. Wheaton, IN: Quest Books. Myss, C. (1996). Anatomy of the Spirit. New York: Harmony Books. Van der Kolk, B. A., McFarlane, A. C., & Weisaeth, L. (1996). Traumatic Stress. New York: Guilford Pres

Taken from: Priestley, M. (1985/2012). Music Therapy in Action (Reprint of Second Edition). Gilsum NH: Barcelona Publishers. CASE SIX Music and the Listeners Mary Priestley This essay outlines 14 sessions of analytical music therapy spread over six months and a follow-up session thirteen weeks later. The client, Renata, was a self-referred lady psychotherapist aged 60. She had one isolated problem which many sessions of psychotherapy had failed to touch, so in fact this was a focal music therapy. Her problem was that she could not play, or even practice the piano, if she felt anyone (including her teacher) was listening. If she did, she had feelings of panic and had to stop. This reduced her playing to the very minimum and naturally hindered her progress and her enjoyment of this art. As she was approaching a more leisure time of life she felt that it was now crucial to try and overcome this anxiety. This essay is based on brief notes made after sessions and a rehearing of the recorded improvisations. The client’s name and some circumstances have been concealed to preserve confidentiality. She has seen the case study and given her permission to publish. In order to give the feeling of the inner meaning and emotional flavour of an utterance, words or sentences in quotes are the client’s own. Discussion recorded before the improvisation took place before we played. The supervisor mentioned twice is the Jungian analyst, Dr. Redfearn, with whom the writer has discussed her work for several years. The 50-minute sessions were weekly as far as possible, but dates are given. February 3, 1986 As I have found so often with female clients with performing difficulties, it came out in the anamnesis that Renata’s music had come from her father, who had played the piano. There also had been chamber music in the home. Her early life was quite difficult. She had a Down syndrome sister Anna, 15 months older than her, whom she sensitively watched over until Anna’s death when Renata was seven years old. When visitors came, Anna was always introduced first and Renata felt almost ashamed of her own greater accomplishments and remembered being refused a bicycle as Anna could not cope with one. When Renata was five and a half, another sister, Kate, was born. I asked Renata to play in the role of “The Listeners” hoping that she might get back her projections of punitive and critical self-parts. The improvisation (which I accompanied on the piano) was short but full of character. She wept. She felt that her left hand was clumsy, letting down the piece. We played “Left Hand” which was very sensitive and beautiful with what she called a “murderous” ugly, banging right hand. I said it was sounding very bossy. She said: “The

right hand said ‘Don’t do that!’ and then turned it into not music at all, while the left hand was like making love using fingers on the keys.” February 10, 1986 She said that she thought her teacher was coming back in three weeks and she had started to make mistakes. I said she could allow herself to need him, but I did not realize at this point that it was for the purpose of self-punishment. She said that he insisted that she couldn’t play in front of him because of her lack of practice. She remembered that Anna was always praised if she had a dry bed but Renata’s was taken for granted. Kate had temper tantrums at three. Renata envied her freedom but thought: “That is not in my repertoire.” Renata had never had a temper tantrum in her life. She had been the observing, caring child, then the doctor doing research, then the psychiatrist, then had psychotherapy and practiced as a psychotherapist. She was almost retired but felt the need to do something completely different. She played as the “Carer” while I played as “Temper Tantrums.” Hearing me, she felt panicky and played the bells as she felt there was some emergency. Her xylophone playing was gentle and the bells were soft. I felt I could not let go when playing as the “Temper Tantrums,” as I felt she couldn’t tolerate really wild playing at that point. We exchanged roles. Her “Temper Tantrums” sounded demanding and assertive as if she was saying “Look at ME!” Later it was sad and childlike with the odd bang in between. She managed to split the drumhead, prolong the session by five minutes and forget to pay me. February 17, 1986 She felt that our improvisation last time had not been so musical. I said that temper tantrums are not very musical. I suggested that we examine the feelings about not paying. “Not worth it comes to mind,” she replied sharply. I pointed out that it can also mean that the relationship is being regarded as a friendly one rather than a professional one. She said that she hadn’t thought of that. She felt “a bit embarrassed at not having paid, but not very.” She had improvised at home and thought she would feel less anxious if she was overheard doing that. She said practice was joyless. I wondered whether this was a defense against too much joy but admitted that there were plateaus in all instrumental learning. My supervisor had suggested that we explore last week’s “Something Completely Different” (see 10/2/86 session). I asked her to imagine a long, high wall with these words on the door and to go through the door (Assagioli, 1968). She approached the door twice then went through in the dark and quickly rushed round trying to look at the packing cases which were there. I said there could have been curiosity about mother’s part in producing little Kate. She played the kalimba gently then there were knockings and shakings of maracas. I said “Go in again but take your time.” She did so and said there was no need of light. She felt that she was being responded to. The music was freely expressive with xylophone glissandi and maracas, drum taps and two taps on the edge of the xylophone, feeling “Can nasty feelings be accepted too?” She wept. I asked if she cried because she felt understood. “No. Just responded to,” she replied.

