Case Examples of Music Therapy for Schizophrenia [1 ed.] 9781937440251

Citation preview

Case Examples of Music Therapy for Schizophrenia and Other Psychoses Compiled by Kenneth E. Bruscia

Case Examples of Music Therapy for Schizophrenia and Other Psychoses 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: 978-1-937440-25-1 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 Composition, Improvisation and Poetry in the Psychiatric Treatment of a Forensic Patient Phyllis Boone CASE TWO The Case of Marianne: Repetition and Musical form in Psychosis Jos De Backer Jan Van Camp CASE THREE From Ego Disintegration to Recovery of Self: The Contribution of Lacan’s Theories in Understanding the Role of Music Therapy in the Treatment of a Woman with Psychosis Lillian Eyre CASE FOUR Singing in the Recovery Model with a Chronic Mentally Ill Offender Vaughn Kaser CASE FIVE The Significance of Triadic Structures in Patients Undergoing Therapy for Psychosis in a Psychiatric Ward Susanne Metzner CASE SIX Group Improvisation Therapy: The Experience of One Man with Schizophrenia Helen Odell Miller CASE SEVEN Integrated Music Therapy with a Schizophrenic Woman Gabriella Giordanella Perilli CASE EIGHT Analytical Music Therapy and the “Detour Through Fantasy” Mary Priestley CASE NINE

Changes in Images, Life Events and Music in Analytical Music Therapy: A Reconstruction of Mary Priestley's Case Study of "Curtis" Lillian Eyre

CASE TEN Edwin, who murdered his wife in a Psychotic Attack A Case Analysis 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 individuals with schizophrenia or psychoses. It has been compiled not only to provide practical information to students and professionals in music therapy and related fields, but also to inform all those affected by psychiatric illness about the potential benefits of music therapy. This introduction is intended to help readers better understand and contextualize each case example presented in the book, not only within the field of music therapy, but also within the literature on psychiatry. To do this, it provides basic information on schizophrenia and other psychoses, music therapy, and case examples. About Schizophrenia and Other Psychoses Schizophrenia is a form of psychosis characterized by distorted thinking and perception, and inappropriate or blunted affect. Symptoms may include delusions, hallucinations, incoherent speech, thought disorders (thought echoing, insertion, withdrawal or broadcasting), catatonia, disorganized behavior, flat affect, alogia, or avolition. The disorder may be episodic (with or without complete remission), or it may be continuous (American Psychiatric Association, 2000). Schizophrenia has several subtypes (e.g., paranoid, disorganized, catatonic, undifferentiated, and residual) each with their own characteristic symptoms. In addition, distinctions are made between other specific psychotic disorders (e.g., schizophreniform, schizoaffective, delusional, brief and shared psychotic disorder) as well as psychotic disorders caused by medical condition, substance use, and so forth. The case examples in this book provide myriad perspectives not only of how the above disorders are manifested differently by each individual, both within and outside of a musical context, but also how these disorders and resulting symptoms can be addressed through carefully designed music experiences that capitalize on the individual’s strengths and resources. About Music Therapy (Based on Bruscia, 1993) Definition and Applications In music therapy, the therapist and client use music and all of its facets—physical, emotional, mental, social, aesthetic, and spiritual—to help the client improve or maintain his or her health. In some instances, the client’s needs are addressed directly through music and its intrinsic therapeutic properties; in others, they are addressed through the relationships that develop between the music, client, therapist, and other participants.

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

feelings and ideas of others, work with others cooperatively, or merely share in the joy of making music—as these are the main aspects of singing or playing pre-composed music that have therapeutic implications. In those therapy sessions that involve improvising, the client makes up his or her own music extemporaneously, singing or playing whatever arises in the moment. The client may improvise freely and spontaneously or according to the musical or verbal guidance of the therapist. Sometimes the client is asked to improvise sound portraits of feelings, events, persons, or situations that are being explored in therapy. The client may improvise with the therapist, with other clients in a group, or alone, depending on the therapeutic objective. Improvising music is most appropriate for clients who need to develop spontaneity, creativity, freedom of expression, self-awareness, communication, and interpersonal skills—as these are the basic components of improvising. In those sessions that involve composing, the therapist helps the client to write songs, lyrics, or instrumental pieces, or to create any kind of musical product, such as music videos or audiotape programs. Usually the therapist simplifies the process by engaging the client in aspects of the task within their capability (e.g., generating a melody, or writing the lyrics of a song) and by taking responsibility for more technical aspects (e.g., harmonization, notation). Activities involving composing music are used with clients who need to learn how to make decisions and commitments, or find ways of working in an organized way toward a goal. Most often, clients create compositions (especially songs) around significant events, people, or relationships in their lives, or to express thoughts and feelings that they are exploring in therapy. In addition to strictly music experiences, music therapists often engage clients in verbal discussions. Clients may be encouraged to talk about the music, their reactions to it, or any thoughts, images, or feelings that were evoked during the experience. Clients may also be encouraged to express themselves through the other arts, such as drawing, painting, dance, drama, or poetry. Music therapy sessions for children often include various games or play activities which involve music. The case examples that follow highlight the goals of music therapy for individuals with a psychotic disorder, and the different kinds of music experiences used to address these goals. Thus, a key to reading these cases is to pay close attention to how each type of music experience affords clients many different opportunities to not only confront their problems within the music, but also to explore healthier ways of dealing with or resolving them. This leads to the next important topic—the ways that case examples can be read or studied for greatest insight. About Case Examples For purposes of the present discussion, case examples can be divided into two main types: clinical cases, and research cases. A clinical case is a professional report written by the therapist, client, or observer to describe what transpired during and upon completion of the music therapy process with an individual client or group. The report is usually based on recordings of the session or notes and logs kept by the therapist and/or client. Efforts are made to present an accurate and unbiased account of the therapy process to the extent possible, and

theories are often used to substantiate or contextualize the therapeutic approach. Objective data may or may not be provided to verify or document the report. In contrast, a research case is a data-based report, provided by the therapist or researcher, to document or verify the specific therapeutic effects of a particular music therapy protocol on an individual client or group. As such, a research case operationally defines and measures how the independent variables (e.g., treatment methods used by the therapist) act upon the dependent variables (e.g., targeted treatment outcomes for the client), when all other relevant variables and conditions are controlled. Perhaps the best way to derive the most benefits from a clinical or research case is to read it from a particular perspective, and to interrogate the case or group of cases from that perspective. Essentially, the reader adopts a particular lens or viewpoint to study the case(s), and then asks questions that arise as a result. Three of the most helpful reading perspectives are: scientific, personal, and clinical perspectives, each of which poses very different questions for the reader to ponder. Reading from a Scientific Perspective Scientists usually look for answers to two basic questions when reading a case. First, is the case credible? That is, how accurate were the perceptions and interpretations of the writer, and how trustworthy are the findings and conclusions presented? Of course, this is not a question that only scientists pose. One’s natural propensity as a reader is to question the truth value of what is read. Certainly, if the reader is involved in some way with an individual with a psychotic disorder, 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 psychosis are as interested in this question as scientists and researchers. Their interest is in whether individuals with psychosis 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 Schizophrenia and Other Psychoses The case examples in this e-book were taken exclusively from various books published by Barcelona Publishers. Thus, these cases, though typical, may not comprise a representative sample of all clinical practices in music therapy for individuals with psychosis. Additional case examples have been written, which further elaborate how these individuals can derive therapeutic benefits from music. Here is a list of other published case examples along with other writings on the topic. Ansdell, G., Davidson, J., Magee, W., Meehan, J., & Procter, S. (2010). From “This F***ing Life” to “That’s Better” … in Four Minutes: An Interdisciplinary Study of Music Therapy’s “Present Moments” and Their Potential for Affect Modulation. Nordic Journal of Music Therapy, 19(1), 3-28. Benenzon, R. O. (1982). Music Therapy in Child Psychosis. Springfield, IL: Charles C. Thomas Publisher. Bloch, B. (2010). The Effects of Music Relaxation on Sleep Quality and Emotional Measures in People Living with Schizophrenia. Journal of Music Therapy, 47(1), 27-52. Bohnert, K. (1999). Meaningful Musical Experience and the Treatment of an Individual in Psychosis: A Case Study. Music Therapy Perspectives, 17(2), 69-73. Burleson, S. J., Center, D. B., & Reeves, H. (1989). The Effect of Background Music on Task Performance in Psychotic Children. Journal of Music Therapy, 26(4), 198-205. Camilleri, V. A. (2001). Therapist Self-Awareness: An Essential Tool in Music Therapy. The Arts in Psychotherapy, 28(1), 79-85. Ceccato, E., Caneva, P., & Lamonaca, D. (2006). Music Therapy and Cognitive Rehabilitation in Schizophrenic Patients: A Controlled Study. Nordic Journal of Music Therapy, 15(2), 111120. Cercone, K. A. (2008). The Effects of Music Therapy on Symptoms of Schizophrenia and Other Serious Mental Illnesses: A Meta-Analysis. Dissertation Abstracts International, 68.

Costa, C. M. (2009). Opening channels of communication. Voices: A World Forum for Music Therapy, 9(1) Retrieved from https://normt.uib.no/index.php/voices/article/viewArticle/361/284 De Backer, J. (1996). Regression in Music Therapy with Psychotic Patients. Nordic Journal of Music Therapy, 5(1), 24-30. De Backer, J. (2008). Music and Psychosis: A Research Report Detailing the Transition from Sensorial Play to Musical Form by Psychotic Patients. Nordic Journal of Music Therapy, 17(2), 89-104. De Backer, J., & Van Camp, J. (2003). The Case of Marianne: Repetition and Musical Form in Psychosis. In S. Hadley (Ed.), Psychodynamic Music Therapy: Case Studies (pp. 273-298). Gilsum, NH: Barcelona Publishers. De Backer, J., & Wigram, T. (2007). Analysis of Notated Music Examples Selected from Improvisations of Psychotic Patients. In T. Wosch, & T. Wigram (Eds.), Microanalysis in Music Therapy: Methods, Techniques and Applications for Clinicians, Researchers, Educators and Students (pp. 120-133). London: Jessica Kingsley. Dreikurs, R., & Crocker, D. B. (1956). Music Therapy with Psychotic Children. In E. T. Gaston, M. E. Hahn & R. F. Unkefer (Eds.), Music Therapy 1955. Fifth Book of Proceedings of the National Association for Music Therapy, Inc. (pp. 62-73). Lawrence, KS: National Association for Music Therapy. Eyre, L. (2003). Into the Labyrinth: Music Therapy in the Treatment of an Individual with Chronic Schizophrenia. Canadian Journal of Music Therapy, 10(1), 8-32. Eyre, L. (2007). Changes in Images, Life Events and Music in Analytical Music Therapy: A Reconstruction of Mary Priestley’s Case Study of “Curtis”. Qualitative Inquiries in Music Therapy, 3, 1-30. Free, K., Tuerk, J., & Tinkleman, J. (1986). Expressions of Transitional Relatedness in Art, Music and Verbal Psychotherapies. The Arts in Psychotherapy, 13(3), 197-213. Frank, G. (2005). David’s Music: An Observation of Musical Interactions with a Schizophrenic Adolescent. Nordic Journal of Music Therapy, 14(2), 179-185. Gold, C. (2007). Music Therapy Improves Symptoms in Adults Hospitalised with Schizophrenia. Evidence-Based Mental Health, 10(3), 77. Gold, C., Dahle, T., Heldal, T. O., & Wigram, T. (2006). Music Therapy for People with Schizophrenia or Other Psychoses: A Systematic Review and Meta-Analysis. British Journal of Music Therapy, 20(2), 100-108. Gold, C., Heldal, T. O., Dahle, T., & Wigram, T. (2005). Music Therapy for Schizophrenia or Schizophrenia-Like Illnesses. Cochrane Database of Systematic Reviews (Online), (2), CD004025. Gold, C., Rolvsjord, R., Aaro, L., Aarre, T., Lars, T., & Stige, B. (2005). Resource-Oriented Music Therapy for Psychiatric Patients with Low Therapy Motivation: Protocol for a Randomised Controlled Trial [NCT00137189]. BMC Psychiatry, 5(39), 1-8. Grocke, D., Bloch, S., & Castle, D. (2008). Is There a Role for Music Therapy in the Care of the Severely Mentally Ill?. Australasian Psychiatry: Bulletin of Royal Australian and New Zealand College of Psychiatrists, 16(6), 442-445. Guze, V. S. (1957). The Drawings of Normal and Psychotic Women as Affected by Music. In E. T. Gaston, W. W. Sears & R. F. Unkefer (Eds.), Music Therapy 1956. Sixth Book of

Proceedings of the National Association for Music Therapy, Inc. (pp. 119-124). Lawrence, KS: National Association for Music Therapy. Hamer, B. A. (1991). Music Therapy: Harmony for Change. Journal for Psychosocial Nursing and Mental Health Services, 29(12), 5-7. Hudson, W. C. (1973). Music: A Physiologic Language (In Treatment of Schizophrenia and Autism). Journal of Music Therapy, 10(3), 137-140. Jensen, B. (1999). Music Therapy as Holding and Re-Organizing Work with Schizophrenic and Psychotic Patients. In T. Wigram, & J. De Backer (Eds.), Clinical applications of music therapy in psychiatry (pp. 44-60). London, UK: Jessica Kingsley. Jensen, B. (1999). Music Therapy with Psychiatric In-Patients: A Case Study with a Young Schizophrenic Man. In T. Wigram, & J. De Backer (Eds.), Clinical Applications of Music Therapy in Psychiatry (pp. 44-60). London, UK: Jessica Kingsley Publisher. John, D. (1995). The Therapeutic Relationship in Music Therapy as a Tool in the Treatment of Psychosis. In T. Wigram, B. Saperston, R. West (Eds.), the Art and Science of Music Therapy: A Handbook (pp. 157-166). Langhorne, PA, England: Harwood Academic Publishers/Gordon. John, D. (1995). The Therapeutic Relationship in Music Therapy in Schizophrenia: Implications for Theories of Working Memory and Cerebral Dominance. In T. Wigram, B. Saperston & R. West (Eds.), the Art and Science of Music Therapy: A Handbook (pp. 157-166). Chur, Switzerland: Harwood Academic Publishers. Killick, K., & Greenwood, H. (1995). Research in Art Therapy with People Who Have Psychotic Illnesses. In A. Gilroy, & C. Lee (Eds.), Art and Music: Therapy and Research (pp. 101106). London, UK: Routledge. Kortegaard, H. (1993). Music Therapy in the Psychodynamic Treatment of Schizophrenia. In M. H. Heal, T. Wigram (Eds.), Music Therapy in Health and Education (pp. 55-65). London, England: Jessica Kingsley Publishers. Langdon, G. S., Pearson, J., Stastny, P., & Thorning, H. (1989). The Integration of Music Therapy into a Treatment Approach in the Transition of Adult Psychiatric Patients from Institution to Community. Music Therapy, 8(1), 92-107. Lehtonen, K. (2003). Towards Holistic and Patient-centered Music Therapy. Nordic Journal of Music Therapy, 12(2), 160-162. Loue, S., Mendez, N., & Sajatovic, M. (2008). Preliminary Evidence for the Integration of Music into HIV Prevention for Severely Mentally Ill Latinas. Journal of Immigrant and Minority Health / Center for Minority Public Health, 10(6), 489-495. Maratos, A. A. (2010). W03-01 - A Randomised Controlled Trial of Co-Improvisational Music Therapy for Inpatients with Schizophrenia, London/UK. European Psychiatry, 25, Supplement 1, 32. McKinnis, I. G. (1953). Melodic Perception and Conceptualization in Schizophrenics. In E. G. Gilliland (Ed.), Music therapy 1952. Second Book of Proceedings of the National Association for Music Therapy. (pp. 251-255). Lawrence, KS: National Association for Music Therapy. Metzner, S. (2003). The Significance of Triadic Structures in Patients Undergoing Therapy for Psychosis in a Psychiatric Ward. In S. Hadley (Ed.), Psychodynamic Music Therapy: Case Studies (pp. 257-272). Gilsum, NH: Barcelona Publishers.

Metzner, S. (2010). about Being Meant: Music Therapy with an In-Patient Suffering from Psychosis. Nordic Journal of Music Therapy, 19 (2), 133-150. Miller, H. O. (1991). Group Improvisation Therapy: The Experience of One Man with Schizophrenia. In K. E. Bruscia (Ed.), Case studies in music therapy (pp. 417-432). Phoenixville, PA: Barcelona Publishers. Moe, T. (2002). Restitutional Factors in Receptive Roup Music Therapy Inspired by GIM: The Relationship between Self-Objects, Psychological Defence Maneouvres and Restitutional Factors: Towards a Theory. Nordic Journal of Music Therapy, 11(2), 152-166. Næss, T., & Ruud, E. (2007). Audible Gestures: From Clinical Improvisation to Community Music Therapy: Music Therapy with an Institutionalized Woman Diagnosed with Paranoid Schizophrenia. Nordic Journal of Music Therapy, 16(2), 160-171. Nakamura, T., Sakai, M., & Takeichi, M. (1990). Basic Studies on Music Therapy Using Body Sonic: Examination of Clinical Effects through State-Trait Anxiety Inventory. Kyushu Neuro-psychiatry, 36(2), 155-160. North, E. F. (1966). Music Therapy as an Important Treatment Modality with Psychotic Children. Journal of Music Therapy, 3(1), 22-24. Nygaard P., I. (1999). Music Therapy as Holding and Re-Organizing Work with Schizophrenic and Psychotic Patients. In T. Wigram, & J. De Backer (Eds.), Clinical Applications of Music Therapy in Psychiatry (pp. 24-43). London, UK: Jessica Kingsley Publishers. Pavlicevic, M. (2007). The Music Interaction Rating Scale (Schizophrenia) (MIR(S)) Microanalysis of Co-Improvisation in Music Therapy with Adults Suffering from Chronic Schizophrenia. In T. Wosch, & T. Wigram (Eds.), Microanalysis in music therapy: Methods, Techniques and Applications for Clinicians, Researchers, Educators and Students (pp. 174-185). London: Jessica Kingsley. Pavlicevic, M., & Trevarthen, C. (1989). A musical assessment of psychiatric states in adults. Psychopathology, 22, 325-334. Pavlicevic, M., Trevarthen, C., & Duncan, J. (1994). Improvisational Music Therapy and the Rehabilitation of Persons Suffering from Chronic Schizophrenia. Journal of Music Therapy, 31(2), 86-104. Peng, S. M., Koo, M., & Kuo, J. C. (2010). Effect of Group Music Activity as an Adjunctive Therapy on Psychotic Symptoms in Patients with Acute Schizophrenia. Archives of Psychiatric Nursing, 24(6), 429-434. Pedersen, I. N. (1997). The Music Therapist’s Listening Perspectives as Source of Information in Improvised Musical Duets with Grown-Up, Psychiatric Patients Suffering from Schizophrenia. Nordic Journal of Music Therapy, 6(2), 98-111. Pedersen, I. N. (1999). Music Therapy as Holding and Re-Organizing Work with Schizophrenic and Psychotic Patients. In T. Wigram, & J. De Backer (Eds.), Clinical Applications of Music Therapy in Psychiatry (pp. 24-43). London, UK: Jessica Kingsley. Perilli, G. G. (1991). Integrated Music Therapy with a Schizophrenic Woman. In K. E. Bruscia (Ed.), Case Studies in Music Therapy (pp. 403-416). Phoenixville, PA: Barcelona Publishers. Priestly, M. (1980). Analytical Music Therapy and ‘The Detour through Fantasy’. British Journal of Projective Psychology & Personality Study, 25(1), 11-15.

Prior, M. (1985). Whatever Happened to the Childhood Psychoses: Are Children Still the Same?. Eleventh National Conference of the Australian Music Therapy Association, Inc. “Growing Together with Music”, 118-125. Rogers, P., & Smeyatsky, N. (1995). Short-Term Verbal and Musical Memory in Schizophrenia: Implications for Theories of Working Memory and Cerebral Dominance. In T. Wigram, B. Saperston & R. West (Eds.), the art and science of music therapy: A handbook (pp. 139156). Chur, Switzerland: Harwood Academic Publishers. Ross, S., Cidambi, I., Dermatis, H., Weinstein, J., Ziedonis, D., Roth, S., & Galanter, M. (2008). Music Therapy: A Novel Motivational Approach for Dually Diagnosed Patients. Journal of Addictive Diseases, 27(1), 41-53. Sakaue, M. (1997). Musical Expressions of Schizophrenics: Their Meaning and the Therapeutic Consequences. In R. R. Pratt, & Y. Tokuda (Eds.), Arts medicine (pp. 91-96). Saint Louis, MO: MMB Music, Inc. Schapira, D. (2003). Last Sounds of the Shipwreck: Aspects of the Plurimodal Method in the Treatment of Psychosis. Nordic Journal of Music Therapy, 12(2), 163-172. Schneider, C. W. (1961). The Effects of Dalcroze Eurhythmics upon the Motor Processes of Schizophrenics. In E. H. Schneider, R. Boxberger & W. W. Sears (Eds.), Music therapy 1960. Tenth Book of Proceedings of the National Association for Music Therapy, Inc. (pp. 132-140). Lawrence, KS: National Association for Music Therapy. Shatin, L. (1958). The Application of Rhythmic Music Stimuli to Long-Term Schizophrenic Patients. In E. T. Gaston, R. Boxberger & R. F. Unkefer (Eds.), Music therapy 1957. Seventh Book of Proceedings of the National Association for Music Therapy, Inc. (pp. 169-178). Lawrence, KS: Music Therapy 1957. Shatin, L., Kotter, W. L., & Douglas-Longmore, G. (1962). Music Therapy for Schizophrenics. In E. H. Schneider, R. Boxberger & W. W. Sears (Eds.), Music therapy 1961. Eleventh Book of Proceedings of the National Association for Music Therapy, Inc. (pp. 99-104). Lawrence, KS: National Association for Music Therapy. Silverman, M. J. (2003). Contingency Songwriting to Reduce Combativeness and NonCooperation in a Client with Schizophrenia: A Case Study. The Arts in Psychotherapy, 30(1), 25-34. Silverman, M. J. (2003). The Influence of Music on the Symptoms of Psychosis: A Meta-Analysis. Journal of Music Therapy, 40(1), 27-40. Simon, B., Holzberg, J. D., Alessi, L., & Garrity, D. A. (1954). The Recognition and Acceptance of Mood in Music by Psychotic Patients. In E. Podolsky (Ed.), Music therapy (pp. 62-78). New York, NY: Philosophical Library. Skelly, C. G., & Haslerud, G. M. (1954). Music and the General Activity of Apathetic Schizophrenics. In E. Podolsky (Ed.), Music therapy (pp. 231-240). New York, NY: Philosophical Library. Solli, H. P. (2008). “Shut Up and Play!”: Improvisational Use of Popular Music for a Man with Schizophrenia. Nordic Journal of Music Therapy, 17(1), 67-77. Spang, S. (1997). Forensic Psychiatry and Music Therapy. Annual Journal of the New Zealand Society for Music Therapy, 17-28.

Stige, B. (1999). Music Therapy with Psychiatric In-Patients: A Case Study with a Young Schizophrenic Man. In T. Wigram, & J. De Backer (Eds.), the Meaning of Music - from the Client’s Perspective (pp. 61-83). London, UK: Jessica Kingsley Publishers. Steinberg, R., Kimmig, V., Raith, L., Günther, W., Bogner, J., & Timmermann, T. (1991). Music psychopathology. IV. The Course of Musical Expression during Music Therapy with Psychiatric Inpatients. Psychopathology, 24(3), 121-129. Talwar, N., Crawford, M., Maratos, A., Nur, U., McDermott, O., & Procter, S. (2006). Music Therapy for In-Patients with Schizophrenia: Exploratory Randomised Controlled Trial. The British Journal of Psychiatry: The Journal of Mental Science, 189, 405-409. Tang, W., Yao, X., & Zheng, Z. (1994). Rehabilitative Effect of Music Therapy for Residual Schizophrenia. A One-Month Randomised Controlled Trial in Shanghai. The British Journal of Psychiatry. Supplement, 24, 38-44. Thompson, M. F. (1955). Piano Ensemble for Schizophrenic Patients. In E. T. Gaston, M. E. Hahn & R. F. Unkefer (Eds.), Music therapy 1954. Fourth Book of Proceedings of the National Association for Music Therapy (pp. 91-94). Lawrence, KS: National Association for Music Therapy. Tysmans, D. (1986). The Use of Instrumental Music Instruction in a Music Therapy Programme with a Young Schizophrenic Patient. The Australian Music Therapy Association Bulletin, 9(4), 2-9. Tyson, F. (1979). Child at the Gate: Individual Music Therapy with a Schizophrenic Woman. Art Psychotherapy, 6(2), 77-83. Ulrich, G., Houtmans, T., & Gold, C. (2007). The Additional Therapeutic Effect of Group Music Therapy for Schizophrenic Patients: A Randomized Study. Acta Psychiatrica Scandinavica, 116(5), 362-370. Wasserman, N., Plutchik, R., Deutsch, R., & Taketomo, Y. (1973). The Musical Background of a Group of Mentally Retarded Psychotic Patients: Implications for Music Therapy. Journal of Music Therapy, 10(2), 78-82. Werbner, N., & Chaffee, A. (1966). The Practice of Music Therapy with Psychotic Children. Journal of Music Therapy, 3(1), 24-31. Wolfgram, B. (1978). Music Therapy for Retarded Adults with Psychotic Overlay: A Day Treatment Approach. Journal of Music Therapy, 15(4), 199-207. Zagelbaum, V. N., & Rubino, M. A. (1991). Combined Dance/Movement, Art, and Music Therapies with a Developmentally Delayed, Psychiatric Client in a Day Treatment Setting. The Arts in Psychotherapy, 18(2), 139-148. Zhang, X., & Ke, C. (1997). Effect of Music Therapy on Chronic Schizophrenia. Chinese Journal of Clinical Psychology, 5(1), 48-49. References for Introduction American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, Text Revision. Washington DC: American Psychiatric Association. Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ.

Case Examples of Music Therapy for Schizophrenia and Other Psychoses

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

CASE ONE Composition, Improvisation and Poetry in the Psychiatric Treatment of a Forensic Patient Phyllis Boone Abstract This study describes music therapy with a male forensic patient diagnosed as paranoid schizophrenic with grandiose, religious, and persecutory delusions and suicidal ideation. Incarcerated for terroristic threats, the man used poetry, musical composition, and improvisation to express his inner conflicts and feelings. Background Information Michael was admitted to the forensic unit of a state psychiatric hospital in 1985 for the purpose of being evaluated for competency to stand trial. He had been charged with making terroristic threats. Upon evaluation, he was diagnosed as paranoid schizophrenic with grandiose, religious and persecutory delusions and suicidal ideation. He believed himself to be the “Antichrist” and that his life was in danger. He was hearing voices that he believed to be demonic, claiming that Satan was directly responsible for many of the natural disasters that were occurring throughout the world. He was found incompetent to stand trial. Michael grew up in a family that had a history of suicide attempts, both by his brother and his uncle. Michael, at age 15, also attempted suicide which resulted in his first hospitalization. At that time he was hearing voices that were telling him to kill himself. Prior to this attempt, he had told his family that he was homosexual, which not only exacerbated some already existing problems within the family, but also caused deterioration in the relationship with his parents. His self-esteem suffered considerably as a result. At the age of 21, Michael began to experiment in the occult and remembers hearing voices that were increasingly malevolent. He was unable to hold a job for more than several months, which culminated in an ultimatum from his father that he either get a job or leave home. At this time Michael expressed fears for his life because he was the “Antichrist” and believed that there was a plot to kill him. This resulted in a second brief hospitalization. During the next two years, Michael began to experiment with drugs, and his parents asked him to leave home several times. His preoccupation with satanic worship and his delusional thoughts intensified, and eventually culminated in his crime. Although the crime was one of threats rather than overt violence or assault, he did target children as his victims, and he

demanded that certain political figures step down from office in order for him and Satan to take control. Competency to stand trial depends upon whether an individual has the ability to “consult with defendant’s lawyer with a reasonable degree of rational understanding and otherwise to assist in the defense, and whether the defendant has a rational as well as factual understanding of the proceedings” (American Bar Association, 1986, p. 167). Michael’s paranoia prevented him from cooperating with his defense, and his delusions also confused his thinking in terms of understanding the possible consequences of his behavior as it related to the trial process. As he was obviously unable to stand trial at that time, he was committed to a forensic unit of a state psychiatric hospital, where he was treated for a period of three years, and then re-evaluated. This time he met the criteria for competency to stand trial. The courts then found him “Guilty but Mentally 111,” sentenced him to 15 years, applied the three years of treatment on the forensic unit towards the sentence, and then paroled him to the civil section of the same state hospital. Although the courts cannot deny probation solely because of mental health status, they can condition probation on receiving the necessary therapeutic treatment (American Bar Association, 1986). A key factor, however, in determining parole eligibility is the assessed dangerousness of the individual. In Michael’s case, this was particularly relevant to his legal disposition. Michael presented as a very intelligent, withdrawn and seclusive individual. He seemed disinterested in participating in many of the therapeutic activities that were available to him (e.g., group therapy, occupational therapy, and gym sports). On the ward he interacted with only a few patients, and at times would talk with select staff. His appearance was disheveled, and at times he appeared preoccupied and depressed. He was articulate but it was difficult to engage him in conversation. The one interest Michael did express was listening to music. Because of this, and the need for the team to observe him in some type of therapeutic group, he was referred to music therapy. Treatment Process Phase One: Assessment through Group Participation Upon referral to music therapy, Michael was placed in an ongoing group that I led once weekly for 60-90 minutes. Although many different techniques were utilized, improvisation proved to be the most valuable in assessing Michael’s treatment needs. When Michael began attending the group, he did so reluctantly, and following the encouragement of his psychiatrist and other members of his treatment team. He was aware that, in order to progress through the legal process, he needed to cooperate with treatment, which minimally required attending and participating in some groups. During this initial assessment period, his attendance was sporadic, his level of resistance was high, and his affect was blunted.

Despite these difficulties, Michael’s intellect was intrigued by the song discussions and his interest stimulated by the variety and quality of the instruments used in improvisations. During song discussions, his grasp of metaphors was apparent. It quickly became obvious, however, that he was only able to project his own feelings onto the lyrics, and that he often used intellectualization to deal with issues that were poignant and pertinent to his problems. Since this was a support group, his egocentricity and guarded responses often kept him peripherally involved. During improvisations, especially those that described feelings or specific relationships, he exhibited very fixed or rigid responses. Rhythm was the most dominant element, and was markedly perseverative. He most often chose non-melodic instruments, but with encouragement would use a xylophone. Because his rhythm was so fixed, his melodies lacked continuity, creativity, and the development of musical ideas. They consisted of short intervallic sequences that were also repeated perseveratively. His playing was loud, and he was seemingly unaware and unresponsive to others in both group and dyadic improvisations. As he became less resistant verbally and interactionally, he began to express an impressive knowledge of popular music. He also began to bring tapes to the sessions that were relevant to the issues at hand for the group. Two significant events occurred during this phase of treatment. The first was his announcement to the group that he was a poet, and that he would like to bring some of his poems to the group so that they could be set to music. When the time came however, he told the group that, on second thought, he did not want to share his poetry because of the type of material expressed. He then took the opportunity to request individual music therapy sessions for the purpose of setting his poems to music. He also requested that an intern (from England) work with him, because she was familiar with the type of music that he liked. The second significant event shed more light on the hypothesis that Michael was unable, and not simply unwilling, to vary his music. Michael expressed a strong preference for “New Wave” and “Punk” music and used that preference to validate his perseverative style of improvising. On one occasion, Michael was asked to improvise in a random and subdued manner in order to convey a specific idea to the group, and after two attempts, showed that he was unable to do so. After the first attempt, he was asked to explain the task and he did so with ease. After the second attempt, Michael became suddenly and acutely aware of his inability, dropped the beaters, and refused to continue. He remained quiet and pensive for the rest of the session. Despite the efforts of the group and myself to talk about what happened, Michael’s defenses had been challenged and he was off balance as a result. Phase Two: Achieving Competency in Individual Therapy Upon his request, Michael began receiving weekly, one-hour individual music therapy sessions with the English intern, in addition to the weekly group. At the time, his clinical status was unstable, and he was not yet competent to stand trial. Being on the forensic unit, therapy had to occur in close proximity to the day hall with very limited privacy or access to much of the equipment that could have enhanced this phase of his treatment. Despite this, Michael was motivated and anxious to share his poetry and to investigate the possibilities of adding music to his work.

One of the main goals of this phase was to enable Michael to musically release the anger and fear that he verbalized in his poetry. It was felt that adding the dimensions of sound would help to “unfreeze” these emotions, while also providing ways of “synthesizing the energies freed from repressive and defensive mechanisms and giving them a new direction through rehearsal of action in sound” (Priestley, 1975). The following is one of the earliest poems that he set to music. The themes of violence and terror were common to his work during this phase. THE PSYCHOPATH Look at all the dead men See the bloody bodies Slaughter them like pigs Cut him open like a dog Bury him in sand Let me be your boyfriend Tell me that you love me (Would you kill for me?) I know something you don’t know I’m gonna get you With a kitchen knife Better pray to Jesus I am coming after you They will tell me where you are I will follow you home You had better run You had better hide I know where you live I know how you die. Michael was at first very interested in sharing his poetry with the intern. He continued to be very concerned about the response that he would get because of the violent and sexual explicitness of the work. Once he was able to be sure that the focus of treatment was not to “clean up his act,” he began to concentrate on the relationship, as well as the task of adding rhythm, ostinati and melodic sounds to his poems. A very simple electronic keyboard along with some rhythm instruments of Michael’s choice became his options for this process. The compulsive and perseverative nature of his music seemed to be paralleled in his poetry. He continued to relate his work to many new wave and Punk artists who successfully validated his style. This process evolved over a period of several months, and was relatively uneventful except for the slight but gradual improvement in his affect and appearance. Along with this improvement were some significant gains in his group participation. He often assumed a leadership role in group improvisation and was less guarded in his verbal responses. In one session, when asked to title a duet improvisation, he defiantly responded, “Orgasm.”

Although Michael never announced his sexual preferences in the group, he began to openly discuss it in individual sessions and had begun to develop a relationship with another male patient on his ward. This interest in others was viewed as progress in terms of his treatment. A strong relationship was also developing between Michael and the intern, as he continued to receive weekly individual sessions with her in addition to the group I led. This relationship was as significant to Michael’s growth at this time as was the opportunity to musically release the emotional energies that drove his delusional and violent thoughts and repressed his self-deprecation and anger. A nondirective approach (Wheeler, 1981) was taken in relating to Michael. In both individual and group sessions, we made no attempt to guide Michael in any direction, but rather accepted his musical and poetic material and ideas. It was this non-judgmental environment that enabled Michael to invest himself in the relationships, and to explore aspects of himself that others had rejected in the past. It was important to build such strong relationships to enable him to proceed to trial, and because Michael would later put them to a test. A significant event during this phase was a state-wide art contest that was taking place in the hospital. Michael wanted to enter, and asked me and the intern to help him create a set of audio tapes containing his music and a booklet with corresponding poems. During this time, he worked intently towards this goal, but in the process, he began voicing his delusions and then expecting the intern to validate them. It seemed as though he was testing us by asking to go beyond accepting his feelings and to become part of his delusional system. I counseled the intern in terms of responding to Michael’s challenges. The ensuing conflict in the relationship was weathered only because of his goal to win the contest and the degree of trust and respect that had developed. The mutuality of musical interests and intellectual pursuit had been extremely important in the relationship. The music that Michael created for the tapes had a strong pulse but lacked the development or formation of rhythm patterns. Meter and accents were quite strong. This was taken as an indication of his need to sublimate unconscious drives. According to Bruscia (1987) “...meter exerts power and authority over the other components of rhythm and thereby provides a moral context for the discharge of instinctual energies (p. 432).” “The components of rhythm are usually considered as manifestations of instinctual energy. Thus, pulse, meter, subdivisions, rhythmic patterns, and accents are interpreted as symbolic derivations of the amount, direction and flow of instinctual energy or drives (p. 430).” His music was almost completely devoid of melody and tonality. He chose to chant or whisper the lyrics. It was as though he was unable to “voice” his true feelings and wishes through pitch. Michael believed that tonality would somehow decrease the intensity of his work by adding another dimension. At this time he was dependent upon the intensity and his control of it. The way he used (and did not use) his voice was also significant. According to Bruscia (1987), “timbre represents the identity of the player through his/her selection of medium, instrument, production techniques, and sound vocabulary. The voice reveals the invisible, inner self, externalizing it so that it is audible (p. 455).” Michael used his voice as if he was concealing his identity and avoiding self-disclosure.

Michael was able to achieve the necessary musical tension through his perseverative use of the musical elements. However, because of this, his music did not permit the catharsis that he needed, but which did occur later in his treatment. Michael continued to improve and was more able to trust others and eventually participate with his defense. Although his delusions remained, he was able to discuss the consequences of his illegal act and proceed to trial. He was declared Guilty but Mentally 111 and was sentenced. Because of his mental illness, he returned to the forensic unit for continued treatment. Michael won second prize in the state-wide art contest. During the process, he was feeling good about himself and his creative abilities; but he was extremely frustrated and confused about only winning second prize, which gave further evidence of his grandiosity. From a therapeutic point of view, writing poetry had been a self-initiated activity, which though self-isolating in the past, had provided him the means of communicating with and relating to others. Moreover, with the addition of rhythm and music, his poems had become an outward expression of his pain and conflict. He had begun to look forward to the future and to discuss his plans after completing his sentence. Soon after winning the contest, he was paroled and transferred to the civil section of the hospital. When faced with the opportunity to work and earn money, which he perceived to be the most expeditious way to earn privileges such as leaving the building and moving freely around the hospital grounds, he refused to continue with his individual music therapy sessions. The transition from a forensic to a civil commitment is frequently difficult for many patients, because they expect an immediate increase in freedom which does not always occur. The amount of freedom allowed is dependent upon the patient’s clinical status, the severity of the crime, the judge’s restrictions on parole, and the hospital’s transfer policy. Though he had decided to discontinue music therapy, Michael did ask me to assist him in purchasing an electronic keyboard. His parents agreed to finance it, and he specifically requested that it feature an extensive rhythm section. When he received the keyboard, Michael assured everyone that he would continue to write and compose on his own. Phase III: Repressed Feelings and Unresolved Conflicts Over the next six months, Michael was enrolled in a vocational workshop, and had earned some degree of independence. Though he did visit the music therapy area for instruction in the use of his keyboard, attempts to get Michael to return to individual therapy were unsuccessful. One day, while visiting the hospital canteen, Michael happened to meet another music therapy intern. After some brief introductions, Michael discovered that this young man had a great deal of electronic equipment, including some sophisticated recording equipment, all set up in a room in the music therapy area. The following day Michael made a formal request to return to individual music therapy sessions with the intern he had met. His request was clear in that he was anticipating access to this equipment. After some discussion with the intern, I agreed that Michael could work with the intern under my supervision. Michael was attracted to this intern for different reasons, but mostly for his usefulness. As the intern’s supervisor, I was concerned first for Michael as a patient, and

second for this particular intern being a novice. Michael’s manipulativeness, intensity, and sexuality were threatening to the intern; however, I decided that with close supervision, both Michael and the intern could progress. Michael was thrilled with the capabilities of the synthesizer and the professional quality of the recordings. He began to experiment with recording separate tracks and mixing them, as well as using some special effects (e.g. “reverb” and “echo”). After several sessions, he announced his intention to record as many pieces as possible while the intern was available to him. He became obsessive-compulsive about this, and later declared that his intention was to become a recording star. He believed this would convince the judge that he should be released from the hospital. His poetry continued to be violent and sexually explicit in nature. He was clear and decisive about the type of sounds and rhythm that he wanted. He quickly learned how to create a chilling effect. Although he was less perseverative and compulsive, both musically and poetically, the effect was no less powerful and provocative. The intern continued with the same approach that had been successful in the past. However, some very difficult transference and countertransference responses began to develop, and the relationship became quite dynamic. The intern’s homophobic reactions and religious convictions were provoking judgmental responses and intense feelings related to his work with Michael. These responses in turn provoked defensive and retaliatory responses from Michael because of his unresolved conflicts with his family, primarily his father who was the disciplinarian. Michael’s poetry became increasingly morbid with graphic descriptions of brutal dismemberment and mutilation. The intern continued working with me on the transference and countertransference issues, and was communicating with Michael’s psychiatrist about the violent nature of Michael’s compositions. At this time there was a concurrent suspicion of possible drug usage by Michael. He was temporarily restricted and tested. The psychiatrist eventually confronted Michael during a treatment team meeting about the violence in his work. She had read the intern’s progress notes and was well informed. The intern was unable to attend that particular meeting, and Michael interpreted this to mean that he would no longer be permitted to compose with the intern. Michael was frantic, and shortly after this he presented “Lord of Slaughter” to the intern. LORD OF SLAUGHTER I hold you under water Bury the city under water Give the world to the Mad Hatter Give him the world on a silver platter I hold you under water in the deep The final resting place where you will sleep Those so grim will surely reap Build me a castle that I can keep Lord of murder, Lord of mortar, Lord of slaughter, Lord of order I hold you under water Bury the city under water

Hey, hey under water He explained that this piece represented what he would like to do to everyone who had hurt him in the past, including his family. This was the first time he expressed the rage he felt towards his family. The following months were clinically significant in that he became increasingly more willing and able to discuss his feelings, although discussing his crime, a hostage situation, remained extremely difficult and painful for him. He had begun to add melody and tonality to his compositions, nevertheless, his first attempts to have them commercially recorded were rejected. Nearing the end of his training, the intern was beginning to make closure with his patients, and encouraged Michael to write a poem about their impending separation. Michael did so, but this piece was never set to music. TOOTH DECAY Tooth decay, tooth decay Learning the truth means Burning my soul away Throwing my youth away I hope you will be the last one Not to know. I hope you can let go. And let go of it without Falling below. I need you not. I must prepare myself for the loneliness That was here before you came And will be here again after you’ve left. Anguish and despair are there And they are all around here. All of hell wishes you well. Go, be on your way And go away from me. I need you not. Michael explained that the metaphor represented his illness, which he often experienced as a decaying process. Michael expressed an interest in continuing with music therapy even though he knew that the equipment available to him would be much more primitive. He asked to work with another intern, rather than me. By this time, he was aware of my role in supervising previous therapy sessions with the intern, and judging by his distance and abruptness when interacting with me, was quite angry because of the difficulties and challenges he experienced. Phase Four: Catharsis and Termination

The vicissitudes of Michael’s illness continued to affect his creativity and participation. Another intern began working with Michael and was introduced as a bit of a composer as well. This intrigued Michael even though he found out that the intern’s style was jazz keyboard and he did not write lyrics to his work. The intern eventually presented Michael with a piece he had written and challenged him to write lyrics for it. Because the piece was the complete antithesis of Michael’s style, he was initially unable to do so. One day, about four months into their work together, Michael came to his session extremely elated. He had written a love poem to the music which he called “Rainbows and Harmonies”. He announced to me: “You’ll never believe it, Phyllis! I wrote a love song.” The intern’s music provided parameters in terms of phrasing, tonality, tempo, and pulse within which Michael was finally able to risk exploring another aspect of his self. He was more able to be vulnerable. For the first time, Michael was accepting and working with a melody. RAINBOWS AND HARMONIES When I see you I see flowers All the hours slip away The price to pay seems meaningless Oh, it feels so much like love When I touch you I see showers Flowing from my eyes like tears The sky rains down upon us All the days melt into one When I see you I see starlight Running through the night and day The moon shines down upon us As hand in hand we walk away Rainbows and harmonies So hard to see before The clouds approaching beckon us As we go off to war The love in my heart Attacks from the start Time and time again Again... He was anxious to make a recording of this song, and obviously believed it was a breakthrough in therapy. He wanted to play it for his psychiatrist as a demonstration of his clinical stability. Soon after this, he was diagnosed as being in remission, and discussions about possible discharge began. He made it clear that the love song was not for the intern, but was an expression of well being. He sang this song on the recording. The sound of his vocal production was almost falsetto and childlike in quality. He had some difficulty in matching pitches, but was very intent upon making decisions about the instrumentation and production of the piece. He made several revisions of this work, and eventually began to express difficulty in knowing what else he could do in his therapy sessions.