February 24, 1986 In the past week, sometimes she had felt like a child and sometimes like a competent adult therapist. Her piano practice went badly and she kept making mistakes. I said this seems to have a persecutory feeling about it. “Yes,” she replied. I said she didn’t seem to be allowed to be playful and expressive. She played to the title “Mother.” The overblown recorder sounded frantic with long melodica notes in between, and then came a gentle, carefully played xylophone melody finishing with a long melodica tone. She said she desperately wanted loving attention. “Mother had been a cold, intelligent person.” The concordant identification was of sadness. Next we played “Father.” The burst of colorful and expressive music was quite joyful with several instruments played in a confident rhythm. Later it sounded more secretive as if she must hide this. She said that she could have fun with her father in a way that Anna couldn’t and she felt guilty about this. Underneath she had really hated Anna and was glad that she died when Renata was seven but had missed her as her personal “job,” as she felt it her duty to take care of her. As a young person, a war baby, she felt grey and shapeless but at teenage she felt that her father liked her better than her mother. I said that in her “Father” music there was everything that seemed to be missing in her practice. She said that it was more difficult for her to express tenderness than anger. When I said “Time,” she said “It is 5 past.” (She came at 2:15, and my sessions last 50 minutes). I pointed this out and she said “Oh, yes.” March 17, 1986 She felt very limp after influenza and hadn’t played. She thought maybe she should have cancelled the forthcoming course that she was giving abroad. She had seen her clients for half of last week. She sat silent then suggested that we should play some limp music. I pulled out the box of chime bars. She played in a slow 4/4 but gradually it became more lively and assertive. I said the music was going ahead to tell us about liveliness. Next we played about “The Course.” The music was very direct and confident and multi-instrumental as in the “Father” music. She felt “I’ll show you I can do it though I’ve had flu.” I felt it sounded quite petulant and then confident. I said the music represented a very intimate phantasy relationship with her father that went way back and that it explained the guilt when she was discovered playing. She agreed. However, I said, it was now necessary for her to desensitize herself to this situation by playing to people. She felt she should be “right” by 60 but felt that the work was worthwhile. I asked her how old her eldest client was. She told me: “60.” She said she did not feel hopeful on the way here but now felt better and would like another five to 10 sessions. April 7, 1986. We played “Stealing Father.” She played grasping, grabbing, triumphant piano music to my drum and cymbal. In “Renata, Father and Kate” she played treble and low bass up and down the piano with a chaotic quarrelling sound, followed by a monotone tune interrupted by chords. Lastly, we improvised on “Playing.” She explored single note and clusters on the piano finishing with a mega-cluster.

April 14, 1986 She cancelled but told me that she had managed to play to her sister Kate. April 21, 1986 We decided to explore the feelings about “Right” and “Wrong.” To her, “Right” meant right feeling and phrasing and “Wrong” meant it was wrong to play at all. “Right” (on instruments) sounded wooden and priggish on the melodica, then rebellious. “Wrong” started with her coming in very expressively on the xylophone and the whole piece seemed to disintegrate into dissonant xylophone tone clusters and come to a halt. “Wrong” (on piano) she held one hand with the other and played with it as if it were a tool, then she took off her red shoes and played with the tips of her toes. The “Wrong” felt right and she was all alight and glowing with creativity. I then asked her to play her easy pieces on the piano while I took the role of her harsh “Super-ego” saying “Wrong!” and so on. Maybe I went too far when I said “Silly cow! She’s done it again!” I hoped that she would build up some resistance against this critical self-part. She persevered in her playing but her concentration seemed to disintegrate and she felt like crying. I wondered if I had overdone it. As it happened, I had. May 12, 1986 She hadn’t practiced and she wanted to stop the sessions. I agreed but said she was like a person who had been clamped in one position for years. When the clamps were removed with difficulty, unless she moved she might as well not have bothered. I emphasized that now it was up to her to test reality by playing to people and seeing that no harm would come to her. At last she said perhaps she would come for a few more sessions and that possibly she had been influenced by the last session. My supervisor had suggested letting her be the Super-ego. We tried this. She shouted sarcastically at me that I was showing off, it was too wooden; there was too much pedal and so on. In fact, it gave me quite a shock, too. (I seldom try a technique on a client that I have not tried on myself with one of my colleagues, but I had reacted quite spontaneously to the situation last week. However, it is a rule that I recommend to other music therapists. One can see what happened when I ignored it). Next we improvised “Playing like Anna.” The playing was much more spontaneous and rather angry. We did “Playing II.” We played well together like chamber music (no recording and my notes didn’t say on what instruments). She decided to play duets and do improvisations with her “cellist friend at home.” May 19, 1986 She actually had played to a friend. It was very dead. Then she improvised a little and her friend liked it. She was seeing the notes as a mould killing her creativity. We did “Deadness to Life:” she started playing one of her pieces in a dead way then improvisation crept in and she played it again in a really lively way. At the end, she came back again to it in a lively manner. Next she played a Bach Minuet in G and I made encouraging and reassuring comments. The second half was full of mistakes but she sang and kept going. Then I asked her to play just the