There was a lingering perseverative quality to his musical choices and a recurrence of an agitated quality to his rhythms and tempi. Michael began to learn photography and the use of computers. His treatment team agreed that he needed to demonstrate his ability to maintain and sustain a full schedule on a daily basis. This was very stressful for Michael, and he did so with a great deal of reluctance and resentment. He expressed that he was waking up angry in the morning because of his (perceived) loss of control over decision-making about his daily routine. He announced that he viewed music therapy as a regression and that he would no longer be involved. Since this was the one aspect of his life that he believed he could control (his creativity), he told the treatment team of his intention and they agreed. Michael agreed to be involved in some of the preparations for this case presentation. When reviewing some of his earlier work, he said it was difficult for him to believe that he wrote some of it. He was very pleased with the prospect of this publication, because he believed that it was important for others to know the full dimension of his personality, which includes his intelligence and creativity. Discussion and Conclusions Some significant aspects of Michael’s illness that relate to both his legal and clinical disposition were paramount to driving the treatment decisions throughout his incarceration and parole. His paranoia, violent fantasy life, history of drug abuse, and intense but repressed anger and self-deprecation were significant determinants in assessing his potential for violence to himself and others. His poetry was and remains a graphic and complex metaphor for his feelings about his illness and delusions, his sexuality, and his family. His music proved to be an additional diagnostic measure in that it finally was the salient feature reflecting significant repressed material for future treatment. Michael’s crime was one of desperation. Although he threatened violence, there was no violent act. When considering this along with his past suicide attempts, violent thoughts, and intense energy commitment in his music, even the most experienced clinician would have cause for concern. When Michael’s lyrics changed, they were driven by the music created for him. Following “Rainbows and Harmonies” he attempted other similar pieces, but his music was in conflict with the poetic theme. Some studies indicate that the potential for suicide may be even greater for those who threaten violence. Future dangerousness may be greater for self than for others in these patients (Kozol, Boucher, & Garofalo, 1972). The addition of music to Michael’s poems was especially important because of the energy that it helped to release. Had the goal been to continue improvisation without linking with his poetry, the depth of his experience would probably have been less meaningful. The intensity of his music and poetry paralleled his fixation on delusional thinking. His selfdeprecation and fear drove the violent fantasies. Consider the lines, “Cut him open like a dog, bury him in sand,” and “I hold you under water in the deep, the final resting place where you will sleep.” Although they are from two different poems and represent two separate phases in his treatment, both are indicative of Michael’s attempts to rid himself of his pain and illness. What is especially significant and representative of the intensity of his delusions is the music. As one would suspect, the energy

required to “cut” and to “hold” were graphically represented in his rhythms and choice of timbre, tempo, phrasing and volume. “Tooth Decay” is especially interesting because of its double message and use of metaphor. Michael’s separation from the intern who had a powerful effect on him, and the initial phase of letting go of his illness are depicted in many lines. His choice of music for this piece could have been particularly valuable in assessing his affect at the time. Ironically, the last piece, “Rainbows and Harmonies,” which seemed to have a cathartic effect on Michael, may have been a critical point in beginning to assess or predict dangerousness. Michael’s attempts to repeat this success which revealed the remaining musical agitation, compulsiveness and rhythmic dominance, may represent some important issues that could be critical to his future success. Hall (1984) and Monahan (1981) articulated several factors that form the basis for predicting dangerousness, including baseline, developmental, and reinforcing variables (e.g., demographic factors, personality, and behavioral traits), and “triggering stimuli.” What is most important here is that the most “potent internal triggers” are substance intoxication, command hallucinations, paranoid states, and obsessive thoughts of revenge or violence. With this in mind, the necessity for Michael to continue writing and composing is further substantiated. The goal of future treatment would be to encourage Michael to listen to some critical indicators in his music that could warn him of negative symptoms. Treatment may eventually begin to encourage more insight. Michael was guarded during verbal processing, and he used the task at hand to avoid confronting his issues. Ironically, Michael’s criminal act was probably the most influential factor in his achieving remission of his disease. The longevity of his treatment probably contributed to the degree of success that was achieved. The use of his creative expression was important, diagnostically in assisting him to achieve competency to proceed to trial, and clinically in forming the basis upon which he could sustain a meaningful and therapeutic relationship. Finally, this process was significant in helping him to cast off his dependence on selfdeprecation and delusions via his improved freedom of expression. Delusional material is most significant clinically in terms of purpose or function for the patient, relationship to any paranoid or grandiose features of the illness, and the degree of the patient’s ability to disguise or hide the symptoms. Even when Michael stopped talking about his delusions, they were obvious in his music and poetry. The intensity of his fear and anger represented in the music, coupled with the grandiosity, self-protection and clearly defined methods of conflict resolution that were identified in the poetry, presented a significant clinical picture with much information relative to his court commitment and assessed potential dangerousness. Michael has again requested to work with a music therapist. This time he wants a bass player—but will settle for a guitarist! Glossary Catharsis: A purification or purgation of the emotions primarily through art that brings release from tension or elimination of repressed traumatic material by bringing it to consciousness and affording it expression.

Compulsion: Repetitive, purposeful, and intentional behaviors that are performed in response to an obsession, or according to certain rules or in a stereotyped fashion. Countertransference: Arousal of the therapist’s repressed feelings by the patient; symbolic libidinal relationships, partly unconscious, of the psychoanalyst with the patient. Delusions: In general, false beliefs: grandiose delusions are false beliefs of having inflated worth, power, knowledge, identity, or special relationships to a deity or famous person; religious delusions are false beliefs of having extraordinary powers, or religious identity; persecutory delusions are false beliefs of being malevolently treated in some way. Falsetto: The male voice above its normal range. A special method of voice production that is frequently used by tenors to extend the upper limits of their range. Forensic: Belonging to, used in, or suitable to courts of judicature. Homophobic Reactions: A persistent fear of homosexuality, homosexuals, or situations involving them, which manifest itself in anxiety responses or avoidant behaviors. Intellectualization: Ego defense mechanism by which the individual achieves some measure of insulation from emotional hurt by cutting off or distorting the emotional charge which normally accompanies hurtful situations. New wave: A general designation for the rock music played by numerous English and American bands since the late 1970’s. The term is applied to a variety of styles whose direct antecedent was punk rock but whose forms and rhythms drive directly from the rock ‘n’ roll of the 1950’s and 60’s. Obsession: Recurrent and persistent ideas, thoughts, impulses or images that are experienced, at least initially, as intrusive and senseless. Paranoid Schizophrenic: A type of schizophrenia in which there is a preoccupation with one or more systematized delusions or with frequent auditory hallucinations related to a single theme, but none of the following: incoherence, marked loosening of associations, flat or grossly inappropriate affect, catatonic behavior, grossly disorganized behavior (APA, 1987). Perseveration: Persistent continuation of a line of thought or activity once it is underway. Inappropriate repetition. Projection: Ego defense mechanism in which the individual places the blame for his/her difficulties upon others or attributes to others his/her own unethical desires and impulses.

Punk Rock: A type of music that emerged as social protest among English and working class youths in the mid-1970s. It rejected rock’s emphasis on technique and professionalism and relied upon sheer volume and rhythmic energy applied to rhythms and forms derived from rock ‘n’ roll of the early 1960s. Regression: Ego defense mechanism in which the individual retreats to the use of less mature responses in attempting to cope with stress and maintain ego integrity. Remission: When a person with a history of schizophrenia is free of all signs of the disturbance (whether on medication or not). Repression: Ego defense mechanism by means of which dangerous desires and intolerable memories are kept out of consciousness. Resistance: Tendency to maintain a symptom, undermine treatment, and/or prevent the uncovering of repressed material. Sublimation: Ego defense mechanism which directs the energy of an impulse from its primitive aim to one that is ethically or culturally higher. Support Group: A group of people with mutual problems or interests where the focus is on sharing feelings, experiences and concerns in order to benefit from one another’s strengths and skills. Transference: Identification, usually unconscious, of some person in the individual’s immediate environment with some important person in his/her past life, i.e. a patient responding to his/her psychoanalyst. References American Bar Association, Criminal Justice Standards Committee (1986). ABA Criminal Justice Mental Health Standards. Washington, D.C. American Psychiatric Association (APA) (1987). Quick Reference to the Diagnostic Criteria From DSM-IIIR. Washington, DC: Authors. Bruscia, K. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C Thomas. Coleman, J. (1964). Abnormal Psychology and Modern Life. Glenview, IL: Scott, Foresman and Co. Hall, H. (1984). Predicting dangerousness for the courts. American Journal of Forensic Psychiatry, 5 (2), 77-96. Kozol, H., Boucher, R., & Garofalo, R. (1972). The diagnosis and treatment of dangerousness. Crime and Delinquency, 18, 371-392. Monahan, J. (1981). The clinical prediction of violent behavior. National Institute of Mental Health, DHHS Publication Number (ADM). Superintendent of Documents, Washington, D.C. Priestley, M. (1975). Music Therapy In Action (Second edition). St. Louis: MMB Music.

Randel, D. (1986). The New Harvard Dictionary of Music. Cambridge, MA: Belknap Press. Wheeler, B. (1981). The relationship between music therapy and theories of psychotherapy. The Journal of the American Association for Music Therapy, 1, 9-17.

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

CASE TWO The Case of Marianne: Repetition and Musical form in Psychosis* Jos De Backer Jan Van Camp Abstract The significant aspect of our work is the finding that, in the treatment of psychotic patients, music is especially relevant in creating a psychic space. Since the psychic space originates from the transformation of sensorial impressions into a form or a representation, and since we know that the capacity to make representations is seriously affected in psychosis, there is a need to find out by which means this capacity can be reestablished. Working with such patients in a music-therapeutic context, we encounter the phenomenon that they often repeat the same musical pattern. In their musical improvisations, they constantly repeat a specific rhythm or a small melodic sequence. It becomes an endless iterative playing, a kind of musical rocking. From our research, we describe this repetitiveness as the presence of the psychotic “experience” of the world. Psychotic patients, from their pathology onward, do not dispose of a psychic space to reach symbolization, which means, in music-therapeutic terms, that they are not able to create a musical form in which they can exist as a subject. Therefore, the therapeutic transition from sensorial impression to musical form (protosymbolization) is a basic condition for the treatment of the psychotic patient regardless. In this case study of a psychotic woman involved in a music-therapeutic treatment, we explore and describe three important levels or moments of the music-therapeutic process (synchronization, development of a musical form, and the musical ending of an improvisation). Introduction Psychosis and Music The world of the psychotic patient is often unknown and inaccessible. Many years of experience with psychotic patients has convinced us that through music we cannot only find a gateway to the amazing world of the psychotic subject, but that we can also develop the means to give a certain shape and termination to the disintegration and timelessness of the psychotic world. It is not the first time that it has been shown that music moves on the same level as where the central problem of psychosis is located. This relationship between music and

psychosis gives music therapy and “the thinking from music”1 a crucial place in the treatment of psychosis. The psychotic subject lives in a world of presence. He is the defenseless prey of thoughts and sensorial impressions, which haunt him continuously. The frontiers between the inside and outside world are so unstable and transparent that it often seems that his psyche finds itself outside rather than inside. The world and the internal movements of drives are not represented in an inner space, but they are characterized by an immediate and brutal presence. Because they can no longer fulfill their representative activity, even words are treated as meaningless things, as pure sound objects. It is more than a metaphor to assert that the psychotic patient lives in a purely musical world. If we assume that the musical element is what is left of the voice when it is deprived of sense, one can, in many ways, assimilate our relationship with music to the relationship of the psychotic subject to the world. Neither the voice nor the music can be said to find itself inside or outside the subject. Its presence, which cannot be located, makes it a fusional object. This means that we are related to the music like a baby is initially related to the voice of its mother. Thanks to the fact that her voice has not yet disappeared behind significance, it has an immediate impact on the child. Just like a dancer starts moving immediately and simultaneously as soon as the music sounds, the child responds immediately and simultaneously to the appeal that comes from the voice of the mother. Coming into the cadence of the voice of the mother is the first affirmation of a signifier that has not yet acquired meaning at that time. Because of the fundamentally dissonant relationship of the psychotic to the signifier, psychoanalytic theory asserts that the problem of psychosis should be put in terms of this primarily synchronic affirmation of the signifier or, in Freudian terms, of primal repression (Urverdrängung). The latter--as the formation of the very principle of repression or of the capacity to repress--is the foundation of the constitution of the unconscious, which not only functions as an explanatory principle for symptom formation in neurosis, but much more generally as the anthropological category which is responsible for the appearance of human desire. As psychotic phenomena are traditionally attributed to the failure of the work of repression, psychotherapy should focus on the very conditions that make for the possibility of repression. Clinical observation of music therapy with psychotic patients shows enormous resistance against musical synchronicity in the first stage of therapy. Music is not only a fusional object that inspires the body spontaneously and immediately and brings it consentingly into motion. Insofar as the specific musical characteristics progress, music also has a linear and narrative form. The musical events do not remain in an endless repetitive play, but they develop themselves, via a play of variations and repetitions, to a totality, a synthesis. Within this development, the successive musical events lose their independence and they are functionally integrated into a whole. Each sound and each movement refers to what preceded it and to what will follow further on, although no one knows exactly what the continuation will be. Fundamentally, one may consider the development of the musical form as a play of loss and the reappearance of the losses in a new shape. It is a constant process of substitutions that takes place within a space, which Winnicott called the “transitional space.” Winnicott does not describe the play within this space as symbolizing in the full sense of the word, but only as a “transition” to symbolization, because, just as in music, the concreteness and the irreplaceability of the substitutive object remains in

the foreground. The transitional object is truly a signifier, but not an “open” signifier. The meaning remains fixed on the object and the latter is not open to other meanings. In that sense, the development of the musical form takes a step further in the symbolization process than the transitional object. In spite of the concreteness and the irreplaceability of the musical event--we had better mention the meaninglessness of the musical event--it is still integrated in the time-bound process, which makes an essentially endless variation possible. Finally, the process of symbolization takes its full shape at the moment at which the concrete object has been completely lost in speech. The unique place of music in the treatment of psychosis therefore lies in the fact that it presents two logical times in the symbolization process, both of which are of crucial significance in the constitution of the psychotic psychopathology and which can be approached much less directly within an exclusive verbal psychotherapeutical setting. We believe, nevertheless, that the “thinking from the music” is--also outside of the music therapy room--important for the comprehension and the treatment of psychotic phenomena. The case below illustrates our theoretical position, but it was, naturally in the first place, just like all other therapeutic experiences, the source of inspiration for the theory. The Clinic of the Sonorous Object in Psychosis Marianne, a young psychotic woman of 25, plays on a metallophone of her choice. She sits motionless, bent over, without facial expression, her elbows pressed against her body, only her underarms move in an alternating automatic motoric way. Is she aware that she plays a metallophone and produces a series of sounds? The music is endlessly repetitive, boundless, without phrasing, without any form of dynamics or nuance, without interaction with oneself or with the therapist. The therapist experiences this music as insusceptible, as grains of sand that slip through his fingers. The therapist does not succeed in coming into contact with the patient or her musical play. Marianne does not allow him into her sensorimotor music. She plays completely turned in on herself. The autistic and automatic character of her music blocks the therapist. There is no way for him to succeed in giving himself over spontaneously and freely to the musical play. The repetitive sounds appear as a dead thing that brings nothing into motion, fits in nowhere, and--as an isolated object--seems to belong to nobody. The patient is absent in her play. Though it is she who comes into motion and plays the metallophone, the sounds remain totally strange to her, as if she were dissolved in the sound object. The object does not affirm her in her function as subject, but it is handled in such a way that the subject loses herself in it, is “dissolved” in it. The stereotypical play gives only sensations which, by their assured reappearance, have a reassuring effect, but without creating an imaginary world. What strikes us in the first place in this musical play is its high degree of repetitiveness. However, let us specify that repetitive music is spontaneously associated with its hypnotizing, ecstatic, and discharging capacity. The obsessive repetition we find for example in house music, in new wave, or in the whipping rhythms of ritual music lead, just as in Marianne’s play, to a certain undermining of the subject function and to loss of identity. Still, there exists a difference with the psychotic sonorous object, a difference which often appears audibly in the musical play, but which is especially experienced in the countertransference. The inability of the

therapist to be in resonance with his patient is in sharp contradiction to the irresistible and immediate appeal, which comes from a hypnotizing rhythm. In contact with his psychotic patient, the therapist experiences a constant subtle defaced rhythm or a continued “disharmonization” which excludes him from playing together with the patient. Sometimes these disruptions are so barely objectively detectable that they also can barely be imitated. We are therefore able to assert that this sound object is not erogeneized, not involved in an exchange with the other. It remains caught within an autoerotic circuit. This refers to the failing construction of an unconscious body image, owing to the absence of the primary narcissism of the psychotic patient. The primary narcissism only develops through the labor of representation, which is produced by the erogeneization of the body zones which are initially involved in the satisfaction of needs. At this stage, it is important to refer to the crucial significance held by the disruption of the pure repetitiveness by surpassing the sensory level of the satisfaction of needs. A mother gives her child true contact and exchange when she does not remain equal to herself and when she brings all sorts of subtle variations (deprivation) in the way in which she meets the demands of her child. The rhythmization of presence (satisfaction) and absence (privation) can convert the sensorial impressions into drives, and by so doing brings them into mentalization. Speaking about the psychotic sound object, we shall use the terms “sensorial object” and “sensorial play” to denote that this object is not integrated into a movement of drive and erogeneization and as such, remains locked up in its quality of real, unimaginable, and indivisible substance. The isolation of the sound object, however, can also be the result of the fact that it is not part of the psyche of the subject itself, but that it is an extension of the psyche of another, namely one or both of the parents. In this context, we should speak of an incorporated object, or, in the terminology of Abraham and Torok (1978), of an object that has not been introjected but rather “included.” The status of this object reflects the fate of having to undergo a trauma when it could not be coped with in a former generation and so was transmitted to one or several following generations. As this object is not imaginable (the “thing presentation” remains absent to the subject itself), it stays subjected to the principle of repetition. That means that the object is only present when it is made present in the most concrete manner and namely in a corporeal-sensorial way. Peculiar to this object is, contrary to the purely sensorial object, that it has been subjected to a (transgenerational) displacement and because of this acquires a psychic character and thus a form. The therapist is often amazed to see the appearance of a musical form which is significant to him, whereas it remains meaningless to the patient and cannot be integrated psychologically by the latter (Van Camp, 1999). The repetitiveness and the character--often experienced as strange by the patient--of a musical sequence, signals to the therapist the possible psychotic status of the sound object. Here, the inability to have the musical sequence take place in a musical thought is as strong as in the purely sensorial play. Sometimes, the psychotic sound object has the shape of a “passionate” object. We sometimes notice in the music therapy session that psychotic patients can be passionately seized by the musical improvisation or by listening to music to such an extent that they lose themselves totally in it, get confused, and even are driven to psychotic decompensation. The object comes to the foreground so prominently that the patient goes into a state of being defenselessly delivered to it, possessed by it, even to the extent that the boundary between subject and object disappears completely. Contrary to the neurotic overinvestment or

idealization of the object, there is no symptom involved of something the patient does not want to know and therefore displaces to an object containing the psychic elements of what has been suppressed and in which he get passionately involved. In psychosis, such a displacement (Verschiebung) does not take place, because there is nothing about not wanting to know. His investment can therefore fix itself on everything, with the most embracing arbitrariness. The passion for music or for a concrete musical object is nothing more than this passion itself. It does not refer, or cannot potentially refer, to a certain object of his desire, which can possibly be raised alongside the musical play. Finally, the musical object can also become part of a delusion or it can constitute itself as such. Freud describes the delusion as an attempt to heal (Heilungsversuch) and the most evident model of this is naturally the auditory hallucination.2 The object is made present by having it “take place,” not as a form of imagination, or of recalling, but by having it accomplish itself in an original manner. This phenomenon is closest to what characterizes the music when we deprive it of its form or it’s “thought.” Music can only exist within this specific modality in which a succession of sounds, intensities, and harmonies “occurs.” Hence, we say that music cannot be remembered; it can only be repeated. The delusion possesses the same eventful character. At the same time, there is more adrift in the construction of the hallucination than purely having new events take place which relate to the subject. The events are also interrelated with one another by a causal band, by which the subject creates itself an alternative history and gives itself an origin. This surpassing of the traumatic sensorial level by the development of a synthesizing history also makes us understand why Freud could see the hallucination as a “Heilungsversuch.” The conception of a new reality and the telling of a coherent and explanatory story about what goes on in this reality truly draw the object out of a psychic isolation, but alienate it at the same time in the exchange with others. It remains an undecipherable hieroglyph; an imposing certainty which cannot be shared with others as being a truth.3 If the musical object obtains a hallucinatory character, it equally becomes the prey of this intrasubjective isolation. In spite of the fact that it has taken a certain form, which extracts it from pure repetitiveness, it still functions as an idiosyncrasy, which cannot be integrated in the musical play. If the therapist does not succeed in breaking through this delusive character, and in getting in musical line with that unimaginable sensorial level upon which the trauma finds itself, the musical play continues to turn aimlessly round in a circle, in spite of its form. Indeed, it is typical of the delusion that it is perfectly unequivocal and allows no new meanings and developments. The common characteristic of the different modalities wherein the musical object appears in the psychosis is its repetitive character. Although the repetition cannot be immediately discerned on the level of the phenomenal appearance of the musical product, it is as a principle always at the basis of the psychotic sound object. It follows that the psychotic sound object is isolated and unimaginable, bearing testimony to the impossibility for the patient to symbolize. Working on a music therapeutic basis with psychotics, we regularly encounter the same musical pattern. Many psychotic patients start their musical improvisations by constantly repeating rhythms or small melodic sequences. It is an endless iterative playing, a kind of musical rocking. Clinical supervision and a review of the literature, mostly Ogden (1986, 1992, 1994), Tustin (1981, 1986, 1990) and Van Camp (2000, 2001), has made it clear that this sort of

playing is characteristic of the psychotic’s sensorial impression. They cannot experience this music as something from themselves; there are only sounding sounds in which they are not implicated. They are not “inspired” by the music. That means that music playing is not really an “experience” for them. We learn that psychotic patients, from their pathology onward, do not tend to have a psychic space for symbolization by which they could appropriate the musical object. In music-therapeutic terms, that means that they are not able to allow or to reach a musical form. The capacity to have an experience can be seriously disturbed and even destroyed in psychopathology. Therefore, it is extremely important that the music therapist can find out how the transition from sensorial impression to musical form can happen. Therefore, it is essential that we verify to what extent there might be a correspondence between the obvious, empirical changes on the musical level, and the subjective experience by the patient. Therapeutic Framework Music therapy is part of the psychotherapeutic offerings in an analytically oriented residential facility for young psychotics. Most of them meet the diagnostic criteria for schizophrenia (DSM-IV R). Bipolar psychotic problems of mood, schizo-affective pathology, and serious disturbances of the personality occur. Symptoms such as hallucinations, thought and perception disturbances, hypochondriac and grotesque interpretations, disturbances in body functions, autism-like or extreme regressive behavior, and serious contact disturbances spring to mind. The music therapy work within a facility with a broad array of therapists of verbal and nonverbal therapeutic approaches puts entirely different demands on the procedure of the music therapist than within a private practice setting. The mechanisms of denial and splitting in the patient often cause incompatible contrasts between the experiences of the different team members with the patients, and require continual synthesis on the part of the treating staff. Furthermore, because of the specific character of this psychopathology, the “thinking from the music” takes a central place in this synthesis work. Music happens to possess the quality to be able to address the traumatic sensorial level directly, and, seeking a form, allows the birth of representations. From this privileged access to the psychotic world, the music therapist also has the task to suggest that the patient continues to explore the possibilities of the presented material in the verbal psychotherapies. Background Information Anamnesis The patient tells that she has been confronted with attacks of undifferentiated fear for about five years. The reason for admission, however, was a vital depressive image. The patient described that she had had communication problems and that she lead a very solitary lifestyle with few social contacts. Marianne is very suspicious toward her parents. During the acute psychotic phase, she is firmly convinced that her mother continually persecutes her, which

excludes any further contact with her. However, this continual persecution is experienced only as the point of culmination of an old situation in which the mother was perceived always as over controlling and inhibitive to her development. The patient is the youngest from a family of three children. The father is retired and, according to the patient, rather aloof with regards to family life. The mother is the housekeeper. After her secondary education, the patient started to study literature at the university. She was passionate about literature and wrote a great deal of poetry and stories. Owing to the many “literary encounters” in pubs/bars, she concentrated little on her studies and did not succeed. After this year, she had a short but very intense relationship with a man. She finally chose another area of study, but also gave this up after two years. At this time she is unemployed. The patient situates the beginning of her troubles around age 20, when her relationship ended. She started to suffer increasingly from feelings of fear, which did not allow her to lead an independent life. More and more, she was convinced that she was being controlled by her mother and that her mother even hired other people to control her. Situation at the Moment of the Admission The patient came across as reserved in the contact. Her facial expression was flat and she had a staring look on her face. The patient seemed to be cut off emotionally. There were a few depressive complaints: sad mood, adynamic, anorexia, sleeping disorder, “anhedony” and fear outbursts. She expressed a passive longing for death and depicted herself in a selfdeprecatory way. She spoke of being overtaken by crying fits and how she had the tendency to regress. The patient did not report any hallucination. There were no disorders of formal thinking, although she had heard a voice in her head once in the past. Conclusion A 25-year-old woman was admitted because of a vital depressive situation, functioning on a psychotic level. The depressive complaints cleared up gradually under an anti-depressive treatment. The patient was referred to our department for young psychotics, for a psychotherapeutical treatment of the underlying psychotic problems. Psychodiagnostic Research Marianne is a talented woman with a general IQ of 126 (W.A.I.S. test), with a big difference between the verbal IQ of 133 and the performant IQ of 112. The balance between the “hold” and “don’t hold” tests indicate deterioration on the organicity scales. The patient has few complaints and does not have an expressed request for aid. Formally viewed, there is a protective shield, especially in terms of her emotional life; she cannot let herself be touched. She tries vehemently to give an answer at the expense of the reality.

The theme of her relationships is receiving. There are many conflicts and quarrels. Aggression and sexuality obviously do not have a specific place in her life. She is a very independent woman who functions on a psychotic-like level. There is nothing that is manifestly psychotic to be seen, but her cutting off and apathy can be read as negative symptoms. The patient especially has a consumer’s question. She wants information. She has unrealistic goals and has little self-reflection. Treatment Marianne and Group Music Therapy Marianne regularly participated in group music therapy, twice a week for eight months. Marianne’s image was that of a withdrawn woman, choosing the same instrument, namely the metallophone, over and over again. Her posture was always the same: bent forward, with a staring glance, withdrawn in herself, always playing in a sensorimotoric way, her arms pressed against her body. She did not have any contact with the other group members or the music therapist. We could say that she was not able to create a psychic space. In verbal psychotherapy she expressed her wish for individual music therapy. This was started two weeks later. She did not take any group music therapy after that. A combination of individual as well as group music therapy, though, was allowed in clinical psychotherapy. Here, multilevel therapy is part of a multidisciplinary treatment. Marianne expressed the demand for individual musical therapy in the following way: “I am blocked in my creative possibilities. There are a lot of bottled-up feelings inside of me, but the moment I want to express them, I just can’t. What can I do? I would like to work on that.” She wrote poetry prior to her admission. Also, she used to play the guitar as an amateur. How does Marianne present herself musically in the group music therapy sessions? She plays purely physically, in a constant repetition, in a kind of ostinato. Although she expressed, in a manifest way, her wish to escape from her blockade, the ostinato is a testament to the paralysis of her psychic life. It is a form of musical concretism. The musical elements cannot be taken up in a movement of displacement (Verschiebung) and substitution, because her psychic life does not allow for any displacement. It is the therapist’s task to experience and come into contact with what this ostinato playing means. Individual Music Therapy First session: “The inability to play music.” Initial situation: Marianne enters the music therapy room, shuffling her slippers as she walks. She carries a plastic bag, which contains some of her personal belongings. She arrives punctually. She gives the impression of being worn out: a woman who is completely exhausted and who has nothing more to say. The therapist experiences a certain dryness and emptiness when he greets her and shakes her hand. Her handshake does not make contact, without any counter pressure or dynamics. It feels like the therapist is just shaking a rubber hand. Her voice is without intonation. The therapist tells Marianne about the music therapy framework: Sessions last for 45 minutes and consist of active improvisation. She will decide whether the session starts with a verbal part or with an

immediate improvisation; after each free improvisation there can be verbal reflection. Furthermore, she chooses the instruments, for her and for the therapist, and decides if he plays with her or not. This opportunity for her to make her own choice is important in the context of transference and countertransference. (In certain therapeutic situations it could make sense that through projective identification the therapist makes a choice about the instrument, or because of the psychohygienic nature--see Session 2--he plays along.) Progress of the session. Marianne chooses the metallophone, the same instrument that she had been playing for eight months in group music therapy. In this choice, she shows her emptiness, the necessity for security and the inability to bring variation in her contact with herself or the therapist. She also chooses a metallophone for the therapist. Marianne places the two metallophones facing one another. She immediately starts to play. The music is as sensorimotoric as during the last eight months in the group music therapy. In an endlessly alternating motorical movement, her arms go up and down along the metallophone. Musically there is no phrasing, no dynamics, and no accentuation. Her improvisation is comparable with “musical rocking:”

This musical fragment is an interesting example of the formlessness in the expression of psychotics. Its analysis shows this clearly. When studying the series of tones for the first musical fragment, the movement direction of the melody seems to be arbitrary. One cannot directly recognize a pattern. However, there are a number of musical structures, such as a series of parallel thirds, fourths and fifths. Moreover, there is musical pedal point. We notice that both hands stagnate in turn, while the other (especially the left hand) further steers the play. At one place/point, however, both hands stagnate: four times the same bar/rod is being hit. It is a musical rest point, a not yet voiced phrase. We can consider these structures as unintentional. They originate rather coincidentally. We can conclude that music searches for structures by itself. The empathic listening stance of the therapist is being illustrated by his musical play, in which he plays almost an identical melody line with the base line of the patient. This happens

intuitively and is definitely not consciously mirrored. The instruments are opposite one another, so that it is out of the question that there is a direct imitation of the hands. In the beginning, the therapist explored her meter and tried to get into contact with her. But the problem is that the patient’s music is not addressed to someone else. The pure successiveness of time, so typical for psychosis and trauma, does not allow it. Her noncommunicative playing refers to the non subjective character of the repetition. Therefore, there is no other for the therapist either. In the beginning, there is only music. The therapist is focused only on the musical part, the sound.

Intuitively, the therapist knew that he would only be able to communicate if there were this psychic space. In trying to create such a space, the therapist introduces a musical form, namely a “bourdon,” and after that, a melody, and he repeated it a few times. To recapture means to create the possibility of having memories. Repetition means to take up something again, to vary, to do something with it, to elaborate on it. If nothing can be remembered, one cannot imagine something. To remember something creates the necessary psychological space for imagination. The therapist tries getting out of the pure repetitiveness and coming to a kind of psychological space with her. In this psychological space the therapist imagines the other for himself. By doing this, he plays himself into the position of being a witness of the traumatic. He tried to stop the endless play by announcing an ending via the introduction of a musical form. The patient did not seem to notice this, and kept on playing in the same repetitive way. With a verbal intervention, the therapist tells her to finish her music. She stops immediately and puts the little hammers down on the metallophone. The improvisation lasted for about 25 minutes. During the entire time there was never one single appearance of contact. For the therapist it is dramatic: it brings him to a level of impossibility to improvise, to make music. So begins a silence that is as regressive as the music. Again, the therapist experiences her emptiness. He gives her the chance to verbalize something, but she only succeeds in answering the therapist’s questions with yes and no. We make a next appointment, after which she takes, without showing any emotion, her plastic bag and leaves the music therapy room shuffling her feet, just like she entered the room. It seemed as though nothing had happened during the 45 minutes of the session, as if the therapist does not exist for her. You could not see any resonance. The sounds that chimed were almost nonexistent, similar to a landscape that is covered in mist and where one cannot see any contours, points of reference, or colors. Is there something behind that cannot be seen? Listening attitude of the therapist. What strikes us while watching the video fragments of the first session is the therapist’s manner of listening as well as the way he is sitting: the therapist has assumed the position of the patient. Bent over, hands pressed against the body, having a rather melancholic facial expression, the therapist looks as depressive as the patient. This is an illustration of a perfect empathetic form of listening. Music situates itself at the level

of the body, the sensorial. The body posture of the listener adapts to the music. It is a sort of physical dialogue toward which psychotic patients are very sensitive. Posture of the patient. The music of the patient is characterized by aleatoric and repetitive sounds. There is no representation, no musical form. Also, there is no intention to build it up starting from a memory, from psychic space. Everything is moving on the traumatic level. The image that we get from the patient is one of an abused, traumatized woman. Second session: “The traumatic instrument, a new melody.” Marianne enters the room punctually, again shuffling her feet. Just like the previous session she has a plastic bag with her, this time with knitting. Marianne says that she has high expectations of music therapy and that she has started to knit and to crochet. It is interesting to see the parallel between the knitting and what is happening musically. Knitting is an autoerotic, and turned into itself, repetitive occurrence, in which no disturbing object appears. To start knitting again, therefore, only confirms what is taking place musically: Her whole being is incorporated into an ostinato. To start knitting again is the confirmation of her emptiness. Progression of the session. Marianne chooses the metallophone again. The choice of the therapist’s instrument happens to be more difficult. She shows a complete indifference toward the instrument choice for the therapist. The therapist encourages her to choose an instrument for him and goes over the possibilities with her: a string, wind, or percussion instrument? Finally it is the kalimba that is chosen, an instrument that she knows from music therapy, but has not yet played. The kalimba is an archaic instrument, with a rather rough and physical sound. Compared to the first session one can notice a variation. Cautiously the variation is still placed with the therapist. He has to present the roughness. She still opts for the metallophone. Marianne starts her sensorial music again. The therapist tries to get into contact with her, but he feels rejected again in the emptiness of her being. Whatever he tries, the therapist stays in an isolated play on his own. He is struck by a number of thoughts. Why should he still try to get into contact with her? Maybe she wants to maintain her regressive music, on her own, without allowing anyone in. Maybe she only wants him to listen receptively to what she has to say. He concluded intuitively not to play any longer with her, but solely to listen to her music, and to wait to see what could originate.

But, Marianne endlessly keeps on playing the same pattern. The style is purely impressionistic. She plays for example a high tone but does not repeat it. There is no structure

in it, no phrasing. She is not developing anything and, therefore, is not able to repeat anything in a reprise. She probably hopes that a melody would originate, but that does not happen. Also, she does not integrate anything from the previous session into her music. For instance, she could have integrated the bourdon of the music therapist, but obviously she is not able to do that. The only change is an acceleration of the tempo. But in the end nothing happens. Through Marianne’s accelerando a certain tension in the musical play is born. “You left me to fend for myself” hangs in the air. Marianne seems to plead to the therapist. He has to create space. She cannot create this space by herself, yet; it can only come from the therapist. She totally depends on him as a therapist. The therapist lets the sounds come to him completely. He experiences something unbearable, something has to happen; she makes an appeal to him. The patient plays for about eight minutes by herself until he moves himself intuitively toward the piano, which is at the left side of him. Without having to move the chair he starts to play a simple melody. The timbre and the volume are amazingly equal with that of the metallophone. One almost cannot distinguish his melody from hers in regards to timbre, tempo, and volume. They are completely at the same level. The therapist puts his psyche in the service of the psyche of the patient.

The beginning is almost a shock: Suddenly there is this melody. Somebody says: “Here I am.” The “unbearableness” of nonexistence finishes. Suddenly, the therapist poses subjectivity. Suddenly, a clear melodic line originates; a kind of anti-poison. The melody evolves into a harmonic entirety, a chorale. The therapist embraces the patient’s sensorial music, even though he does not experience getting into contact with her. He continues playing because he wants himself to be heard as a subject. After about five minutes, the therapist plays a definite cadence, to which the patient does not react. She continues playing on her own. Again, after a subverbal intervention she stops her music. From the short verbal reflection that follows the improvisation, it is obvious that the musical part does not penetrate her. She did not even notice the therapist’s piano playing. Just like the previous session she leaves the music therapy room shuffling her feet. Does the musical play even make sense? At this moment one could wonder whether it ever did make sense. Does it have any significance in this therapeutic context? Diagnostically, it

definitely does. This playing is a perfect illustration of how music can enter the traumatic level. The musical play is a purely successive sound, without any form. There is only repetitiveness, without reprise. The choice to play the piano (the therapist’s favorite instrument) becomes obvious to him through countertransference. It is against the therapist’s music therapeutic attitude that he does not play the instrument that has been chosen by the patient for the therapist (the kalimba). For Marianne, there was the desire to be able to exist as a subject and, intuitively, the therapist felt that he could only represent this through a musical form, through a melody. At this point the kalimba was not form-giving enough for him. Only rhythmically could the therapist offer an eventual form, but this was too far away from Marianne’s successive sounds, and also from his. Third session: “The projected provocation.” Marianne again enters the music therapy room shuffling her feet. First improvisation. Marianne takes a place at the metallophone and asked the therapist if he wants to play the kalimba again. It is the first time that she, consciously, points out an instrument for the therapist and involves him as a subject in her music. It is interesting to note that she keeps the same instrument with the angelically, heavenly sounds, and that she delegates the rough, traumatic sound of the kalimba to the therapist. The patient plays her sensorial music again, monotonously, without any dynamics. The therapist provides support and structure but at the same time he tries to provoke the patient rhythmically. The whole time she plays “syllabically,” the therapist starts to play more “melismatically.” Marianne, however, does not react to any provocation. There is no single variation. She never uses phrases. The therapist experiences a projective identification. Anything Marianne cannot bear, she projects to him. Because it is the therapist who is playing the kalimba, it is also him that has to bear the roughness; a comfortable situation for the patient. She leaves the expression of her traumatic psyche to the therapist. She can keep on pretending that nothing happens. The therapist takes it upon himself to continue playing. For a moment Marianne comes a little closer. From time to time she is tempted to take over something from the tempo or dynamics, but it stays at the level of exploration. At a certain point she has the tendency to play in a defensive way. She makes the distance bigger again, the need for projection increases again. After a somewhat more melodic piece, she continues playing in a heavenly, sensorial way. Each time he provokes her, but she covers it up with the cloak of charity. Nothing happens to her. Marianne coughs when the therapist plays a cadence at the end. However, she does not stop at the same time with him, but only (and abruptly) because of his verbal intervention. She coughs as a reaction to his intention to stop. The therapist interprets this cough as a signal to round off the improvisation. So, she notices that he would stop, but she does not do anything with it. She does not have any autonomy, she cannot decide for herself to stop as well. She therefore needs a verbal prompt. She is completely dependent. There is a “fusional” connection between the patient and the therapist, yet without any dialogue. Her defenselessness makes the therapist think about a baby that after being fed has been put back into the crib.

There is something strange about it: a patient that takes up therapy because she is traumatized, but only plays heavenly music and leaves it up to the therapist to take up the traumatic part. At a certain point she follows a little bit, takes something over, starts varying on the basis of the temptation of his music, and seems to make the projection less great. But then she withdraws. The therapist experiences that he does not break, or play phrases, or take space in the music. It is as if it is not possible yet. That would come later on, when a real dialogue is formed. Marianne still experiences her music as something that stands apart from herself. Nevertheless, she recognizes in the music of the therapist on the kalimba something of her previous aggressive side. The rhythms on the kalimba correspond with the rhythm in the poems that she wrote before her illness. Rhythm as aggression against the outside world, that she could not display directly because such aggression was not expected from her, was not allowed or was even denied in her family. In the rhythm of her poems, she made an attempt to shock the outside world. It was traumatic for other people; she was repeating the aggression from which she was previously the victim. Spontaneously, in the therapist, the image arises of a battered child. In his provocative playing, something of this image appears unconsciously. She expresses the hope to continue with this experiment with rhythms, even though she is aware of not being able to do that at this moment. Second improvisation. In a second improvisation, that we later called “The preparation to become autonomous,” the therapist invites Marianne to improvise on this theme. She surprises him by consciously choosing the kalimba, and by asking the therapist to play this instrument as well. It is interesting that they play the same instrument and that by doing this she increasingly gets the feeling that she has more space for herself. The improvisation on the kalimba takes a very interesting turn. In a shy way, Marianne starts to play, with the same motor alternating movement as she played on the metallophone. The therapist takes over the musical rocking. By reflecting her, he creates a possibility to “reflect.” He hopes that an image can originate from this, but the therapist-patient relationship remains purely fusional, just like the mother-child relationship when the mother rocks the child to the rhythm of his crying. The therapist starts to play off beats. With this he starts to differentiate himself from her. They are no longer one but two. It is a kind of individualizing, the basis of a dialogue. The complexity of this situation lies in the fact that even though there are two individuals, the therapist is simultaneously sounding the other in a projective identification. The therapist takes a part of the patient upon himself. Detaching from each other is a de-projective movement. So, Marianne takes a part again upon herself. The therapist increasingly experiences a dynamic movement in her music. He brings on rhythms and she tries to vary. She becomes increasingly distant from the bright and heavenly and moves to the rough and rhythmical. In the improvisation, more cathartic elements are now present. Marianne is more able to present unbearable things. The therapist experiences that she starts to take initiative. She plays fragmented rhythms that she cannot hold conceptually for some period of time yet. Each time she breaks off the rhythms; she does not allow for musical cells to develop. By this, the therapist is led to feel, again and again, that a real dialogue is not yet possible. By the choice to play the same instrument, Marianne chooses the fusional bond between therapist and patient, as if there is no difference. Paradoxically enough, this situation

made it easier to present difference, to start differentiating. And it made it easier for the patient to come into contact with her own aggression. In addition to this, she specifically chooses the kalimba, the instrument that she first pointed out for the therapist and on which the therapist played her aggression, or projected the denied feelings. She puts herself in the therapist’s place by choosing his instrument. Through this choice she identifies with the therapist, or better: with the projected part in the therapist. She can now play more easily the rough, the aggressive. At that moment, it is the patient who appropriates the projected and, as a consequence, can play autonomously. She probably would never have been able to do this by herself. This identification with this split part of the therapist is a remarkable psychic phenomenon. The patient takes from the therapist the expression of her own aggression. In this way, the therapist becomes autonomous, he has freedom, but at the same time the projection must continue to exist. Because only through the projection can she come into contact with this part of herself. The therapist is autonomous, but at the same time he is not. The therapist makes a new appointment with the patient. This time Marianne gives the therapist a rather strong handshake and leaves the music therapy room with more dynamics. Fourth session: “The musical form Lieder ohne Worte.”4 Marianne looks more refreshed and dynamic. The dull glare in her eyes and glassy look, has disappeared. Also, she is no longer wearing a plain shirt with a neutral color, but one with colorful figures. There is a longing for the therapy, a longing that the therapist cannot understand. This makes him really curious. Marianne sits down and starts to talk immediately. She tells him that during the last week she was haunted by several rhythms and series of sounds. “These are sounds that came repeatedly to my mind, but I could not do anything against them, I could no longer find any words or…I also found it difficult to write them down. I tried to write them down but...” Therapist: Rhythms and sounds... You tried to write them down? Marianne: Yes, they were irregular rhythms, they were rhythms that you also find in language. Therapist: Were you able to do something with them? Marianne: I don’t know if I could, because yesterday they disappeared and also today they didn’t come back yet. Since yesterday however I have felt tension. Therapist: Could you play these rhythms? Marianne: We [sic] could try. Therapist: Could you imagine on what instrument you could play these rhythms? Marianne: Maybe that thing from last time. (Marianne points to the kalimba.) In this new improvisation that we later called “Lieder ohne Worte,” Marianne and the therapist play the same kalimba. In the quietness that precedes the improvisation (the face of “Einstimmung”) the therapist experiences certain autonomy from Marianne. From her first tone, he knows already in which direction the improvisation will develop. She plays the rhythmical figures that the therapist directly recognizes as the ones from the

previous session. Unconsciously, she repeats and integrates them. Immediately, the therapist experiences her rhythms as a musical form. A phrasing is noticeable, a tension that is building up. It is authentic music; it is her poetry. “Lieder ohne Worte” comes to his mind spontaneously. It is a story, an image from which the therapist is allowed to be a witness. He is searching for a meter that will allow him to be present in an active way, although he remains a neutral listener at the same time. The improvisation develops in a mutually interactive play, whereby rhythmical themes are being developed and integrated. The “making autonomous” of each other’s space is put first. The therapist feels entirely free in this, taking initiative and taking over her rhythmical proposals. The specific timbres of the kalimba are showing up extremely well.