bass and I took the treble on the violin and she kept going in spite of mistakes. I suggested that she write 4 bars in G with only steps of 1/2 or whole tones. I can’t remember why I said this; in fact, although she agreed to try, she never did. June 9, 1986 She had played with the cellist but couldn’t hear her, and her piano lessons had gone badly. I said that her teacher sounded as if he played totally into her self-punishing side. I asked her to play, and when she faltered, to start talking about what she felt. She did this, mostly stopping between bars and she said, “It was such a mess.” I answered, “You’re giving me a mess, a constipated mess. How does sensation rate in your four Jungian functions?” She wept. She felt that she wanted it to be a sensation of caressing the instrument and a kind of special relationship with the composer - a kind of love-making. I commented, “No one must know of this pleasure and instead you produce a mess to hide it.” We discussed the possibility of her getting a music therapist as teacher and I gave her a local colleague’s address. I felt that she not only wanted to learn to play the piano, but had the need to explore her feelings about learning and expressing her emotions musically. I asked her to be “The Teacher I’d Like.” In talking she was kind and directive, the piano playing was wild, she gave wide boundaries as teacher. July 7, 1986 She had been for a lakeside holiday. She was to start the next week with a new teacher she had found (not a music therapist). She had played the piano at home with her windows wide open. We improvised on “What I Want to Give My New Teacher.” There was multiinstrumental playfulness, yearning, destructiveness and firm assertiveness in her music. We talked about the destructive part and she told me that when she was a pathologist she never completed her research so as to be able to write a paper on it. She said it was laziness. I told her I did not believe in laziness, it is a cosmetically defensive word which provides an excuse for avoiding further exploration of hidden aggression and resistances. We played about “Completion.” She thought of having to relinquish something and finished with a bang on the drum “finishing it off!” We decided to have three more sessions then stop, but I said it was only enough if she continued to play with and to people at home. I said that it was possible that she had feelings about allowing a music therapist to carry out some successful therapy when so much psychotherapy had failed to touch the problem. She agreed. July 14, 1986 She had started with her new teacher who was affirmative. She had made lots of mistakes in her Open University theory paper and only managed 47 instead of 80 marks. I felt she needed this area of allowable non-success in her life as previously it had been all success. In this work, unlike in music therapy and piano teaching, she was not getting any help. I thought it

could be a sign of strength for her to allow this. We played “Mess” and both made a musical mess. Then we did “Making Mistakes,” she made little tapping’s on the instruments and sang “I don’t know what to do,” played melodica clusters and drum, sang “Help,” and finished with melodica clusters. Last we improvised “Successful/Unsuccessful,” her Successful was not very definite on the xylophone then with single and double notes on the melodica sailing above my “Unsuccessful.” Her “Unsuccessful” was chaotic with busy drum, cymbal and xylophone glissandi. July 21, 1986 She felt she had let people down: calling the A.A. and then extricating her car, something about a porter and then letting me down because she hadn’t played to anyone. However, she had had a good piano lesson focusing on special difficulties and enjoying his jokes. We played “Letting Down/Being Let Down,” she felt depressed and helpless in both roles. Her “Letting Down” was rather vague and faint and my “Being Let Down” very angry. My “Letting Down” was quite manic and her “Being Let Down” was slightly more fierce but finishing off with a tremulous melodica tune. Next we played “I Can’t.” She sang softly with gentle xylophone glissandi then became her angry, destructive super-ego on the double naqqaras, spoiling it. July 28, 1986 She told me with some satisfaction that she had practiced in the presence of a house guest who was reading, and that she had had her second piano lesson which had included transposition and sight-reading. She had decided to learn the recorder again, and hoped to play with others when her playing improved. Because she had a definite task to work at I suggested that we should have a follow-up session on 6/10 and she agreed. She improvised on “Playing As I Would Like to Play” (on the piano). There were bass chords, plonk, plonk of free clusters all over the piano. I felt that she was now “Master of Chaos” and could form it. We improvised imagining there was “No Music in the World and Then Music Comes.” The thought made her tearful. Her playing and vocalization was gentle, then happy, free sounds with bell and cymbal, finishing with drum and song. She asked me what I felt about the title. I said I felt it was like not being able to lift up one’s heart in the religious sense. She felt it was important to be playing with people. I said that an audience was a great resonating chamber like a violin’s belly. We finished off with a black note duet. She felt she did not know the notes well enough to play freely, but if we could play together often enough, she could. As we lived in different towns this was difficult but our improvisation sounded better than it had seemed to her when we played it back. October 10, 1986 Follow-up session. She had been playing duets with her teacher who she experienced as being much better than her former one. She had played to two new people, though she had