Marianne: This is the ideal instrument to do something like this. It approximates the rhythms that I heard the previous days. Therapist: They are very dynamic rhythms, not so calm. Marianne: It was very restless like I experienced them. Therapist: What did you experience when you played your rhythms? Marianne: What I experienced was that...what I always experience when I come here. That is that lots of myself comes to the outside, that otherwise would stay covered up. Therapist: It was your music. Marianne: Yes, it is not just hitting a bar, it is...really coming to the outside with what lives inside of me...I let something from myself be heard.

Therapist: Did you also experience a dialogue in the improvisation? A question and answer; that is something new, isn’t it? It is the first time that this has happened. Marianne: It certainly has a significance, it has a...it is...a way of living and surviving. When you have at one side the society and at the other side the poet, who doesn’t fit in with society, and reacts to that society. Because he does not fit in with that society he is almost doomed to be a poet, but it is also thanks to that society that he is a poet. And that I can react to that as a kind of seismograph. Therapist: You definitely let yourself be heard. Marianne: ...Yes, it is...it is more the restlessness that lives in me and the aggression that is in me...and...feelings, contradictory feelings...that are in me...but feelings that are withdrawn in me, my being introverted.... As soon as Marianne came to her musical form, the whole relationship and our position changed. The transition was much more present. The next step toward the elaboration of her problems was obvious. How important the symbolization was, her musical giving form was, was shown by the fact that she integrated elements from this musical form in all of her later improvisations. She varied these and developed other musical forms from fragments that she integrated starting with what she adopted out of the central form. The musical and therapeutic interactions were sometimes very dynamic and radical, emotionally empathizing. Marianne was released from the hospital about four months after the start of her individual music therapy sessions and left her therapist in a very touching way. She knew that she was not ready yet, but because of her release from the psychiatric center it was impossible to continue the individual music therapy treatment. Conclusions We can observe three phases in the music therapy process that were also present in the treatment of Marianne. The moment of synchronicity or resonance between the therapist and the patient is the particular and sometimes laboriously achieved moment on which one makes music together. The occurrence of this moment is being signalized to the therapist by the appearance of the feeling that he can freely make music with the patient. Where, initially, he was searching for a sound that appealed to the real or traumatic part of the patient, suddenly in a liberating manner it becomes apparent that the music takes over. Two bodies dancing on the same rhythm, spontaneously and immediately being moved by the unexpectedly appearing music. An important part of the therapy is devoted to manage the resistance to the appearance of this moment, especially with the more severe psychopathology. The analysis of the fears of being captured or possessed by the “Spirit” of the music is the crucial task for the music therapist. The second moment is the moment of the development of the musical form. Once the moment of loss of one’s own identity in music has been reached, it depends on the subject-being within this synchronicity--to abandon the musical phrase that brought him to the loss of him/herself. In the same way the infant is confronted with the interruption of the drive by motherly deprivation, the music-making patient is being forced to break away from the purely repetitive, circular character of his musical phrase. At this moment, the therapist is a kind of

Winnicotian “good enough mother.” The feeding breast of the mother is not always as soft or as hard, her look is sometimes directed at the child and sometimes distracted by something else, her voice sounds sometimes sweet and reassuring, then again insecure and full of sorrow. This whole play of variations of a mother which is not always similar to her forces the child to develop the capacity to recognize the same mother in all these different forms of appearance. This preverbal internalization of an image--what we call “recognition”--is originally very similar to a hallucination. The hallucination is being constructed as a way of resisting this play of variations and of guaranteeing the non-variety of the object in the outside world. The recognition, on the other hand, accepts the variations in the outside world thanks to the construction of an original inner space. Finally, between hallucination and recognition there is still a transitional space in which one still frenetically clings to the musical phrase, but at the same time without coinciding with it any more. These different modes of relating to the absolute repetition of the phrase can also be recognized in the different forms of popular and art music. The capacity to abandon the ecstasy of the repetition and the analysis of the resistances against it form, in our opinion, the most essential, although sometimes hardly manageable, tasks of music therapy. When the work of variation and development--which can be considered as a form of primordial mourning--is completed, the patient is also able to finish his improvisation musically. If everything is all right, the traumatic affect and speech are no longer disassociated. In his speech, the affect can be heard. Like a tragic actor the patient has now broken away from the ecstasy of the Dionysian choir and he is now able to speak for himself. References Abraham, N., & Torok, M. (1978). L’Ecorce et le Noyau. Paris: Aubier-Flammarion. De Backer, J. (1993). “Containment in Music Therapy.” In T. Wigram & M. Heal (eds.), Music Therapy in Health and Education. London: Jessica Kingsley Publishers. De Backer, J. (1996). “Regression in Music Therapy with Psychotic Patients,” Nordisk Tidsskrift for Musikkterapi, 5(1), 24-30. De Backer, J., & Van Camp, J. (1996). “Muziektherapie in de behandeling van psychotische patiënten.” In M. De Hert, en E. Thys (Eds.), Zin in waanzin. De wereld van schizofrenie, Amsterdam: uitgeverij EPO. De Backer, J., & Van Camp, J. (1999). “Specific Aspects of the Music Therapy Relationship to Psychiatry.” In T. Wigram & J. De Backer (Eds.), Clinical Applications in Music Therapy in Psychiatry. London: Jessica Kingsley Publishers. Lacan, J. (1981). Le Séminaire, Livre III, Les Psychoses (1955-1956). Paris: Texte établi par J.A.Miller, Seuil. Ogden, T. H. (1992). The Primitive Edge of Experiences. London: Karnac Books. Ogden, T. H. (1994). Subjects of Analysis. Exeter, U.K.: PBC Wheatons Ltd. Ogden, T. H. (1986). The Matrix of the Mind: Object Relations and the Psychoanalytic Dialogue. Northvale, NJ: Jason Aronson Inc. Tustin, F. (1981). Autistic States in Children. London: Routledge. Tustin, F. (1986). Autistic Barriers in Neurotic Patients. London: Karnac Books.

Tustin, F. (1990). The Projective Shell in Children and Adults. London: Karnac Books. Van Camp, J. (1999, November). “Musique, répétition et affect,” La Revue de Musicothérapie, 4. Association Française de Musicothérapie, Paris. Van Camp, J. (2000). “Musik, Wiederholung und Ritual,” Musiktherapeutische Umschau, Band 21. Van Camp, J. (2001). “De muzikale vorm,” Tijdschrift Beroepsvereniging Muziektherapie, Leuven. .

________________ * Acknowledgment: This article is based on a more extensive research study (Ph.D. Program: Aalborg University, Denmark). The authors would like to acknowledge the research supervision of Pr. Dr. Tony Wigram. 1 We believe that the inquiry of the relationship between music and psychosis is not only relevant to music therapy stricto sensu, but can also contribute to a broader understanding and a more appropriate approach of psychosis in general. 2 We used the terms of delusion and hallucination interchangeably because, in this context, the stress is put on what they have in common: the experience of some events taking place, apart from the initiative of the subject, but dictated by persons and destinies in the outside world. Those events are always seen as involving the subject himself. 3 Lacan (1981) makes a clear distinction between “certainty” and “truth.” The truth can (in principle) always be shared with others, while the “certainty” of the psychotic is imposed on the subject, which does not have the need to verify his content with others. 4 “Lieder ohne Worte” is German for song without words.

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

CASE THREE From Ego Disintegration to Recovery of Self: The Contribution of Lacan’s Theories in Understanding the Role of Music Therapy in the Treatment of a Woman with Psychosis Lillian Eyre What is the psychotic phenomenon? It is the emergence in reality of an enormous meaning that has the appearance of being nothing at all--in so far as it cannot be tied to anything, since it has never entered into the system of symbolization--but under certain conditions it can threaten the entire edifice (Lacan, 1993 p.85). Introduction This case describes the music therapy process with Julie, a 24-yearold woman who was treated for three years in the psychiatric outpatient and inpatient departments of an urban teaching hospital. When Julie was first seen as an outpatient, she had experienced three major traumas beginning at the age of 16. Consequently, Julie suffered from anxiety, reclusiveness and bizarre behaviors. Over time, Julie fell into psychosis, unable to eat, care for herself, or speak. Various diagnoses were proposed, each one resulting in a trial of different medications, yet none seemed to help. Eventually, Julie’s anorexia created a life-threatening electrolyte imbalance, and the last recourse was to prescribe Electroconvulsive Therapy (ECT). I worked with Julie throughout her admissions, often seeing her individually three times a week during her deepest phase of psychosis. In a parallel process, Julie’s months of internal darkness were mirrored by an intellectual darkness that I experienced when I grappled to understand how music might help Julie to engage with the world. Jacques Lacan, a French psychoanalyst who worked with psychotic patients, wrote a seminal work on psychosis (1993). It was in this work, that I began to glimpse what Julie’s constellation of psychotic symptoms might mean. This, along with Lacan’s semiotic theories of identity formation (Muller, 1996), provided me with a therapeutic direction. Eventually, music proved to be the means by which Julie was able to break through her isolation and begin to relate to herself and others. Foundational Concepts Lacan’s Three Orders Confronted with a client who seemed to initiate and maintain a strong barrier against the world, I sought a theory that would provide me with an understanding of self and other in

psychosis. Jacques Lacan’s (Benvenuto & Kennedy, 1986) constructivist theory of psychoanalysis was based on Freud’s (1905/1977) concept of psychosexual development. Lacan (1988) explored psychosexual developmental stages from the perspective of semiotics and the development of language. Central to Lacan’s theory was the concept of the contribution of interpersonal interactions and dialogue in the construction of identity. He suggested that knowledge, self and reality were constructed by way of linguistic structures that organized not only our conscious but also our unconscious lives (Felluga, 2003, Module I). Lacan’s concept of the structure of the psyche was expressed in three registers, also called orders or dimensions: the Symbolic, the Imaginary and the Real. Lacan’s concepts bring insight into the communicative process and shed new light on infant-caregiver communication, particularly as it applies to music therapy. In the Symbolic order, one acquires and uses language in a co-constructed and cultural context. This order corresponds to Freud’s psychosexual developmental stage where the child passes through the Oedipal complex (Eagleton, 1983). In the Imaginary order, the self is constructed through images that are evoked in relationships, corresponding to Freud’s anal stage when the infant moves from primal need to the stage of demand and mastery as s/he begins to form ego identity. Lacan’s concept of the ‘Gaze’ is important in the achievement of a sense of mastery, which occurs when one sees the image of oneself as the ideal ego mirrored in the Gaze of the ‘Other’ (Muller, 1996). The Real order is linked to both unconscious and psychotic states. The Real, as experienced in early infancy, can be described as an oceanic state in which there are no boundaries and no separation between oneself and the external world. In adulthood, intrusions of the Real may be experienced as feelings of loss or failure, and are described as dumbfounding, painful, incomprehensible, confusing or horrific (Neubert, 2003). Conversely, the Real is also the feeling that leaves us speechless when we come upon ecstasy or inexpressible beauty (Muller, 1996). Real events cannot be fully expressed in the Symbolic order of language, nor do they completely fit into known or lived experience that has been assimilated into the Imaginary. Psychosis and the Real Order This brief introduction to Lacan’s theory of the structure of the psyche provides a basis for a discussion of psychosis in Lacanian terms. In psychosis, the unconscious is brought to the surface and becomes conscious (Lacan, 1993). Thus, psychosis can be described as a falling into the Real, a phenomenon that occurs when words in the Symbolic order no longer function adequately, and “the patient is left with only the fantastic quality of images with which to grab hold of their import. These images alternately terrify or seduce, promising destruction or paradise…the isolation is extreme” (Muller, 1996). Another essential characteristic of psychosis is the non-existence of the Other: “…in psychosis, the Other, where being is realized through the avowal of speech, is excluded.” Instead, the subject has a “relationship of internal echo to his own discourse” (Lacan, 1993). The dimension of the Real is the essential element in trauma. When trauma cannot be adequately expressed in language, it is excluded from the Symbolic order and cannot be assimilated into the psyche. Thus, it must be repeated. The trauma confronts the subject with an “ever-missed encounter with this ‘real’ object of anxiety that cannot be named” (Lacan,

cited in Patsalides & Patsalides, 2001). The traumatic residue reappears in the Real as psychotic symptoms (Benvenuto & Kennedy, 1986). Lacan (1993) stated, “It can happen that a subject refuses access to his symbolic world to something that he nevertheless experienced; …what comes under the effect of repression returns …expressed in a perfectly articulate manner in symptoms and a host of other phenomena.” In the same process, the place of the Other is deleted or seriously disordered because of this gap in the Symbolic order (Benvenuto & Kennedy, 1986). The task then, in the treatment of psychosis, is to integrate and bring into the Imaginary and Symbolic orders, that which has emerged in the Real, “for the subject represents something of himself that he has never symbolized” (Lacan, 1993). With regard to treatment of psychosis, Lacan (1993) stated that “[i]n order for the human being to establish…relations, a third party has to intervene, one that is the image of something successful, the model of some harmony.” Lacan further stated, “The ambiguity and the gap in the imaginary relation requires something that maintains a relation, a function, and a distance.” Music Process in Lacan’s Conceptual Frame Lacan’s conceptual framework describes how a rupture in intrapersonal communication can be seen as the fundamental problem in psychosis, while withdrawal from the world and lack of interpersonal communication can be understood as a breakdown in the psyche. This provided me with therapeutic direction in my work with Julie: music might be used to reestablish communication and integration within the Real, Imaginary and Symbolic orders. In the course of my work with Julie, there emerged eight roles that music played in the treatment of her psychosis: 1) As a mediator between the Real and the Imaginary order; 2) As a mirror to facilitate ego awareness in the Imaginary order; 3) As a mediator to symbolize the trauma of the Real in the Imaginary and Symbolic orders; 4) As a semiotic code creating awareness of the Other in the Imaginary order; 5) To elicit desire, motivation, intention and will; 6) As a transitional object leading to a relationship with the Other in the Symbolic order; 7) As a facilitator of ego reconstruction and identity formation in the Imaginary order; 8) As a facilitator of ego integration in the Symbolic order. These functions will appear in italics as they relate to specific events in the therapeutic process. My role throughout the therapeutic process was to: 1) maintain the necessary balance between distance and intimacy to create safety so that Julie might accept the music; 2) facilitate Julie’s intrapersonal communication in the three orders by singing songs and playing instrumental selections or improvisations that matched Julie’s energy, mood and vitality states; 3) establish interpersonal communication through trust established in the musical relationship; 4) help Julie gain access to calm, soothing, internal states when she was traumatized by the

chaos of the Real; 5) provide Julie’s mother with appropriate recorded music that she might use with Julie in my absence; 6) facilitate, through music, the integration of the three orders; 7) facilitate, through music, Julie’s ability to articulate whatever she was capable of regarding her experiences in the Symbolic order; and 8) support Julie’s emerging identity through music. Background and Assessment Process I first met Julie in the outpatient department where her mother provided a history of the events leading to Julie’s difficulties. Julie’s early life was one of apparent promise; she was gifted and had tested with an I.Q. of 170. When she was 14, she experienced adjustment difficulties when she moved from a small town to a large city. A few months after her 16th birthday, Julie was date-raped by her older boyfriend. Confused and guilt-ridden, she did not tell anyone about it. Six months after the rape, Julie gradually began to avoid contact with most of her friends and eventually refused to go to school. The second trauma occurred two years later when Julie’s father was diagnosed with cancer and died within six months. It was likely that because of Julie’s dissociated state of mind from her first trauma, she was not able to fully mourn her father’s death, and this provoked a complicated grief reaction that exacerbated her trauma. Two years after the death of her father, at the age of 20, Julie’s third trauma occurred when she had a motor vehicle accident (MVA). Julie was in a coma for three days, registering 4 out of 15 on the Glasgow Coma Scale. Following the MVA, Julie remained reclusive and had minor cognitive difficulties. Two years later, alarmed by Julie’s request for a gun for her birthday so that she could kill herself, Julie’s mother brought her to an emergency room, where she was diagnosed with non-specified psychosis and referred to the outpatient program. Julie isolated herself in the outpatient group program and spoke very little. After two weeks, her mother found it impossible to motivate her to come to the program, and I did not see her again until five months later when she was admitted to hospital as an inpatient. At this time, music sessions occurred most often at Julie’s bedside, sometimes with the aid of, or in the presence of, her mother. Julie was withdrawn; she did not play an instrument or sing. I used a guitar, voice, and keyboard to sing pre-composed songs with occasional lyric substitution; I improvised with gentle humming. Because Julie’s verbal communication was minimal, her mother was crucial during the assessment, providing me with information regarding Julie’s symptoms and her music preferences. Julie’s psychotic ideation was formulated around a refusal to urinate because she believed that she would pollute the water supply; she refused to eat or drink, and she believed she could not walk. The goal of music therapy during this phase of her illness was to ease her distress and to establish contact with her through music. Julie made some progress, and when she was able to walk again, she left the hospital without discharge. This was a pattern that occurred for the next six months. At times, her mother returned to the hospital with her; at times, she took over Julie’s care at home. During these admissions, I attempted to work with Julie in the Symbolic and Imaginary orders. In individual sessions, I focused on ego structuring experiences, for example, teaching Julie how to play a song her mother said she liked. I used song choice and suggested instrumental improvisation to develop a relationship with her. She often refused to choose a song, and when she did, she became distressed and rejected the song soon after I began to sing. She became

more distracted and distressed when she was out of her room, and my goal was to use recreative and receptive music experiences to keep her in the music session for up to 30 minutes. It was clear from her numerous admissions that the course of Julie’s illness was mysterious and complicated. Likely, this was a neurophysiological response to the emotional traumas she had experienced, as well as unidentified brain damage from the MVA. Over the following months, Julie regressed considerably. In addition to being almost mute, she was anorexic. After a few courses of neuroleptic medications were unsuccessful, Julie was given a series of 32 ECTs. On the basis of the trust we had established, and my knowledge of her ability to relate to music, I continued to provide music at Julie’s bedside one to three times a week. The goals were to provide comfort, to maintain trust, and to encourage interaction with an external stimulus. Therapeutic Process Phase One: Terror and Soothing in the Real and Imaginary Orders As Julie used less speech, it became evident that she was losing her ability to function in the Symbolic order. In this period, I often improvised vocally over guitar accompaniment to match her mood and to calm her, thus using music as a mediator between the Real and Imaginary orders (1). When one dwells in the Real it is all-encompassing. Thus, in order to mediate between the Real and Imaginary orders, a boundary must be delineated in the Real. For Julie, this was achieved by using music to help her access and identify soothing feeling states that she might recall from her past experience in the Imaginary order. For example, after ECTs, Julie became less fearful and allowed herself to be comforted when I sang songs such as “The Rose.”1 One evening, however, instead of being calmed, Julie began to tremble; her state of terror was induced and exacerbated by my presence. Uncertain how to proceed, and unwilling to leave her alone, I sat in silence with her. I noticed that Julie was joining her thumb and second finger of both hands to form a circle. Thinking this might be significant, I imitated Julie’s sign with my left hand. She stared at my hand, began to breathe more calmly, and relaxed physically. I began to improvise vocally again, picking open strings while making this sign in my left hand for the rest of the session while Julie watched my hand. When she was able to speak in her recovery phase, I asked Julie what the sign meant; she told me that it symbolized a circle of protection. In this situation, music was not enough to create the boundary; only when a boundary in the Real order had been created through a symbolic act of interpersonal resonance, could Julie utilize the music in the Imaginary order where she had a sense of self. Over the next month, Julie completely lost her ability to function in the Symbolic order. Falling into a deep state of psychosis in the Real order, she lay in her bed, eyes averted, speechless, showing no signs of recognition of her mother or anyone else. I continued to sing songs to her. Six weeks after the beginning of ECTs, Julie began to react to songs I sang with subtle physical movements, which I interpreted as a communication of her song preferences.