to force herself to do so, and she had played with a recorder-playing elementary pianist. She remembered that her father had had a pupil who he said would never be able to play Chopin. At once Renata felt she could never play Chopin. I said she felt she could never be better than anyone else, Anna or the pupil. She agreed. She told me that her new teacher chose the Chopin “Raindrops” prelude for her to play and she felt that after all she could play it. We talked about pentatonic duets as a prelude to duet playing and we played one with me doing a formal bass, then one free, then free with her in the bass, and the last, atonal with a little poaching on each other’s territories and much laughter afterwards. Lastly, we improvised on “Chopin.” She played the instruments. Her playing was amazing because there was a plaintive melodica tune finding its way into being and then a fierce drum and cymbal voice and the occasional xylophone. Towards the end there was the multi-instrumental playing we heard in her “Father” improvisation earlier. She felt angry at not being able technically to express what she wanted to. She still wasn’t sure she could play Chopin. At the end she said that if she got stuck, or if there was something else she couldn’t express otherwise, she would come back. Ten months later she invited me to speak at her local Psychotherapy Society, where I showed my video “Music and the Shadow,” and led a discussion which they said they found very stimulating. So it seems as if we are still happily poaching in one another’s territories. I asked the client if she would like to read the case study and write some comments for publication with the paper. Here are her comments on the therapy: “I cannot recall the work very well but the overall memory is that it was good. I had a sort of childlike delight in being in charge, as it were, in the way that I could influence the mood, rhythm or loudness of the music. I also loved making music with someone. Memorable moments were when I discovered that I could sing and that, to me, my voice sounded clear and an important and integral part of the ensemble of percussion and piano. In two sessions, M.P. talked to me, or rather about me (or so I remember) while I played some easy pieces badly from music which I had brought with me. In one session she denigrated me and that felt deeply familiar, particularly when she said, ‘She is so stupid that she doesn’t even know what key she is in.’ Being called a cow did not bother me, but it was too unlikely. When she praised me, that felt good momentarily but I was not convinced. Maybe it is difficult to praise me.” “An important decision I made during the therapy and I think because of it, was to sack my piano teacher and to find a new one. It dawned on me that I did not have to adapt to something that was so constricting, (and I am sure that I was right in my assessment of the situation).” “I still have some difficulty in playing in public and I have not practiced doing so enough. I have played chamber music with myself on the recorder---no problem---but not with me at the piano--- not yet!” Stop Press: Yes, she had done this recently, tentatively but with satisfaction. Summary

Altogether Renata and I had 15 analytical music therapy sessions. Many hours of psychotherapy previously had failed to address the problem of playing the piano when anyone was listening. The sessions gradually uncovered Renata’s association of music with her intimate phantasy relationship with her father, but because this knowledge was not enough without repeated reality-testing in the present, the sessions continued until her playing and improvising became freer and more enjoyable and she was able to experience elementary chamber music playing to and with friends at which time she felt that the therapy “moved something.”

Taken from: Sekeles, C. (1996). Music: Motion and Emotion—The Developmental Integrative Model in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE SEVEN Jacob: Reviving Prayer through Song Chava Sekeles Introduction This case deals with the loss of musical abilities by an adult as a result of brain damage. As an example I have selected the case of a cantor who suffered a cerebrovascular accident1 in the right hemisphere. At the outset we shall briefly describe various research concerning the location of musical function in the brain. Later we shall present an example which demonstrates the need for music therapy in order to rehabilitate specific musical skills, as well as to elaborate on relevant emotional issues. The Brain and its Musical Functions The cerebrum is divided into two hemispheres, linked by nerve fibers which serve as channels of communication between these two halves. Each hemisphere serves as a mirror image of its opposite partner, just as do the two sides of our body. The sensory and movemental control of our body is divided between these two hemispheres in a contralateral organization. It is already generally accepted that both hemispheres contribute to complex (high) mental activity but are different from an organizational and functional point of view. For example, a simple check of hand skills will reveal a difference between right and left. Statistically some 90% of human beings use their right hand for writing, others prefer the left, while a small minority are ambidextrous. Among right-handed people it is the left hemisphere of the brain which dominates not only the right hand and arm but also speech. Left-handedness or right-handedness is only one of many aspects which can teach us about the asymmetry of the brain hemispheres. Reports concerning the differences between these hemispheres date back about a hundred years or so, but systematic research and a growing interest in this subject began only in the 1960s. Research into auditory perception and performance divides into two major approaches: 1. Lateralized stimulation in which only the left or right ear is subjected to stimuli, in order to examine the way in which it is processed by the opposite hemisphere. 2. Dichotic stimulation in which the subject listens to two different and simultaneous auditory messages, each of which is directed to a separate ear. It is the subject’s task to differentiate between the two.

Research undertaken by Kimura contribute the following observations: a) Verbal stimuli are processed by the left dominant hemisphere. b) Verbal activity leads to an increased blood flow to the left dominant hemisphere, whereas music activity increases blood flow to the right minor hemisphere. c) The right minor hemisphere takes precedence in perceiving and processing musical stimuli. d) The right hemisphere also has a preferential ability to memorize pitch and nonverbal continuity (Kimura 1963; Kimura and Archibald 1974). In their research, Bever and Chiavello (1974) stress the difference between perceiving and processing music material among musicians and naive listeners. The professional displays an advantage in receptiveness and memory through the right ear, apparently due to his ability to absorb music both structurally as a gestalt as well as analytically. The greater the degree of musical education and practice, the better the integration between analytical and gestalt perception, whereas with the non-musician musical perception is almost totally gestaltic. Regarding musical disabilities, it appears that excision of the left or right temporal lobe2 causes a variety of deficiencies. Excision of the right hemisphere leads to errors in perception and performance of melodic structures, intensity, rhythm and timbre. In terms of melody, the major damage was in the ability to control pitch; the sense of rhythm was less impaired. On the other hand excision of the left hemisphere led to no music disabilities whatsoever (Bogen & Gordon 1971). Even more fascinating information can be gleaned from research into song birds. Fernando Nottebohm shows that the canary’s syrinx is divided between the left and the right hypoglossus nerve. The majority of the adult canary’s singing ability is controlled by the left hypoglossus, hence Nottebohm speaks of “The dominance of the left hypoglossus,” damage to the bird’s left hypoglossus results in severe impediment of its singing ability. Sectioning of the right hypoglossus, however, has virtually no effect on its song. We should recall here that the canary’s singing does not serve a purely musical function. It is in fact a means of vocal communication, hence the dominance of the left side—as in man. Nevertheless it would seem that man’s development of speech has led to greater polarization between the two hemispheres of the human brain. (Nottebohm, in Rahmani 1984). Rahmani (ibid.) stresses that the more man grows and develops, and his verbal abilities improve and expand, so does the asymmetry between the two hemispheres of the brain. This asymmetry finds its initial expression at the start of embryonic life. Seventy percent of embryos only a few months old were found to have a left temporal lobe larger than that on the right; the pyramidal tract was more extended on the left than on the right; on the other hand the angular gyrus was larger in the right hemisphere. In general, the left hemisphere specializes in language functions, due to its analytical abilities, whereas the right hemisphere specializes in visual and spatial functions, as well as in nonverbal sound, due to its superior ability to deal with information in a holistic manner. Since we are concerned here with music, perhaps a more definitive clarification is called for:

1. The right hemisphere is responsible for memory, tonal and modal performance, recognition and reproduction of melodic patterns, sound duration, and performance of timbre and intensity. 2. The left hemisphere is responsible for judgement of duration, temporal order, sequencing, music reading, composition and analysis (Springer & Deutch 1985). It would seem therefore that as far as music is concerned, as in all other fields, there is a significance to this hemispherical system inasmuch as it can lead to mental unity. Rahmani describes it thus: “The linkage between the two hemispheres serves as a mechanism through which is created the illusion of a single and perfect psychological space” (Rahmani 1984, 17). This is of primary importance in understanding any attempt at musical organization which combines words and singing, or those intermediary forms between singing and words: vocalization, incantation, recitation, etc. If there did not exist such a psychological space which Rahmani describes, it would be impossible to treat someone whose singing ability had been damaged (the right hemisphere) without being aided by the nonaffected left hemisphere using combined and integrated techniques. The following case of a professional musician who suffered a stroke in the left hemisphere can increase our understanding of the hemispheres’ musical functions. Maurice Ravel suffered from Wernicke’s aphasia (receptive)3 as the result of such brain damage. Ravel was at the height of his musical career, but lost his ability to write music or play it. Nevertheless his musical mind remained unimpaired; he was able to distinguish any false note, and to continue to hum or play any of his own compositions as soon as he heard the first few notes. He was, however, unable to organize his thoughts and ideas into a musical grammatical form due to this aphasia, or even to name the notes (Alajouanine 1984). Another example, from my own personal experience: as a music therapist in Holland I treated a patient who had once been a famous concert pianist; at the age of sixty-plus he suffered diffuse cerebral damage in both hemispheres. He lost his analytical music ability and it was clearly apparent that he could no longer maintain a constant rhythm, nor avoid acceleration or express dynamic change. Despite this he was capable of reading a score, and once I had played him the opening of any given work he could recall this from his audio-motor memory as a complete structure and play it reasonably well. Here we see that in cases of diffuse injury the skill and ability loss is also multi-faceted and so we must carefully consider therapeutic approaches and techniques.* Similarly, we must take into consideration the possibility of performing impaired activity by way of the undamaged hemisphere. Such development has been clinically observed in numerous patients, who suffered from Broca’s aphasia (expressive), but were nevertheless able to sing words in sequence. Over and above the obvious emotional value of this, in which someone who has lost his power of speech is nevertheless able to give voice to meaningful sound, it is something which can be developed into speech through therapy, with music serving as an interim bridge. An example, again from personal experience, is that of Anton, a forty-year-old patient who suffered from cerebral palsy (right spastic hemiplegia) and unfortunately had never developed verbal skills. However, after a certain period of music therapy he was able to