Phase Two: Awareness of Self and Other in the Imaginary and Symbolic Orders Though Julie continued to look at the wall and give no indication that she knew I was present, she began to respond to songs with particular behaviors, such as silently mouthing undecipherable words to the music I sang. As she became animated with her internal representation of the song in her Imaginary order, she expressed her feelings through gestures. For example, when I sang “What if God was one of us, just a slob like one of us,”2 Julie at first shook her fist at the ceiling, then weeks later, she humorously stuck her tongue out in mock anger against God. In calm songs such as “Scarborough Fair”3 and “Like a Bird on the Wire,”4 Julie became physically quiet and listened to every word intently. If I substituted different words for a line or verse of the lyrics, her body language expressed her awareness of the change. Julie recognized the music was something outside herself that nevertheless corresponded to her experience of being “like me,” or “not like me.” In discovering how the musical affect matched her internal world, she became more aware of her identity. She often used nonverbal signs to communicate how she felt about the music that was chosen for her. She became, in Lacanian terms, “iconically captured by the image which lured her narcissistic investment” (Lacan, cited in Muller, 1996 p.139). In this situation, the musical affect was the “image” to which Lacan referred, and in this process, music was used as a mirror to facilitate ego awareness in the Imaginary order (2). In creating silent words to the music, in her gestures, and by living through the emotions evoked by the music, Julie used the Imaginary order to create personal rituals that expressed the traumas that she was experiencing in the Real: rape, death, loss and being physically put in restraints. Muller (1996) stated that when dealing with trauma, the psychotic person’s symptoms “have as their context a specific field in a relationship where the representation of an unnamed catastrophe has to be killed…and the symbolic killing occurs through naming. This naming can be done in words or ritual, even by gesture or by the use of transitional objects.” Music was the transitional object that facilitated the identification of unbearable affect, created boundaries around it, and made it bearable. Though Julie was not speaking words out loud, it was evident that she was using language internally. Thus, she confronted the traumas she experienced in the Real and used music as a mediator to symbolize the catastrophe in the Imaginary and Symbolic orders (3). Gradually, Julie became less invested in avoiding contact. She was not only aware of herself, but she was also aware of the music, and by extension, aware of me as the Other who was the agent of the music. She began to develop more energy and often became so animated after ECTs that she was put into restraints for her own protection. One day after ECT, Julie was in a combative mood; she had thrown her lunch against the wall and was repeating something like uh-uh softly under her breath. Interpreting this as a negation reflecting her rejection of life, I used these sounds to improvise on the keyboard. At first, I imitated and supported the uh-uh’s (No) with a diminished seventh chord resolving on C minor triad, then I challenged the uh-uh’s with light, operatic um-hms (Yes) with an arpeggiated C major triad. We “conversed” for over thirty minutes; Julie seemed to derive pleasure from it, insisting playfully on the uh-uh’s with a loud whisper when I challenged her with um-hm’s. Twice during this session, she forgot to be

mute and laughed; she said, “Oh God,” then clapped her hand to her mouth to stop the sound. This was the first time she had used audible language in months. In the musical dialogue, Julie was not only asserting her identity with uh-uh, but she was recognizing the difference between uh-uh and um-hm, the “me” and the “not me.” Caught up in the playfulness of the musical expression of sameness and difference, she entered into dyadic contact. Thus, creative musical play substituted for the speech that Julie was not capable of expressing in the Imaginary order. Music functioned as a semiotic code creating awareness of the Other in the Imaginary order (4). When Julie was feeling intense energy after ECTs, I played and sang rock and roll music as vigorously as possible. On one occasion, shadowed by her mother for protection, she danced wildly and threw herself around the room with no awareness of her physical safety. When she had spent all her energy, she collapsed, and I sang “Like a Bird on the Wire” as she fell asleep on the floor in her mother’s lap. By expressing her internal states of tension and energy in physical movement through her resonance with the music, Julie expressed her needs, her desire and her will. In doing so, Julie was feeling the impact of the presence of the Other (therapist, music and mother), which also awakened her desire for the Other (5). Another way that music elicited desire for the Other and evoked motivation, intention and will (5), was in the vocabulary of gestures that Julie developed to indicate her feelings about the songs I chose to sing for her. She used signs such as scratching the sheet, tapping her arm or blinking yes or no to indicate whether or not she wanted to hear a particular song. I could not always understand the personal meaning that Julie associated with a gesture. When Julie had regained speech, she explained that the gesture of tapping her arm was related to a childhood memory of a nurse who tapped her dying grandmother’s arm to administer an intravenous drip to keep her alive. Julie had used this gesture to communicate to me that the song was bringing life into her veins. By expressing her desire or lack of interest for a particular song, she was engaged in co-creating her identity with music and with the Other. Phase Three: Meeting the Other in the Imaginary and Symbolic Orders By using gesture to communicate desire, Julie was beginning to use music as a transitional object to relate to the Other in the Symbolic order (6). In her reliance on the Other to meet her desires, Julie was also creating the possibility that misattunement might occur. An example of misattunement that drew Julie more directly into relationship with the Other occurred when I put on a 20-minute tape of Bach for her to listen to while I went to a meeting. When I returned, Julie was sitting on the floor in what appeared to be urine. I immediately recognized my poor judgment; the music had brought up difficult emotions, and I had left her alone with no way of defending herself, since she couldn’t manipulate the boom box. I wondered if Julie’s incontinence might have been intentional, and without expecting a response, I said, “I left you all alone with the music.” She nodded yes, and I added, “I’m thinking maybe that wasn’t very good for you,” to which she again nodded in agreement. This was the first time that Julie responded directly to a verbal communication since she had fallen into muteness eight months previously. I discovered that she had not been sitting in urine, but in apple juice, which she had purposely spilled on the floor. I interpreted this act as an attempt to

communicate her anger toward me and her frustration in her situation of being unable to stop the music. Since music was a powerful means of connecting with Julie, her mother often played music I had selected for her when they were together. One morning, she played and replayed Schubert chamber music while Julie stood and stared at the wall. After a few hours, she turned to her mother and had a conversation, asking what had happened to her. This was the first time Julie had conversed in nine months. After this event, Julie established a pattern of attempts to communicate with speech followed by regression into mutism. Two days after speaking, Julie knocked over the boom box and said that she was angry that she had been brought out of her isolation by “that music.” Gradually, Julie was able to consistently give one-word answers to questions and showed other signs of being aware of being in relationship with others in the world. For example, she demonstrated empathy toward me; when I told her I was sad that I was unable to understand something she was trying to communicate, she reached out to console me. She also displayed emotions of joy and happiness in the music and when she saw her mother or me. Thus, music served as a transitional object in awakening relationships with the Other in the Symbolic order (6). As Julie regained more speech, she was able to choose songs and express her desire to hear Heavy Metal or fast-paced rock music with lyrics that carried a tone of anger or cynicism. Julie now had no recollection of the last year she had spent in the hospital when she had lost her speech. She began to reject hearing all the songs that had sustained her this past year. Since these songs would have evoked the now unconscious and repressed chaotic feelings she had experienced in the Real order, her rejection of them suggested that Julie was establishing her own protective defenses against the Real. Phase Four: Integration of the Orders and Identity Reconstruction Very rapidly after regaining her ability to speak and re-establish her connection with the Symbolic order, Julie began in earnest to reconstruct her identity. She refused to be addressed by her given name, reconstructing her ego based on a fantasy that she was a male, AfricanAmerican rapper. In a symbolic act, she took a musical instrument, an African shaker that consisted of two balls tied together on a string, and wore it on the belt loop of her jeans for weeks; this object transformed her into the male gender, thereby decreasing her female vulnerability, the source of much of her trauma. She also occasionally joined the music group where she interacted with others, particularly males. Her musical interest was exclusively rap music, as she used music to facilitate her ego reconstruction and identity formation in the Imaginary order (7). Julie had regained more speech, but she was still very disorganized and had difficulty functioning in the world. Her affective world was problematic, and she was sad and confused. During this time, Julie was still focused on her identity as a male rapper, but she presented another persona: the vulnerable Julie. The rapper was the vulnerable Julie’s protector. We improvised on various instruments, but Julie had difficulty sustaining any interaction musically for more than a few seconds. During one session, Julie said that she had to “bring in the big boys to take over” when she was tied down in restraints in the hospital because “Julie” was too weak to tolerate being restrained. She said, “I left her [Julie] curled up there in a ball in the

same position they had left her when they raped her.” The vulnerable Julie was not able to take care of herself, so she split off from her and abandoned her, becoming instead, a strong rapper who was capable of defying the external world. It is significant that in addition to the two personas, the “I” also emerged at this time. Julie was discharged and I saw her three times as an outpatient. During these sessions, Julie fluidly slipped in and out of psychosis, cried in sadness and fear, and presented dream-like material as reality. For example, she said she felt like she had been raped many times, and couldn’t tell which of them was real anymore. When she talked about the rape, she also talked about the restraints that had been used in the hospital, associating them to the rape because in both situations she had been held down. She was beginning to articulate the violations against herself and describe her traumas in the Symbolic order. It was important to work on integrating the two parts of Julie that she had identified-the protective male rapper and the vulnerable female Julie. This split, which had been initially helpful in protecting her and helping her to gain a sense of self while she was in a vulnerable state in the Imaginary order, was now inhibiting her experience of herself as an integrated person. For example, she was preoccupied with the polarities of God and the Devil, stating that the Devil was her friend. We found sounds for the Devil and God, then put the sound of them together, which she said brought her comfort. We also worked on the images of the rose (which she chose for the vulnerable Julie) and the dragon (which represented the rapper-strength). I asked Julie to consider what each image (dragon and rose) could bring to the other so that the two of them might communicate. Two weeks later, Julie spontaneously created the story of the rose and the dragon while she strummed on the guitar: Lillian: Can you tell me about the rose? Julie: The rose? … The rapper is kind of like the dragon; it used to be that the rose was surrounded by the dragon and the dragon stomped on the rose. Now the dragon has a corona, a garland of roses around his neck--like a wish bone--a revelation; he’s a pretty dragon; he and the rose are married. …The dragon switched his colors. Lillian: How did it happen? Julie: The Queen and King of the Roses went up to the dragon and said, “Why are you stepping on our people, dragon?” But the dragon didn’t have much to say because the dragon’s a Taurus. … He said that he had been stomping on roses for centuries, but now that the Queen and King had come to him and there were petals falling from the sky, he said, “I don’t have to be breathing fire and stomping on these roses, they’re beautiful roses, I don’t want to damage them.” So the dragon changed his colors. He found out he could change; he was still the same person, still had the same skin, but his color could change. In these sessions, Julie worked on the integration of her Real order experiences of trauma and aggression, vulnerability and self-protection, in both the Imaginary and Symbolic orders. Thus, she was using music as a facilitator of ego integration in the Symbolic order (8). Phase Five: Endings

Julie’s sessions occurred in the music room that was in the inpatient unit of the hospital. Because she was an outpatient, I could not see Julie privately. For Julie, coming to the hospital brought up memories of being restrained and made her very fearful that she would not be allowed to return home again. After three sessions, she refused to continue, and I supported her decision because there were signs of regression in her behavior. I visited her in her home a few weeks later for closure. At that time, she was under the care of a psychiatrist who specialized in dissociative identity disorders. She refused to continue to see him after two sessions, stating that he made her talk about things that made her feel confused. She was withdrawn and had some bizarre behaviors, but she still possessed the ability to use speech and to communicate in the Symbolic order. Summary Emotional health requires an integration of the three orders that are based on an assimilation of psychic phenomena. This requires the ability to use defenses, such as repression, to avoid falling into the Real, while at the same time remaining sufficiently aware of one’s Real events to be able to adequately symbolize them in the Imaginary and Symbolic orders. Once the Real has been inhabited, it exerts a strong magnetic pull on the individual to fall back into it. To continue on her path to integration, Julie had to be able to recognize what was healthy for her, to use whatever could bring her out of Real, and to avoid what could bring her back into it. Julie remained under her mother’s care for three more years. Eventually, she had integrated her psyche well enough to be able to attend a long-term residential psychiatric rehabilitation facility from where she successfully began her university education. Music reached Julie when she was lost in the Real order and it was essential to her return to the Imaginary and Symbolic orders. But this could not have been accomplished without the courage and will that was demonstrated by both Julie and her mother through a long sojourn that baffled her psychiatric practitioners. Music was able to reach inside to find Julie, and following the music, Julie found her way back out to those who loved her. References Benvenuto, B. & Kennedy, R. (1986). The Works of Jacques Lacan; An Introduction. London: Free Association Books. Eagleton, T. (1983). Literary Theory: An Introduction. Oxford, England: Basil Blackwell. Felluga, D. (2003, November). Modules on Psychoanalysis: Introductory Guide to Critical Theory. Purdue University. Retrieved from http://www.purdue.edu/guidetotheory/psychoanalysis/psychmodules.html. Freud, S. (1977). Three Essays on the Theory of Sexuality and Other Works. (James Strachey, Trans.) Hammondsworth: Penguin Books. (Original work published 1905). Lacan, J. (1988). The Seminar of Jacques Lacan: Book I. Frued’s Papers on Technique 1953–1954. (J. Forrester, Trans.). Cambridge: Cambridge University Press. Lacan, J. (1993). The Seminar of Jacques Lacan: Book III. The Psychoses 1981. Muller, J. (1996). Beyond the Psychoanalytic Dyad: Developmental Semiotics in Freud, Peirce, and Lacan. New York: Routledge.

Neubert, S. (2003). Some Perspectives of Interactive Constructivism on the Theory of Education. University of Cologne. Retrieved from http://www.unikoeln.de/ew-fak/konstrukt/texte/download/introduction.pdf. Patsalides, B. & Patsalides, A. (2001). Butterflies caught in the network of signifiers: The goals of psychoanalysis according to Jacques Lacan. Psychoanalytic Quarterly, 70, 201–229. ____________________________________ 1 Written by Amanda McBroom, 1977. 2 Written by Eric Bazilian, released by Joan Osborne, 1995. 3 Anonymous. Traditional English Ballad. 4 Written by Leonard Cohen, 1968.

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

CASE FOUR Singing in the Recovery Model with a Chronic Mentally Ill Offender Vaughn Kaser Introduction The adult male forensic mental health setting is typically thought of as a challenging work environment. In addition to being diagnosed with a major mental illness, most of the residents at this large forensic state hospital have also committed some type of felony. Serious assaultive criminal behavior often occurs as a symptom of the individual’s mental illness. This type of behavior is often related to the individual’s Axis II diagnosis1 (i.e., personality disorder). As in many psychiatric treatment settings, substance abuse issues are often an additional part of the problem and can also lead to serious criminal behavior problems. Some drugs can lead to violence with extended usage, whether the individual is mentally ill or not. Many of the individuals being treated in adult forensic mental health facilities have similar diagnostic combinations and can be a significant challenge to work with therapeutically. Response to medication, intellectual functioning, family and community support systems, and acquired life skills are all important factors related to how an individual might respond to therapy. This, in turn, affects their chances for being released back into the community. Despite the challenges many of the individuals face in this setting, the first step or steps are often the most important and difficult to make. Despite the numerous problems confronting them, some may continue to be resistive to treatment and in denial of their problems. For others, their symptoms are more severe and do not respond successfully to medications. Individuals in this category are often assigned the label of “chronically” mentally ill and are by nature the most difficult to treat. This chapter describes music therapy with Alex, a man suffering from a severe mental illness who was able to engage in a range of music therapy experiences to express and release feelings related to earlier life experiences and his current life circumstances. His struggles to maintain participation in groups and verbally process experiences reflected deep struggles with his mental illness and recovery. Foundational Concepts A Prison Recovery Model The forensic state hospital system discussed in this chapter has adopted the Mental Health Recovery Model as a treatment philosophy (Anthony, 1993; Deegan, 1988; Magler, et al., 2001). Early components of this model began in the late 1980’s and borrowed elements of

the 12-step substance abuse treatment program (Alcoholics Anonymous, 1976). Recovery has been referred to as “both a conceptual framework for understanding mental illness and a system of care to provide supports and opportunities for personal development. Recovery emphasizes that while individuals may not be able to have full control over their symptoms, they can have full control of their lives. Recovery asserts that persons with psychiatric disabilities can achieve not only affective stability and social rehabilitation, but transcend limits imposed by both mental illness and social barriers to achieve their highest goals and aspirations” (Anthony, 1993; Deegan, 1988; Magler, et al., 2001). In the Recovery Model, individuals (the terms patients or residents are also acceptable in this model) are encouraged to more fully participate in their own treatment. As such, they are empowered and encouraged by the treatment team to take an active role in both determining and deciding the course of their own treatment program. In the Mentally Disordered Offender (MDO) program2 these men are encouraged to select from a wide variety of treatment groups and activities. They are also given the choice to attend therapy groups without fear of some sort of disciplinary action by the treatment team. During team meetings, the individual Wellness and Recovery Treatment Plan is projected onto a wall for them to view and discuss with members of the team. Progress reports and changes in the plan are also discussed. This Recovery Model also includes what is referred to as a Treatment Group Mall Program. In this type of program, groups are offered to individuals throughout the entire facility. Individuals are given the opportunity to choose groups they would like to be involved in. All therapy groups are based on 12-week lesson plans designed to address specific areas of treatment outlined by the Wellness and Recovery Plan. In this model an individual might select an activity group involving playing music designed to address specific therapy goals that address barriers for them to be released back to the community. Individual Barriers to Discharge are identified within the first seven days as Recovery begins from the first day of admission. The focus of treatment and the interventions (treatment groups) are assigned to address what the individual will need to do in order to be discharged to the next least restrictive anticipated placement setting.3 The Role of Music Therapy When attempting to motivate unstable problematic resistant individuals to attend a music therapy group in a long-term adult forensic mental health setting, it is recommended considering the following guidelines. Try to create and offer a group experience that is well structured and supportive as much as it is musically and socially enjoyable for the entire group. Nothing can be accomplished therapeutically if the men don’t come to group! The therapist should be active in the musical improvisation with the rest of the group. When the music therapist engages in the group experience this way he/she becomes more like another member of the group. In this interactive role, staff may appear less authoritarian, less threatening, and this supports a therapeutic alliance in which everyone shares their personal expressions. Any discussions the therapist might facilitate after an improvisation should be designed primarily to elicit verbal comments directly related to the improvisation. Positive comments related to the

focus of treatment are targeted in addition to feedback in support of how the group can achieve a healthy sounding musical creation. This approach is primarily in support of the notion that it is the actual musical expression that provides the most therapeutic benefits to these men. Spontaneous musical group expression contributes to helping integrate the individual, both internally and externally (with the rest of the group). This integration occurs through the simultaneous use of cognitive, emotional (visceral and psychological), and kinesthetic movement experiences (Schneck & Berger, 2006). In discussing this multi-level integration, Schneck and Berger (2006) examine music from a biomedical/physiological engineering perspective and draw parallels between the complexity of the music created by patients and their multidimensional health. A music therapy improvisation group, when offered to a more challenged individual who has an emotional investment in musical expression, can begin to address multiple symptoms of their mental illness while at the same time helping to develop their ability to focus, tolerate others and interact more successfully in a group setting: • • •

Self integration supports grounding and reality testing problems related to symptoms of a patient’s Axis I disorder Problems encountered with social interactions related to Axis II personality disorders are confronted directly in support of listening and responding spontaneously to others in a musical improvisation Agitation, stress and anxiety are often reduced through playing musical instruments by supporting the expression of feelings and the physical process of moving, playing instruments or singing The Client

Alex was a 47-year-old single white male who had been transferred from a regional county jail pursuant to PC 2972 (MDO). His controlling offense, Assault with a Deadly Weapon (ADW), with prior incarcerations, occurred some years earlier. His County CONREP4 caretakers readmitted Alex to the hospital. His first arrest was at age 16 for petty theft. He was placed in jail at age 18 for receiving stolen property. Adult arrests and convictions include: reckless driving, burglary, trespassing, resisting arrest, vehicle theft, exhibiting a deadly weapon, lewd and indecent exposure, disorderly conduct, loitering, defrauding an innkeeper, and multiple counts of battery. Alex has had prior admissions to a state hospital in 1984, 1988, and from 1995–1998. He had also been admitted to regular psychiatric inpatient facilities for the treatment of his mental illness. Alex was adopted at a young age and has no siblings. It was reported that Alex became depressed and started using drugs after his mother died of cancer when he was 17 years old. His father died from cancer when he was 24. Drug use has included marijuana, cocaine, methamphetamines, and alcohol. He has previously been diagnosed with ADHD and was treated with Ritalin. Alex attended special education classes and dropped out of high school in the 11th grade. He has had no employment history except for working as a gardener for his father’s mobile home park.

Upon evaluation at the prison, Alex was given the following diagnosis according to DSM IV-R criteria: Axis: I 295.70 Schizo-affective Disorder. Axis: I Polysubstance Dependence. Axis: II Anti-social Personality Disorder. At the time the music therapy treatment began, Alex was struggling with various problematic interpersonal behaviors on the unit. He was often observed by staff to be making nonsensical comments, stating that he was agitated, and requesting a PRN for agitation and making bizarre hand gestures in the patient dining room serving line. He was having difficulty following the unit daily routine and was thought to a have cognitive impairment. Twice in the last few months he had been in physical altercations with peers, resulting in slight injuries. There were almost daily reports from both staff and peers that Alex initiated annoying behavior toward his peers. He was receptive to taking his psychiatric medications and was thought to be responding well to them. However, Alex was refusing all of his assigned treatment groups.5 It was often difficult enough for Alex to tolerate a brief informal conversation with one staff person if he was not interested in the topic of the conversation. An interactive group setting was very difficult for him in terms of staying focused, listening and absorbing the material being presented, and being able to tolerate the presence of others. Assessment Alex had been in hospital for over one year before beginning the therapeutic work described in this chapter. He had not begun to address any of his seven barriers to discharge in the treatment groups assigned to him. Three of these barriers included: 1) maintaining a period of psychiatric and behavioral stability, 2) remaining free of physical and verbal assaults or threats, and 3) acknowledging the presence of a mental illness and the need for treatment. Alex’s behavior was such that he has not been able to tolerate the treatment group setting. During the initial Rehabilitation Therapy (which included music therapy) an assessment referred to as the Initial Assessment of Rehabilitation Therapy revealed that Alex had a particularly keen interest in rock music. He had been observed engaging in informal interactions with the nursing staff during which Alex would accurately imitate various guitar riffs with his voice and hands. Alex would also sing the lyrics to parts of each song. He would occasionally ask to play the unit acoustic guitar, though his “playing” ability was exclusively limited to reproducing the opening guitar lines of Deep Purple’s “Smoke on the Water.” At that time, Alex was assigned to begin two music therapy groups being offered to the residents on the unit: An improvisation group called Interacting through Music, and the on-unit informal music listening group Fun with Music. Alex would also be encouraged to attend the evening leisure karaoke singing group. One of the main goals of the music therapy program would be to attempt to use Alex’s interest in music to help reduce his resistance to attending therapy groups, develop his social interaction skills and help reduce anxiety and agitation by developing frustration tolerance for others. The Therapeutic Process Stage 1: Inconsistence