combine music and song and to gradually go over to speech which was not dependent on musical melody.* Since high-level training of knowledge and music in the population at large seem to be the exception rather than the rule, it is probably justifiable to assume that dominance for general musical faculty tends to develop in the right hemisphere first. A gradient theory would explain how, as training progresses, dominance would be gradually transplanted to the opposite hemisphere for perceptual processing (Damasio & Damasio in Critchley & Henson 1977, 152). Damasio & Damasio go on to discuss the phenomenon of words in song: The former process concerned with words within the framework of a song or poem operates out of an “oppositional” store and emerges in a global gestalt way. The latter, which is concerned with most regular verbal utterances, stems from a “propositional” mechanism, resulting from a more analytical construction…. In fact, one might propose that language and music do unite in the right hemisphere in order to escape interhemispherical rivalry (ibid.). However, the development of speech independent of singing in patients who are able to sing but unable to talk, demands a systematic and well-defined therapeutic process and cannot be expected to develop automatically. Despite the fact that many open arguments still remain regarding the hemispheres and their musical relevance, we must nevertheless take into consideration all the aspects of current research when dealing with a patient suffering from brain damage in one of the hemispheres. My chosen example is that of an elderly patient (over sixty years of age) who suffered a sudden cerebrovascular accident in the right hemisphere. As a result, he became severely handicapped in his ability to perceive, comprehend and perform music. JACOB: PATIENT PROFILE Sometimes someone bends down to pick up something which fell from his hand and when once again he straightens up the world is not what it was.** Jacob was born in the 1920s. He lectured in Jewish religion and philosophy, and was the cantor of his local congregation. He had no formal musical education, and his cantorial skills were attained solely by practical experience over many years. One could say that in Jacob’s life both hemispherical functions were integrated: professionally his was a verbal occupation, dealing with abstraction and analysis. It was his emotional inclinations which led him into his occupation as a cantor in an Orthodox Jewish Synagogue. In late 1983 he suffered a stroke as a result of high blood pressure, which led to the paralysis of his left side. After some three months of hospitalization he attended a day center for rehabilitation in which the emphasis was placed on physiotherapy as well as improving speech elements such as breathing, articulation, intonation and resonance. It should be noted that the aspects on which the speech-clinician concentrated were the musical elements of speech. Jacob had not lost his ability to speak and was not suffering from aphasia, but there were certain musical deficiencies in his speech which led to a lack of verbal clarity. At this stage his ability to function in his capacity as a cantor had not been examined. We should also note that standard procedure for the examination and treatment of hemiplegic

patients still does not include any examination of auditory and musical losses, even in cases where music plays a major role in the patient’s emotional and professional life. When Jacob discovered he was no longer able to sing properly, he sank into a mood of depression. It was this development which led his clinician to invite me (as an outsider) to assess the possibility of vocal/musical rehabilitation. The initial examination consisted of two full-hour sessions which highlighted the following crucial problems: 1. Difficulty in recognition and performance of pitch. 2. Inability to maintain a steady beat-unit. 3. Difficulty in integrating on time and tending to accelerate when singing within a given tempo. In other words the two most fundamental elements of music, perception and performance of tempo and pitch, had been severely damaged. At this stage Jacob was able to sing only within an approximate four-note range:

After examining recordings of cantorial music which Jacob had performed before his injury, it was clear that the damage was indeed serious.* Emotionally, Jacob was depressed. His impaired singing ability was a critical factor for him. As he put it, “True, they can treat my body, but I’ve lost first and foremost my ability to sing—which means my soul.” It should be mentioned here that some 62% of hemiplegics suffering from damage to the minor right hemisphere tend to display emotional instability, whereas only some 10% of those suffering from damage to the major left hemisphere show similar symptoms. This has been proved by laboratory experiments based on the Wada Test.4 Recent research utilizing modern analytical techniques has revealed differences between the two cerebral hemispheres regarding emotional reactions after brain damage (Lishman 1987). Whatever the case, Jacob displayed symptoms of depression, and during therapy further symptoms of emotional instability ranging from nervous laughter to uncontrollable weeping. Beside the organic causes, his depressions could also be related to the damage inflicted on his vocal abilities, which once served as the essence of his emotional world. On the other hand, even during the initial interviews for music therapy one could perceive an improvement of mood which gave both patient and therapist a certain optimism regarding the possibilities for improvement. Replay of the initial interview recordings revealed that whereas Jacob proved incapable of controlling pitch, imitating intervals or even performing a brief melody without any harmonic support, when this was supplied, from piano or electronic organ, his vocal exactitude and clarity immediately improved. When these tapes were replayed, Jacob became encouraged and his motivation for music therapy was enhanced. Indeed he displayed

extraordinary self-will and determination which doubtless were of inestimable aid to him in facing the challenges he had chosen. Here we must stress two intermediate, but extremely relevant points: 1. Musically accompanied singing is not acceptable in the Orthodox Jewish Synagogue. It was therefore an essential long-range goal of therapy to free the patient from any dependence on harmonic-chordal accompaniment. During the initial stages of therapy this was totally impossible because chordal support was the way of enabling him to hold a tune. At this stage it was also essential to keep the expectations of Jacob’s family within realistic proportions. 2. That same year I examined another three patients who had suffered stroke in the right hemisphere and consequent left hemiplegia. A few years later I encountered a further four patients of a similar nature. Apart from the severity of the injury, the progress of each individual patient regarding musical ability and emotional stability differed from case to case. There can be no doubt that the patient’s progress was dependent on his individual personality and maturity, as well as on his ego-strength (see Versluys in Trombly 1977,27). In Jacob’s case, both his personality and the constant support of his family and community served to advantage. Therapeutic Considerations: Restoration Of Musical Skills. As already mentioned Jacob never studied music as a profession, he simply acquired it through experience. Any analytical approach to music as a communicative language with its own rules of syntax was totally foreign to him. This meant that any rehabilitation of music skills could not rely on the functions of the undamaged left hemisphere. Unfortunately the intuitive perception and performance of music upon which Jacob naturally relied were the very functions which had been damaged. This is typical of injury to the lateral region of the right temporal lobe which causes musical agnosia. He was unable to differentiate between the acoustic nature of a sensation and its significance. Working with the support of musical instruments can often restore the linkage between a sound and its origin while taking into consideration the need to reinforce self-confidence and to encourage the patient’s strength, I decided to devote a great deal of time to accompanied singing which would emphasize the harmonic potential of the melody. Such harmonic support could stimulate and reactivate inherent codes, similar to inherent verbal codes, on the assumption that such codes are the basis of melodic singing. Since Jacob had lost his sense of pitch and his ability to reproduce it, instead of working on single notes he began to practice on complete structures emanating from tonal codes. It should nevertheless be noted that the ability to repeat simple tonal or modal melodies could not guarantee the ability to perform complex liturgy such as the “Kol Nidre” sung on the Day of Atonement.

Start of Kol Nidre:

Along with the rehabilitation of his melodic skills, it was essential to deal with rhythmic ability. First and foremost this demanded developing hearing and response to constant beatunits and tempo. At this point I should like to stress that while psychophysiological researchers can devote their time to discussing the sources of rhythmic behavior, proposing and deposing various theories (instinctive, physiological, motor, acquired, etc.), the music therapist must approach the problem directly in order to facilitate the patient’s growth. According to D.I.M.T., reconstruction of beat-units is done through a combination of auditory and locomotive functions as they occur in natural development. This involves auditory stimulation of repetitive beats in utero, its transfer after birth to passive movements of rocking and rhythmic touching and a gradual development into complex movement.5 Indeed, both exercise and rhythmic treatments were conducted according to the abovementioned principles, even though the patient himself was more than sixty years old. At the same time these exercises also had their effect on both the relaxation and stabilization of breathing, something which is essential for any patient who lacks both physical and emotional control. Jacob’s initial physical response to a strict rhythm which matched the rate of an average human heartbeat consisted of activating various limbs in response to metronome beats accompanied by the piano. The music was tonal or modal, and hence reinforced his own loss of tonal and modal ability. Next, Jacob went on to rhythmic exercises on a variety of instruments, with a gradual but steady improvement. The use of various instruments served to develop and restore fine motor skills. We made use of various sized drums, xylophones, metallophones, an autoharp, a dulcimer, psaltery, a variety of bells, etc. The tendency to react with movement to audible rhythm has been subject to vast research. Boring stated as early as 1942: “Only after a rhythm has been actually played, can it be perceived and internalized.” This theory, proven over and over again in various recent research (Deutsch, Fraisse, Sternberg, et al. in Deutsch 1982), can help us as music therapists. After two to three months of intensive therapy Jacob’s receptiveness and performance regarding rhythmic units had improved to such a degree that he was able to progress to more complex structures and to better combine melodic and rhythmic activity. From an emotional viewpoint it was essential to take into consideration the patient’s own educational background in order to understand his limited freedom regarding both physical and vocal expression. In the case of an introverted personality such as Jacob’s, emotional inhibitions (due in part to education and life-style) are liable to limit or even block physical expression. In such a situation a step-by-step approach must be adopted: controlled exercises whose rules are limiting but nevertheless inspire self-confidence, vocal and

instrumental improvisation which graduates from the well-known and familiar to the freely imaginative, and eventually guided fantasizing in music. From my point of view as a therapist, the fact that I am a woman could have created difficulties. A religious Jew is actually forbidden to listen to a woman singing: “The voice of a woman in song, is tantamount to self-exposure” (Benedictions: Babylonian Talmud). Despite being of an orthodox background Jacob was able to regard my singing as an integral part of his therapy, and soon displayed the ability to enter into the musical experience and to respond in movement and vocality with a sense of enjoyment. The first stage of therapy lasted a full year, with stress on the restoration of musical ability and skills and the encouragement of self-confidence. Summary of First-Year Therapy Means Duration of Therapy

Goal

Technique

1. Rehabilitating beat-units

a) Listening to rhythmic stimulation b) Selfperformance

2. Rehabilitating rhythmic patterns

3. Tonal/modal rehabilitation

4. Tonal/modal rehabilitation

a) Perception (listening) b) Vocal and instrumental imitation and performance a) Listening b) Repeating single sounds, intervals and melodies a) Listening to musical compositions especially religious songs b) Singing melody and parts of melody c) Singing, with transpositions

Metronome drums percussion dulcimer autoharp organ singing As above Religious and secular songs and poetry*