For the first two months, Alex was assigned to a small free improvisation group, with about four or five men attending fairly regularly. However, Alex was not one of them. His attendance was very sporadic, and when he did attend, he would repeatedly ask to leave soon after arriving (usually so he could go to the courtyard to smoke). The two times he stayed to play, Alex was interested in trying out most of the percussion instruments in the room including the bass and tenor xylophones, a percussion table, and the drum set. His playing on all these instruments was disorganized rhythmically, with little connection to what others were playing. He played with both hands simultaneously, striking random notes softly on the xylophone. He would often stop in the middle of an improvisation and require verbal guidance before starting again. The role of the therapist in this group was very focused and supportive. The therapist was responsible for selecting the various percussion instruments, drums and xylophones, the manner in which the instruments were set up in the room, and determining the method for how the group was going to begin each improvisation. After a moment of silence, the group was free to begin playing however they wanted. There was no set structure for how the improvisations were to end and no direction from the therapist to initiate the ending. The group members were allowed to move freely between the instruments if they wished. The therapist facilitated a brief discussion after each improvisation. The intent was to allow the group to voice how they felt about the improvisation and to indirectly suggest ways of improving the experience by asking questions such as “Who were you listening to during the improvisation?” or “Could everyone hear all the instruments?” After eight weeks, Alex attended his fourth improvisation group. During the third improvisation of the group, he was able to organize his rhythm on the xylophone with the rest of the group. This was the first time Alex made an attempt to engage with the group while playing any instrument. He was also becoming more familiar with the process of improvising, how to play the instruments, as well as the playing of the rest of the group. He appeared relaxed and focused enough to actually play and listen simultaneously, at least for a moment. On this particular day, Alex had been in a fairly positive mood before starting. He had sung a guitar part from a song by Dio (a heavy metal band led by Ronnie James Dio) on his way to the music area. This was the sort of thing Alex enjoyed doing on the unit when he was in a good mood. Around this time, Alex began participating in the evening leisure karaoke group. He sang two songs, including “Don’t Fear the Reaper” by Blue Oyster Cult. Alex sang in a low monotone voice, but in rhythm and on pitch with the recording well enough to tell he was familiar with the song. Singing a song he was familiar with appeared to offer Alex the additional structure he needed to stay organized in relationship to the music. Stage 2: An Isolated Voice It would then be three weeks before Alex was willing to attend the music improvisation group again. The week before he did attend the karaoke group on the unit and sang two songs: “Caribbean Queen” by Billy Ocean and “Thriller” by Michael Jackson. It should be noted at this point that in both the informal karaoke group and the music therapy improvisation group, Alex

would rarely interact with others in the group outside of a few polite words of acknowledgement. It was becoming apparent that Alex had a preference for attending groups only when and if he felt like it, no matter how much he might enjoy the activity when he did attend. His attendance at the improvisation group was inconsistent, and though we felt he would benefit more if he came regularly, some positive signs were beginning to appear. Among the three different groups, he was being seen almost every week in some type of music group. During the third month, Alex attended the improvisation group for two weeks in a row. Though he had again insisted on leaving the group right after he first arrived, the staff on the unit was able to convince him to return. While playing the drum set, Alex began playing in rhythm with the rest of the group, using the mounted toms and a cymbal. While he was playing, the therapist began to imitate his rhythm on another drum. Alex responded by making eye contact. This was the first time Alex had responded to the music of someone else in the group. On the way back to the unit Alex stated: “That was fun.” The following week Alex again requested to leave early. He appeared agitated and distracted, but agreed to stay and play the bass xylophone for part of the first improvisation before leaving. At the same time, Alex was attending the karaoke group. He sang several songs including “Sexual Healing” (M. Gaye), “Yesterday” (Beatles), “The One That You Love” (Air Supply), and “Paradise City” (Guns & Roses). Alex continued to display his knowledge of a wide variety of songs, singing them all fairly accurately without assistance from the therapist or the rest of those in attendance. At this point it was felt that Alex might enjoy the structured improvisation music group where familiar songs are utilized to help structure the improvisational experience. Alex attended his new music therapy group the first two weeks in a row and stayed the entire 50 minutes both times. At the beginning of the first group he did make a request to leave but he was able to stay without requesting again. He played the wind chimes while the group improvised to “Heaven’s Door” (B. Dylan). For the next song, Alex made a request for the group to play “Drive” by the Cars. He sang and played the bass xylophone. He sang the song well, with little prompting, in his usual low, soft voice. For the third and final song, Alex was able to play an organized steady beat on the drum set to the song “Can’t Help Falling in Love.” The next week Alex had a similar experience when he sang two more songs, including “Hotel California” (Eagles). It now appeared Alex was poised to become more consistently and actively involved in the music improvisation group. However, this did not eventuate. Alex’s music therapist had three weeks’ vacation scheduled and this, combined with Alex’s refusal to attend any groups, meant that he did not rejoin the music therapy group for another two months. This is a typical pattern for many chronically mentally ill patients. Just when they seem to be moving in a positive direction in a certain group, they suddenly stop attending. They are inconsistent, ambivalent, and unpredictable. It certainly did not help that the therapist went on vacation and disrupted a pattern of Alex beginning to attend more consistently. However, Alex had not been forming any particular interest in playing instruments. He always seemed more interested in singing. His anxiety level, when off the unit, was always fairly high and he often had complaints concerning various individuals in the music improvisation group, whether staff or peers. Though

he did not attend regularly or even stay for long when in the group, the music therapy groups were still the only groups Alex attended at all. Stage 3: A Fuller Voice During the next three months, Alex ended up attending the new music therapy structured improvisation group only three times out of the nine sessions held. However, he attended the karaoke group eight of the nine sessions. Alex would stay for most of each group, requested and sang several songs when he had the opportunity, and requested different songs almost every week. By now it was becoming quite clear that Alex was primarily interested in singing and more successful musically when doing so. The music therapy improvisation group known as “Interacting through Music,” was specifically designed to address Alex’s socials skills deficits as part of his Wellness and Recovery Plan (WRP) and was considered to be a treatment group. The karaoke group, on the other hand, is held in the evening, and was not considered to be a treatment group. It was known as an “Enrichment group.” It was this fun, informal singing group that had emerged to become Alex’s primary treatment. The karaoke group experience had several specific advantages. Alex was able to sing without the rest of the group improvising on instruments, hearing himself with fewer distractions. This more informal group was held on the unit and allowed Alex the option of leaving anytime he felt uncomfortable. Alex attended regularly and enjoyed singing the various songs he chose. There were a wide variety of songs for Alex to select from that allowed him to express a range of feelings. Being able to express these feelings through the songs appeared to be a significant emotional release for him--a release we felt was probably related to the trauma of losing his parents (Kaser, 1993). In the following months, Alex requested and sang 26 different songs in the 14 karaoke groups he attended. Of these 26 songs, 15 share some lyric content related to the expression of feelings of a lost love, experiencing the memory of a better time with a loved one, a desire to reunite or be together again, physical touching or holding a loved one, and missing something that is now gone (see Appendix A). There was no discussion or processing of Alex’s thoughts or feelings related to these songs. However, during his monthly treatment team review in September, Alex described how he had been thinking a lot about his mother. It was around the time of his mother’s death that Alex began using drugs and living on the street. His first criminal activities also began at that time. Perhaps Alex was now beginning to connect to and express some of these feelings. Our hope was that such expression would lead him more deeply into his emotional world, and help him build tolerance for being with others For the next month, Alex attended the Karaoke group twice. During one of the groups he sang “Sara” (Starship) for the first time. This song contains the lyrics: Go now, don’t look back, we’ve drawn the line, Move on, it’s no good to go back in time. I’ll never find another girl like you, For happy endings it takes two.

During this group it was noted that Alex made a rare direct verbal comment, using my first name and thanking me, something he rarely did. For the most part Alex avoided any type of verbal exchange with staff beyond initiating a request for something, complaining about another patient bothering him, or saying hello. During the karaoke group Alex rarely spoke to anyone beyond initiating his request for the song he wanted to sing. He would occasionally offer praise to someone after they finished singing their song. He would often come and go from the room during the group without commenting. Outside of group, Alex would almost always be the one to initiate any contact. If he was not in the mood he would usually wave staff away with a backhanded flick of his wrist and walk briskly away. His affect would often be stern and he might mutter something like “Don’t talk to me.” Alex would not attend the Karaoke group for the next three months. It was also around the Christmas holiday, often a time when individuals enjoy getting together with others to sing. The time of the group was changed to 3:30 p.m., and it was still up to Alex to decide if he wanted to go or not. It was not uncommon for Alex to be sleeping during the new group time, whereas he was almost always awake during 7.00 p.m. group time. It was at this time that Alex initiated a discussion in which he stated he would no longer be coming to the karaoke group. He added that he did not want to go because it was making him think about his mom and dad and this was bothering him. He recalled the last time he went into the room and, after he sat down and I tried to hand him one of the song lists, he waved me off and left the room. During this brief discussion Alex appeared more relaxed and he spoke directly, clearly and with good eye contact. A few weeks after this discussion Alex attended two more karaoke groups, both of which he attended briefly. He requested the song “Sara” again but did not stay to finish singing it. He appeared to struggle to find the melody and read the lyrics in time to the music. The final week Alex requested “Paradise City” by Guns & Roses. This song contains these lyrics: Take me home (oh, won’t you please take me home) Just an urchin livin’ under the street, I’m a hard case that’s tough to beat. I’m your charity case. Strapped in the chair of the city’s gas chamber, Why I’m here, I can’t quite remember. He said turn me around and take me back to the start, I must be losing my mind. Are you blind?! I’ve seen it all a million times. I want to go, I want to know, Oh, won’t you please take me home. A week later Alex learned that his CONREP has decided to accept him and the process for his release and return to community care was put into place. Alex appeared both very happy and apprehensive about the news. After, I asked him if this meant that he wouldn’t be

coming to the Karaoke group any longer. He looked at me sternly, flicked his hand back with a “don’t talk to me!” gesture, turned his back, and walked away. Summary Given the severity of Alex’s mental illness and the difficulty he had forming meaningful relationships in order to process his feelings, expressing himself musically through songs appeared to help him reduce the emotional tension and anxiety related to traumatic events of his past. The relief of tension and the possible processing of long held feelings were the beginning of Alex’s journey into recovery. Alex presented important challenges for the music therapist. He had a chronic mental illness that was not in total remission, and as a result he was not able to tolerate treatment for his Axis I Poly Substance Abuse problem. He was also resistant to getting involved in most of the therapy programs being offered that would address these barriers to discharge. However, Alex enjoyed music and had the opportunity to get involved in three separate groups, all of which had the potential to help him. Our therapeutic focus was initially placed on the music therapy improvisation group (interacting through music) where he had both the opportunity to play instruments and to sing with a small group of his peers. However, we soon learned that he could tolerate this level of interaction and expression. In the end, the music therapy group Alex preferred was technically not considered a treatment group in the Recovery Model. Despite this, Alex attended the karaoke group regularly and appeared to gain something very positive from this experience. As Alex had difficulty socializing with others and expressing himself verbally, the many songs he chose to sing gave him a way of expressing significant emotional events in his life. Mentally ill individuals like Alex, with anger management issues, have difficulty expressing feelings of anger, frustration, and anxiety effectively in order to prevent themselves from acting out aggressively. When given the opportunity to express feelings through the creative act of singing, Alex was able to manage his overall stress levels sufficiently to avoid being overwhelmed by anger when difficult circumstances arose on the unit. Alex’s work over the course of this 12-month time period attests to the difficulties of working with severely mentally ill persons. Alex was very resistant to change, and the instability of his mental state contributed to, or was expressed as, difficulties engaging in therapy. The karaoke group represented the first stage in this treatment process--one that would likely be very long term. While it was easy to see that Alex needed to work musically in a group in order to address his core problems, he was not ready to do so. Singing in the evenings allowed him time to build strength internally without the tension of having to work with others while doing so. References Alcoholics Anonymous World Services, Inc. (1976). Alcoholics Anonymous (3rd Ed.). New York: Alcoholics Anonymous World Services, Inc. Anthony, W. (1993). Recovery from mental illness: The guiding vision of the mental health service system in the 1990s. Psychological Rehabilitation Journal, 16(4), 11–24.

Deegan, P. E. (1988). Recovery: The lived experience of rehabilitation. Psychological Rehabilitation Journal, 11(4), 11–19. Kaser, V. (1993) Musical expressions of subconscious feelings: A clinical perspective. Music Therapy Perspectives, 11(1), 16. Magler, D., Tavano, P., Gerard T. & Baber, D. (2001, October 1-8). The recovery model: A conceptual implementation plan. Contra Costa County Mental Health Recovery Task Force. Schneck, D. & Berger, D. (2006). The Music Effect: Music Physiology and Clinical Applications. Philadelphia, PA: Jessica Kingsley Publishers. ____________________________________ 1 DSM IV-R 2 The Mentally Disordered Offender (MDO) law applies only to prisoners whose crimes were committed on or after January 1, 1986. The statutes governing the MDO program are contained in Penal Code (PC) Sections 2960-2981. The law requires that a prisoner who meets six specific MDO criteria shall be ordered by the Board of Prison Terms (BPT) to be treated by the Department of Mental Health (DMH) as a condition of parole. An MDO patient is a parolee who meets the criteria and is paroled on the condition that he or she receives DMH treatment. 3 There are 11 separate areas of treatment, including Psychiatric Symptoms, Social Skill development, Anger Management and Impulsive Behavior, and Substance Abuse. All groups, including the music therapy treatment groups, are designed to address a specific focus of treatment. The treatment team can then select from a variety of groups provided by the various disciplines to address each focus. Groups provided for this focus are also designed to address the level of motivation or treatment readiness of the individuals and are referred to as “The Stage of Change.” 4 Conditional Release Program. A County mental health system in California where patients, who are accepted, receive follow-up care in the county where they committed their crime. 5 Anger Management; Mental Illness Awareness and Wellness; Recovery Action Planning (relapse prevention and community reentry group); substance abuse treatment.

Appendix A 1. “Caribbean Queen” B. Ocean, Now we’re sharing the same dream, and our hearts they beat as one no more love on the run 2. “One That You love” Air Supply Tell me we can stay Hold me in your arms for just another day 3. “Yesterday” Beatles Why she had to go I don’t know, she wouldn’t say, Now I long for yesterday, Now I need a place to hide away, Oh, I believe in yesterday 4. “We’ve Only Just Begun” Carpenters We start our walking, Talking it over just the two of us, Working together day to day, Together 5. “Sweet Child O Mine” Guns N Roses She’s got a smile that it seems to me, Reminds me of my childhood memories, Where everything, Was as fresh as the bright blue sky, Now and then when I see her face, She takes me away to that special place, And if I’d stare too long, I’d probably break down and cry 6. “Groovy Kind of Love” Phil Collins When I’m feeling blue, all I have to do, Is take a look at you, Then Im not so blue, When you’re close to me, I can feel your heart beat, I can hear you breathing near my ear. When I’m in your arms, nothing seems to matter, My whole world could shatter, I don’t care 7. “Make it With You” Bread And if I chose the one I’d like to help me through, I’d like to make it with you. I really think that we can make it girl 8. “Dust in the Wind” Kansas I close my eyes, only for a moment, and the moments gone, All my dreams, pass before my eyes, Nothing lasts forever, It slips away 9. “Born to be My Baby” Bon Jovi I don’t need nothing when I’m by your side, We got something that’ll never die, So Hold me close better hold on tight, If we stand side by side, There’s a chance we’ll get by, And I’ll know that you’ll be live, In my heart till the day that I

die, My heart beat like a drum, one to one, And I’ll never let go cause, There’s something I know deep inside 10. “Thriller” M. Jackson They’re out to get you, there’s demons closing in on every side, Now is the time for you and I to cuddle close together, All thru the night I’ll save you from the terror on the screen 11. “Yesterday Once More” Carpenters Lookin’ back on how it was, In years gone by, And The good Times that I had, Makes today seem rather sad, So much has changed. I’d memorize each word Those old Melodies still sound good to me. All my best memories come back clearly to me 12. “Crazy for You” Madonna Two by Two their bodies become one. You’re so close but still a world away, What I’m dying to say is that. Im crazy for you, Touch me once more, Soon we two are standing still in time 13. “I Don’t Want to Live Without You” Foreigner I want you now and forever, close to me, I’m longing for the day, hoping that you will promise to be mine and never go away, I don’t want to live without you, I could never live without you, You see I’m lost without your love 14. “Don’t Fear the Reaper” BOC Love of two is one, Here but now they’re gone, Came the last night of sadness and it was clear she couldn’t go on, And she ran to him, They looked backward and said goodbye, She had taken his hand, Come on Baby 15. “All Out of Love” Air Supply I want you to come back and carry me home, Away from this long lonely night, I’m reaching for you, There’s no easy way, it gets harder each day. Please love me or I’ll be gone

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

CASE FIVE The Significance of Triadic Structures in Patients Undergoing Therapy for Psychosis in a Psychiatric Ward Susanne Metzner Abstract The significance of triadic structures is shown with the example of a young schizophrenic patient undergoing psychodynamic therapeutic treatment. The author presents a triadic structure model that serves as the basis for theoretically reflecting upon a multilateral transference situation in a multidisciplinary treatment team of a psychiatric ward. Introduction In psychodynamic psychiatry, music therapy is one component of the clinical treatment concept fitted to the personal needs of each patient. This coordination occurs in the interplay between what the multidisciplinary treatment team offers as therapy, on the one hand, and the use of this by the patient who shapes his or her therapeutic environment and forms therapeutic relationships, on the other hand. Therapy, following a psychodynamic approach, pays special attention to this interrelationship and the resulting social network in the ward, because it is seen as a reenactment, which provides insight into the intrapsychic and interpersonal real-life situation of a patient. An understanding of this can help to locate and activate resources as well as to treat disorders. Dyadic and triadic structures comprise the smallest components of this complex social network. In this chapter, I will focus on the significance of triadic structures in the inpatient treatment of individuals with psychotic disorders and illustrate these structures with the help of a case vignette. My presentation begins with the description of my first encounter with this patient. This is followed by a theoretical introduction to the triadic structure model, which I have developed. Finally, I will analyze a significant musical scene, taken from individual music therapy with this patient in the context of the hospital treatment, in relationship to the biography and present life circumstances of the patient and the psychotic symptomatology. My descriptions and interpretations, which are of a rather subjective nature, are written in italics. Background Material Casuistry: My First Encounter with Ms. K.

I make an appointment with Ms. K., a 23-year-old, much younger and quite girlish-looking patient with long blond hair, for Friday, which I write down for her on a note. Ten days ago she was admitted to our psychiatric ward in an acute psychotic condition. She had the delusion that her father had been shot by her ex-boyfriend with whom she had broken up a couple of weeks before. During the first few days after admittance she was in a condition best described by the old-fashioned term “mentally deranged.” For four or five days now she has been more responsive with the help of neuroleptic treatment. In the meantime, she takes part in the day-to-day routine of the ward. The patient is now offered further psychotherapeutic help through individual music therapy. The fact that I have the time to take on another patient fits nicely with my spontaneous interest in this young woman. As I enter the patient’s room on the Friday in question, her mother quickly moves away from her and says: “Oh, music therapy, I already thought that was some kind of mistake.” Everything goes so fast that I don’t even have time to say hello and introduce myself. It seems to me that the patient leaps up from her bed very suddenly in order to follow me to the music therapy room, which is located on the first floor of the building. I am worried about her circulation because she looks very pale. However, Ms. K. says that everything is okay and starts to walk off. She hesitates at every door through which we must pass. At the door to the ward she says that this must be a mistake, she doesn’t want any music therapy after all. I am surprised, pause for a moment, and wait for the patient to move either in one or the other direction. Forward or backward? She goes forward and comes with me to the music therapy room. In this first session, I confine myself to giving the patient information about music therapy. It seems to me that this rather objective level of communication gives the best support to this hesitant patient who is still in danger of regressing. Although I act very cautiously, the situation between us remains depressingly nontransparent. The sluggishness of her verbal, as well as gestural-facial, reactions makes me feel as if I were in a dense fog which swallows up everything. The only thing that is clear, in the end, is the patient’s declaration that she does not want any further treatment other than medication. I tell her that I respect this decision for the moment and that I will ask her next week again in case she changes her mind in the meantime. So there doesn’t seem to be anything left to discuss, and it seems to be time to part. But all of a sudden it is difficult to end the session. The patient finds it difficult to part? To detach herself…and I have the feeling as if I have to break off something by force. After the session, I become aware of a very unpleasant, all-embracing feeling, which I cannot put into words. It is not easy to get it out of my thoughts. At the beginning of the following week, I want to address the music therapy question once more, as promised. However, during the doctor’s rounds the patient is so sleepy that I am not able to reach her on this occasion, nor am I able to do so on two further attempts. A few days later, my student, doing practical training, runs into the patient’s father in the ward by chance. He mistakenly takes her to be the responsible

music therapist and asks her about music therapy for his daughter. My trainee doesn’t know how to react because she is not informed about the current state and, in particular, because she is interested in conducting the treatment herself. She puts him off until later, which does not leave him in too happy a state. Nothing seems to be alright anymore. Nobody knows who wants what from whom, and I have the desperate wish to be able to start over from the beginning. At this stage of development Ms. K. is willing to begin music therapy. Where do we meet if we do not meet? With this ambiguous question, Deuter (1995) pinpoints the predicament which seems to be so typical of the treatment of psychotic patients. This does not only concern the meeting between patient and therapist but also a disturbance in interpersonal contact, in which the concerned persons either are unable to reach each other on an emotional level or meet each other in a state of high vulnerability, which leads to fear and defense reactions. In our case, this concerned more than two persons, for example, different members of the treatment team and/or members of the family. In not all cases are the latter involved as strongly as in the case of Ms. K. From her family we obtained a wealth of information--some of it was given intentionally and some unintentionally--about the relationship structures in the family, to which I will refer later. This is not typical of our therapeutic work: What happens more often is that our psychodynamic understanding, as well as what we do in therapy must rest solely upon the conclusions we draw from the reenactments in the ward and our own countertransferences. Treatment Excursus: On Multidisciplinary Teamwork In the multidisciplinary, psychodynamic treatment of psychiatric patients in general, and psychotic patients in particular, each team member involved in the treatment relates not only to the patient concerned, but also to the other team members who all have equal rights. Thus, multidisciplinary teamwork is not simply based upon the sum of different therapeutic processes. Rather, it involves the use of a specific method which places particular emphasis on working on, and with, the relationships of the concerned staff. Although I let the term “equal rights” slip into the above formulation in passing, I am not denying the fact that there is a hierarchical structure that has evolved over time in the hospital workplace. Neither do I want to deny that there are differences in qualifications and competencies between staff members. Multidisciplinary teamwork in a psychodynamic treatment concept, where members enjoy equal rights, means that one must be willing to reflect upon the relations within the team and, among other things, to think about one’s own use of power. Therefore, the interdisciplinary treatment of patients in a psychiatric hospital is more than the sum of various therapeutic processes. It encompasses the work on and with the relations of the professional staff. Thus, the mutual task is to examine the emerging constellation of multilateral relations with the patient. In this connection, attention is paid not only to the transference relations between the respective patient and the individual team

members, but also to the relations that are transferred to other team members. What is so special about this perspective is that whatever happens in the team, or between different therapists, during treatment is taken into account to the same extent as whatever happens during the different therapeutic sessions. To formulate this in somewhat stronger terms, this means that the team lets the patient have an influence on the relations between the team members. From what has been said so far, it follows that I, as a clinical music therapist, relate not only to the patient, but also to my colleagues who are involved in the treatment of this patient. In this process, I pay close attention to how our professional relationships are influenced by the mutual treatment of a patient. This approach is based upon a triadic structure model, which I have developed for the systematic analysis of multiperson relationships and for the formulation of hypotheses about possibly disturbed triadic relationship experiences of a patient, who-through his or her reenactments--asks us to help him or her come to terms with these problematic experiences. The Structure of the Triad In the attempt to examine the structure of the triad, the first important thing to do is to free oneself from thinking in dyads, for example, considering a triad either merely a dyad plus another interaction partner (AB+C) or a series of three dyads (AB, BC, CA). Rather, a triad has a structure that is produced by triadic interaction forms. Although quite a large number of such interaction forms exist, they can be reduced to three triadic interaction modes. These three interaction modes together make up the internal structure of the triad. Thus, triangulation-understood as both an intrapsychic and interpersonal triad-forming process--does not take place by extending a dyad by a third interaction partner nor by joining three dyads, but in multiple interrelations between three interaction partners. In the following section, I will describe the three main triadic interaction modes in more detail. Triadic Interaction Modes Triadic Interaction Mode 1: Each Interaction Partner Relates to Two Objects. This interaction mode is acquired during early childhood and consists of various elements. Prerequisite for this interaction mode is that the subject is able to relate to two distinguishable objects. Already, a newborn baby is able to differentiate between his or her mother and other persons. As if to express this relatedness, the subject uses eye movements: This is connected with casting one’s eyes in the direction of one person and looking away from the other, with an alternation between foreground and background. In the course of time, representations are formed on the basis of the experience that an object, which momentarily is not in one’s field of vision, has not really disappeared. This interaction mode is different when, for example, the voice or--at a later point--words are used. In his or her imagination a subject turns to two or more objects simultaneously and connects them, joins them together. A conversation between three individuals is a highly complex phenomenon, because each person relates to both of the others, looks and words between the involved parties wander back and forth, overlap with each