1 ½ hrs + practice at home for 3 months

1 ½ hrs + practice at home for 10 months

Singing with harmonic accompaniment

1 ½ hrs + practice at home for 3 months

Accompanied singing

1 ½ hrs + practice at home for 10 months

Progress Versus Pre-Injury Condition*

40-50%

60-75%

40-50%

Composing songs Singing with selfaccompaniment

60-75%

At the end of his first year of therapy, Jacob was able to return to his previous position at his local synagogue as a cantor and in coaching boys for their bar mitzvah (coming of age) ceremony. True, the restoration of his musical skills was as yet incomplete, but was functionally satisfactory, and had restored his self-confidence as well as a sense of achievement and compensation in the face of loss. Therapeutic Considerations: Emotional Rehabilitation During his first year of music therapy Jacob, who was mostly used to cantorial and liturgical music, encountered musical and verbal material which was completely foreign to him. This included unfamiliar musical instruments, free-style singing, a variety of vocal and instrumental improvisation, the associative verbal response to music, freedom of movement, and so on. Early in 1985 he wrote about this new awareness of openness: I do things in this room which emerge from layers inside me of which I know nothing. Invisible worlds. I feel as if the paralysis and the loss of the physical body serve as the gateway through which an ailing existence went in, and from which a regenerated musical entity emerged. As you know, I come from a different musical tradition, aware that Western music has its sources in Christianity. However, as a result of this new experience I learn that it is not the literal, religious, philosophical roots which are of the essence, but rather the pure music—which can touch agony and transmute it into pleasure. These words summarize a period which was mainly devoted to functional rehabilitation and the opening up of a new stage in which it would not only be necessary to encourage and preserve these achievements, but also mostly to elaborate the emotional aspects involved. The more the patient’s musical organization improved, the easier it became to devote additional energy to confronting emotional matters which he would now raise quite freely. Linking his love of music with his love of words, Jacob began to compose his own songs. His two central motifs were, on the one hand loss and death, and on the other hand love and eroticism. These were themes which were easily aroused during free-association sessions in which he could verbally interpret musical motifs or passages from musical works. For example, a descending chromatic passage in an adagio tempo on the lower part of the piano was interpreted by him as an embrace. Choral sequences were seen as a kiss; a diminished chord and its solution meant a tragedy ending in love.* At this stage Jacob’s playing was endowed with rich dynamics which expressed a variety of emotions. It should be noted that during the first year of therapy this dynamic variation emerged quite spontaneously with no overt guidance on the part of the therapist. In music, changes of intensity (dynamics) constitute one of the most significant elements of emotional expression and its transmission to others. It would seem that the more the patient was able to identify with his own inner feelings, the better he could express them in music. In the art therapies in general (and in this case music therapy in particular) as opposed to psychodynamic verbal therapy, it is at least partially possible to deal with emotional subjects

by means of the artistic modality itself. By arousing musical associations, by composing tunes and lyrics, by choosing poetry and narrative and setting them to music, by verbal conversation emerging from guided imagery with music, we can help to elaborate emotional content and to open up the emotional world for the patient. In addition, these love songs which he composed and accompanied enabled a process of sublimation which suited Jacob’s religious upbringing, served as a personal compromise, and avoided any confrontation with his environment. Through the realization of erotic fantasy in song (whether adopted from literature or self-composed) it was possible to identify the focus of transference. Love of woman? Of mother? Of child? Does his preoccupation with the themes of death and loss indicate the termination of therapy? True, at this stage music therapy gave birth to love songs to a woman, which later became lullabies to a child, and apparently to some kind of closing of a life-cycle. This brought an end of longing, of conscious return to childhood, to primal object-relation and to a better acceptance of physical loss.** Jacob’s choice of poetry made him more aware of his own affinity to certain subjects. We could now work on a chosen poem through music, and discuss musical metaphors as well as verbal content and meaning. All of these led the patient toward a confrontation with his emotions, while reducing his guilt feelings and strengthening his sense of enjoyment. With this in mind, I proposed two books by Yehuda Amihai: Hour of Mercy and From Man Thou Comest and to Man Thou Shalt Return, on the assumption that the patient would be able to identify with poems concerning love, the relinquishing of youth, and departure from this world. Jacob began to examine his choice of instruments not only from an iconographic and structural point of view, but also regarding their emotional-musical potential. He began to clarify his love-desires, and expressed this in abstract musical terms, in composing poetry which was not only direct but also made use of metaphor, and in conversation. During this entire process it seemed that Jacob had learned to see human instinctive urges as leading to a positive process of creativity. During the last months of therapy, various existential questions were raised and expressed not only in his music but also in what he wrote. For example, this lyric written in November 1985: Why does the sea never end and only one’s life ebb away? Why do the waves change themselves every day and only the people die? Why does the mountain rear up like a rock And God’s alone, silent, up there? The sun’s scorching frown Lasts for ever and ever It’s only one’s life which bends down.* Epilogue

Music therapy was concluded in 1985 and Jacob was planning a family visit to the land of his birth, something which was also an obvious attempt at “closing the circles.” He never made it. Only a few days after the completion of his therapy Jacob suffered a heart attack and died. References Alajouanine, T. “Aphasia and Artistic Realisation,” Brain, 71 (1948): 229-241. Bever, T.; and Chiarello, R. “Cerebral Dominance in Musicians and Nonmusicians.” Science 185 (1974): 137-139. Deutsch, D., ed. The Psychology of Music. New York: Academic Press, 1982. Kimura, D. “Right Temporal Lobe Damage.” Archives of Neurology 8 (1963): 24. Kimura, D.; and Archibald, J. “Motor Functions of the Left Hemisphere.” Brain 97 (1974): 337350. Lishman, W.A. Organic Psychiatry. Oxford, London: Blackwell Scientific Publishing Co., 1987. Rahmani, L. Brain and Learning, Processes and Defficiencies (in Hebrew). Papyrus, Tel Aviv University, 1981. Rahmani, L. An Approach to Clinical Psycho-Neurology (in Hebrew). Tel Aviv: Diyunon, 1984. Springer, S.; and Deutch, G. Left Brain, Right Brain. New York: Freeman & Co., 1985. Trombly, C.A., ed. Occupational Therapy for Physical Disfunction. Baltimore: Williams & Wilkins, 1983.

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

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

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

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

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

Voice

• • • •

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

• •

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