other, and sometimes proceed in opposite directions. The basis for this is a psychic structure which comprises the “either-or” and the “both...as well as....” Triadic Interaction Mode II: Always Two Objects Together Relate to a Third One. This statement expands upon what has already been said above and describes a triadic interaction mode in which the elements’ mutuality (self with other) and counterposition (self versus other) are combined with one another. The experience of mutuality includes the subjective experience of the individual that another person shares the contents of his or her feelings. Stern (1986, p. 179) believes that the first signs of this ability in the development of the child become evident starting in the seventh month. If an individual is certain that the other person feels, thinks, or acts the same as him or her at a given moment, then he or she experiences themselves as a perceptual unity and the “we” as such a unity. In a triadic interaction, two who are united together in a “we” relate to a third. They confront a third with their mutuality who, alone, from this opposite position-merely by his or her presence--shapes the interaction process and influences the mutuality of the two others. In a well functioning triad, the mutuality of two against a third party is not structurally fixed. However, changes do not occur very quickly because this second interaction mode needs some time to become established. It has a certain tendency to perpetuate itself, as shown by the results of social research. Triadic Interaction Mode III: Each of the Involved Relates to the Relation Between the Two Others. The statement made here refers to a triadic interaction mode, which was already mentioned before in connection with the influence of a third on the mutuality of two others. This is now extended and put into more precise terms, because the relation between two encompasses more than the aspect of mutuality. The kind of relationship between two objects influences the position that a third party can take toward it. Abelin (1975) describes that the young child initially experiences him or herself as being between the parents and internalizes the relationship between the parents in the course of individuation. If the relationship between two persons is disturbed, then a third person has only limited possibilities to take a position toward it. The interaction attempts he or she undertakes, which do not meet with a response, must be defended against. Consequently, such forms of interaction appear as a substitute, which are geared toward maintaining the defense reaction. On the Developmental Psychological Prerequisites Father, mother, and child--these three terms first of all indicate biologically based positions in a triangle. Triad and dyad develop from originally biological basic prototypes of relationships between parents and children. The formation of a dyad is preceded by the physical connectedness of mother and child during pregnancy. The triad, on the other hand, has its origin in the act of procreation, which marks the beginning of parenthood for a man and a woman. Before a child is born, structural preforms of relationships between parents and child already exist. However, the individual developmental course of these three positions is inextricably linked with unconscious fantasies, prescribed role expectations, and socially determined evaluations. Triadic structures are also relevant if a child does not grow up in the traditional nuclear family, which is more common nowadays.

Whereas the parents or, as the case may be, the respective adult significant others use their ability of triangulation in their relation to the child right from the start, the child develops this capacity only in the course of his or her development. This means that the child grows into already existing structures. In this process, dyadic and triadic structures become superimposed and influence one another. Already during the first year of life, the developing child finds out how it is to experience him or herself in relation to two objects which have something to do with each other. In the course of the further development of self and object representations (via transitional objects, Winnicott, 1971), the child also experiences that a third person relates to the relationship between him or her and another person. At that moment, when he or she understands what it means to have the feeling “both of us,” the child also recognizes the dyad’s boundary. Consequently, the development of the dyadic relationship depends upon this close interaction process with a third person. In other words: The existence and relatedness of this third person, which has a counter position to the dyad or which surrounds the dyad from the start, induces the development of interpersonal abilities in the dyad. This approach has a direct influence on the concept of the so-called “early disorder” and its treatment. In the case of a disorder which is rooted in disturbed early relationships, the influence of the mother cannot be considered as a singular force, but must be seen and analyzed in the context of the triad. Triadic Disorders in the Development of Schizophrenic Illness From the viewpoint of the psychology of self and object relations, psychotic disorders can point back to deficit situations and disturbed interactions experienced very early in life. The clinical manifestation almost always indicates the inability to triangulate, which stems from a fragmentation of the triad or a specific form of splitting of the triad. It is not always the case that the family situation is extremely burdened, marked by deficits, or perhaps even hopeless, in which the child has been neglected with respect to his or her mental, physical, or social wellbeing. Even in the seemingly intact families of schizophrenic patients, one can very often find a triadic structure characterized by a relationship between the parents which left no room for the child. The parents live in a relationship in which they are not able to mutually relate to the child. One example is a relationship characterized by extreme dependency: If both parents are constantly fighting with each other, they do not relate to two objects at a time, rather, they ignore the needs of the child. If they live in a symbiotic relationship, then they reciprocally gratify their dependency needs and shift their hostile impulses from the relationship between themselves to the one with the child. Under such circumstances, the development of the dyadic mother-child, and the respective father-child, relationship is disturbed as well. The triadic structure model provides information about the extent of the disturbance. The child is not able to relate to two objects either because the objects are not sufficiently distinguishable or because they are incompatible. The parent, in most cases both of them, does not relate to two objects, namely the other parent and child. Moreover, the parents do not mutually relate to the child. On the other hand, the child cannot experience a mutual relatedness with one parent toward the other parent, because neither parent would be able to form a mutual relationship with the child without seriously threatening the adult relationship.

As a consequence, the child cannot relate to a (mature) parental relationship. He or she is forced to internalize a parental relationship which is characterized by dependency and open or latent destructiveness. Sometimes these pathological structures in the primary family become virulent only in the further course of development of the child. I am talking about that point in time when the main focus no longer is solely on the needs of the child and their satisfaction (as during the first months of life), but when the child’s own will starts to emerge--when he or she has to reconcile his or her grandiose ambitions with the perceived limitations of the real world, both his or her own and those of his or her objects. The stubborn child, who in the crisis of the “rapprochement-phase” (Mahler, 1975) is clinging at one time and domineering at another, no longer meets the ideals of his or her parents. This, in turn, taxes their ability to deal with ambiguous feelings toward their child. The less successful the parents are in smoothing out these conflicts in their relationship with one another and maintaining their confidence in the mental healthiness of their child, the deeper the parents get into a crisis with their child. If they are not able to accept the narcissistic defeat, and bear the disappointment of not having a perfect child and not being able to create a perfect world for him or her, interpersonal constellations evolve in which the integration of omnipotence and powerlessness, and the development of more mature object relations, are blocked. Especially if the relationship between the two parents is dominated by the myth that aggression is destructive, retaliation is unconsciously demanded of the child. A child in this position draws the conclusion that his or her developmental needs are destructive and that he or she is responsible for preventing the emotional breakdown of his or her parents by attempting to compensate for the retaliation wishes (Benjamin, 1990). In extreme cases, the child needs a justification for his or her mere existence. The failure of the process of individuation in early childhood is reactivated during adolescence, when the already existing psychic structures are reorganized once more. In particular, events such as final examinations, moving away from home, and similar experiences make great demands on mental stability, which can trigger the initial manifestation of a psychosis. Casuistry: Multidisciplinary Psychodynamic Therapy of Triadic Disorders In a psychodynamic approach to therapy, the aim is to reconstruct the disturbances that are responsible for the symptoms and reenactments of the patient and to restore interaction forms. If, in this process, triadic interaction forms are also considered, a certain therapeutic perspective will result, in which there is room for a third party in one’s imagination, in other words, for persons who also have contact to the patient. This means, as already explained above, the willingness to closely examine the relationships between the involved individuals and to also consider one’s own emotional feelings in reference to the third party in the countertransference analysis. With help of the example of Ms. K.’s treatment, I will show which position I, as music therapist, took in the social network which the patient set up around herself, and illustrate what value music therapeutic material has for understanding the patient. But first I must

mention the fact that Ms. K. broke off the treatment so that it was not possible to bring therapy to a satisfactory close. A Scene from the Music Therapeutic Process with Ms. K. In music therapy, I work with free improvisation and verbal discussion. The only therapy session during which we played music was the third one (of a total of five). At that time I made the following notes: (...) In the music therapy room we soon start playing. A few plucked notes on a one-string Indian instrument, the gopiphant, come from the patient. After a while I find a heartbeat rhythm on a low register clave and am inwardly happy about it, because it provides such an unobtrusive support for her and for me. But suddenly the tables are turned, and I have the feeling that the heartbeat is dissolving. It is both an unpleasant and inexplicable feeling. How can a heartbeat be dissolving? Then, in our mutual playing I have the feeling as if a chick were hatching out of its egg. Mother hen answers from outside the eggshell. But the short dialogues quickly cease. Afterward, the patient tells me that at this moment she was afraid of doing something wrong. Ms. K. tries out some other string instruments and eventually returns to the gopiphant. She has not yet found out how to modulate the notes on the single string. I am on the cello. A soft, enchanting, but icy music emerges, which I find fascinating…like frost patterns in a window. If one assumes that schizophrenic illness is the result of a dyadic relationship disturbance, then one would not spontaneously think that a triadic disturbance comes to light in the musical interactions described above. But the expression “the heartbeat gives support to her and to me” implies that there is a third entity which could provide support to both, if only it had not dissolved. The whole thing becomes clearer if one imagines that the expressions refer to an early developmental stage, in which mature representations have not yet been formed and the “other” is perceived not so much as an object than a living substance. This living substance is disintegrated. In other words, it is as if the emerging relatedness, or even the core relatedness, as described by Stern (1986), was being dissolved once more. After this, it seems for a while that patient and therapist go on in a more reassuring manner with this interaction between unhatched chick and hen. But only for a short period, then this attempt to get in touch with each other fails as well: The patient develops fear. What exactly could be so threatening in this scene? Apparently the eggshell does not provide any protection for further development. Further, it is not a symbol for the stabilizing third entity in the relationship between hen and chick. Rather, it is the fear of doing something wrong which at least saves the fragile self from dissolving or from being disintegrated. The price which has to be paid for keeping up the self-feeling is that the interaction, and its further development, freeze, in other words, come to a halt. Despite this freezing, I, as a therapist, have the feeling that I am on the right track in the therapy with this patient. My colleagues share this feeling. The assistant medical director and

the ward doctor have family discussions together with the patient and both of her parents. This triggers numerous dynamics in the family situation. Many members of the nursing staff devote a lot of attention to the patient. One staff member helps the patient write a curriculum vitae consisting of several pages. In art therapy, a number of interesting works are produced that provide valuable information, such as a fragile, weary-looking chicken made of clay and a picture of the patient’s name, hardly discernible from a background of curlicues and floral patterns of creeping and climbing plants. All staff members had a special interest in the patient, all had “adopted” her, and all had the feeling that they were doing everything really well. It would have been only natural for rivalry to come up in our team. But this did not happen; we were hardly aware of one another. A relationship situation developed in which rivalry was completely missing and in which we were more or less content with filing away our detailed reports in the records without exchanging any information with one another. We did not personally meet with each other, neither in the concrete nor in the figurative sense. The knowledge of the patient’s biography and the careful analysis of the therapeutic scenes helped us to understand the reenactment of the patient as well as our countertransferences. The Patient’s Biography--Facts and Interpretations Ms. K. was an adopted child. Her birthmother was 20 years old and single when she became pregnant. She only noticed that she was expecting a child when she was seven months into the pregnancy. What a diffuse body feeling this woman must have had. The only explanation is that she must have misinterpreted the movements of the baby as digestion problems. Referring back to the music therapeutic scene, one can say, “The chick in the egg could give as many signs as it wanted, these expressions of its existence were simply misunderstood.” The birthmother was pressured by her mother to give the child up for adoption because she had not yet finished her vocational training. One week after birth, the baby was already adopted by the K. family, which is unusually fast under German law. Mr. and Ms. K., both teachers, already had a biological son and wanted to adopt another child because there are so many unwanted children in the world. The parallels to our behavior in the treatment team are obvious. On the basis of these countertransferences one could suppose that the adoptive parents were driven by the desire to improve the fate of another person with all their might, and so to become the better parents. The child was difficult right from the start. As a baby she cried for hours, and it was not possible to soothe her. As soon as she was able to talk, she asked her parents if they really loved her. She was still a bed wetter as a schoolgirl. In spite of all these difficulties, her parents did not stop trying to give her their best and also to seek therapeutic help. Everything indicates that the parents tried as hard as they could to reject the narcissistic defeat in connection with the fact that they were not able to create a perfect world for their child. So, the ambiguous feelings--more than understandable for parents in this situation--had to be split off. It seems that this inevitably resulted in the parents not being able to give their daughter one thing, namely a secure feeling of

belonging. She saw her existence altogether as a big mistake, and as a little girl she never ceased asking her parents if they truly loved her. This must have hurt the parents very deeply because they really loved this child. But in view of their ideals of good adoptive parents, they could not allow themselves to be “hit” by this question. The little girl was not able to develop a feeling for the reality of this parental love and had to feel guilty because of this. After finishing school, our patient contacted the adoption agency in order to obtain the address of her birthmother, which she received. She met her birthmother and hoped to find a good friend in her. However, she was forced to realize that her birthmother saw her as the lost daughter and--much too late--tried to bind her too closely to herself. Ms. K. wanted to get out of this situation, but she was afraid of hurting this mother and so she made no decisions--neither for nor against this relationship. This was the situation at the time of treatment. However, almost two more years passed before the first manifestation of psychosis. During this period, the patient had started to study teaching in order to take up the same profession as her parents. She had also moved into her own apartment, but she did not manage very well on her own, became more and more isolated, and neglected herself. Discussion and Conclusions I already mentioned that a striking feature of the multidisciplinary treatment of Ms. K. was that no rivalry existed. In discussions with the family it became apparent that rivalry was also missing in the relationship between the adoptive parents. They gave the impression of being a harmonious married couple, who not only had the same occupation, but also had dedicated themselves to the same goal of becoming adoptive parents. From the perspective of another person they merged to form one whole, in which there was no room for anything that was different. Especially for the adoptive daughter it must have been difficult to find herself as a different person. On the one hand, she was the planned baby of the adoptive parents; on the other hand, she had originally not been expected by her birthmother, who was not even aware of the fact that she had started to exist, and was exceptionally fast in giving her consent to the adoption. Therefore, the adoptive parents had all the more reason to feel that they were the better parents. From the beginning, doubts, contradictions, and a latent rivalry between birth and adoptive parents hovered over the child’s existence. All of this did not get any more concrete when the now grown-up daughter expressed her wish to contact her birthmother. The adoptive parents did not only approve of this undertaking, they even arranged to meet with the birthmother themselves. They described this as being a harmonious meeting, but this harmony seems to have been icy. In this, we saw the repeated failure of the patient to discover the reality of the relationships. As in the music therapy session, the dialogue ceased, and everything remained undecided. The relations in the parent generation did not give the teenage daughter the support she needed--they did not serve as a springboard from which she could take the crucial step toward individuation. It was not possible for her to create her own individual life, the same as in music therapy where she did not find out that it was possible to modulate the note on the string of the gopiphant.

In a situation characterized by separation, namely breaking up with her boyfriend, the patient decompensated psychotically. Various things come together in the delusion that her exboyfriend had shot her father: the desperate search for the missing father, the desire to get out of an unresolvable relationship situation with the help of a third person, and the latent fear of her own destructive anger. This is how far we had gotten in understanding the psychodynamics of the patient. We started to question the one-sided success of the pharmacological and sociotherapeutic treatment and to exchange our thoughts about the interaction process in the team. This evoked the resistance of the patient. To get out of this dilemma she followed the strategy that attack is the best means of defense. After two and a half months she was well enough to have herself discharged from the hospital against the doctor’s advice. She argued that it would be better for her to continue therapy in a day clinic. Unfortunately, she never appeared there. Although I referred to this end of therapy before as the breaking off of treatment, I would like to suggest a different interpretation, although it cannot be confirmed without the help of the patient and information about her further development. The analysis work in the team, which had just started but was quickly increasing in intensity, brought the reality of relations into play, so that the patient was able to use them as a springboard to find her own way. We, who had been used by her as parent figures, were simply left behind together with our relations. References Abelin, E. L. (1975). “Some Further Observations and Comments on the Earliest Role of the Father,” International Journal of Psychoanalysis, 293-302. Benjamin, J. (1990/1993). Die Fesseln der Liebe. Frankfurt, Germany: Fischer TB-Verlag. Buchholz, M. B. (1993). Dreiecksgeschichten. Göttingen, Germany: Vandenhoek & Rupprecht. Deuter, M. (1995). Beziehungsformen in der musiktherapeutischen Arbeit mit psychotischen Patienten. Unveröffentl. Manuskript, 22 Seiten. Heltzel, R. (1996). Der psychoanalytische Beitrag zur stationär-psychiatrischen Versorgung, Vortrag vom 27.1.1996 in Berlin, unveröffentl. Manuskript. Lempa, Günther (1995). “Zur psychoanalytischen Behandlungstechnik bei schizophrenen Psychosen.” Forum der Psychoanalyse 11, 133-149. Mahler, M. S., Pine, F., & Bergman, A. (1975/1996). Die psychische Geburt des Menschen. Frankfurt, Germany: Fischer TB-Verlag. Metzner, S. (1999). Tabu und Turbulenz. Musiktherapie mit psychiatrischen Patienten. Göttingen, Germany: Vandenhoeck & Ruprecht. Stern, D. N. (1986/1992). Die Lebenserfahrung des Säuglings. Stuttgart, Germany: Klett-Cotta. Winnicott, D. W. (1971/1985). Vom Spiel zur Kreativität. Third edition. Stuttgart, Germany: Klett-Cotta. Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH: Barcelona Publishers.

CASE SIX

Group Improvisation Therapy: The Experience of One Man with Schizophrenia Helen Odell Miller Abstract This case describes the involvement in group therapy of Brian, a 40-year-old man with schizophrenia. A psychoanalytically informed approach is taken to group work using interactive musical improvisation and verbal discussion. Music therapy provided Brian with a way that he could gradually begin to relate more to people around him and the environment in general. The case outlines the struggle of long-term work with small changes gradually apparent, within an initially negative transference relationship fraught with criticism and conflict. Acknowledgement I would like to thank members of the group and Brian in particular for all I have learned. I would also like to express gratitude to my colleagues and supervisors with whom I have discussed this work. Setting and Approach Brian attends a day clinic for people with a variety of psychiatric problems associated with long-term mental illness. The clinic provides a broad program of individual and group treatments, including medical, social and psychotherapeutic services (i.e., music and art therapies, problem-solving, life skills, vocational rehabilitation, etc.). The staff forms a multidisciplinary team that operates a case management system. I attend the clinic once a week to run a music therapy group and liaise with the team. Criteria for referral to the music therapy group are broad, and over the years, the staff members have recognized, increasingly, the particular problems people have which the group can help. These problems are related to interpersonal and intrapersonal difficulties rather than diagnosis, although diagnosis is a consideration in assessment. Within the clinic, I have said to clients and staff that the group is for those who feel they can benefit by using music as a means towards coping with various problems, and who do not find verbal ways of doing this easy or appropriate. Referrals are considered at any time, but the group is semi-closed in that no visitors are allowed, and membership is constant within this slow, ongoing referral system. That is, people cannot drop in, and for all new members, a degree of preparation by members already in the group is necessary. Assessment for participation in the group is by interview with me. The group runs at the same time each week for one hour, with me as sole music therapist. Current members of the group are:

Dorothy: A 57-year-old woman with diagnoses of severe depression and self-mutilation, who has been in the group for 61 weeks. Reasons for referral by the charge nurse were: to provide long-term support and a place to deal with suicidal and lonely feelings through nonverbal media. Brian: A 41-year-old man with diagnoses of schizophrenia and personality disorder. Reasons for referral by the psychologist were that he spends nearly all of his time on his own, hardly communicating in groups at all. He has also expressed an interest in the music therapy group, which he has never expressed for any other type of group. Peter: A 31-year-old man with a diagnosis of schizophrenia, who has been in the group for 43 weeks. Reasons for referral by the social worker were that people do not understand him, and he does not know how to make them do so. Hopefully, through music he can express his feelings about the past, present and future. Anthea: A 29-year-old woman with diagnoses of hysteria, M.E. (Myalgicencephalomye Utis), depression and personality disorder, who has been in the group for 15 weeks. Reasons for referral by the occupational therapist were to help her deal with expression of and understanding of feelings constructively, through a medium she finds acceptable. Stephen: A 45-year-old man with a diagnosis of manic depression, who has been in the group for 20 weeks. He was referred by the psychologist, psychiatrist, and music therapist. They feel that music therapy would be useful for containing anxiety he feels with others in a group and expression of aggressive feelings. He also needs ongoing therapy to provide a secure place for him to be understood, while also understanding some of his depressive feelings. Hopefully, the group will prevent recurrent patterns of admissions, together with a whole discharge package (e.g., sheltered work). Firm boundaries are kept for the group, and I do not see the clients intentionally outside of it. Contact with other staff in sheltered housing where some clients live happens if necessary, but with the client’s knowledge. Theoretical Orientation A detailed description of method and rationale for my approach to group work can be found in a published article (Odell, 1988). For purposes of this case, a summary of the main points will be given. The group runs using a psychodynamic model, which can be described as “analytically informed music therapy.” This approach involves live interactive methods using improvisation as the focus for making relationships with clients that may reflect other relationships in their lives, and thus enable an awareness of difficulties that may be taking place. A wide variety of instruments are available for the improvisations, including tuned and untuned percussion, violin and piano, all of which are set up in the music therapy room before the group begins.

It is important to recognize that the way clients improvise may reflect their current states, and can lead to an understanding of changes which may need to take place internally. Freud, and subsequently other dynamic therapists such as DeMare and Kreeger (1974), learned that catharsis is not enough. Lieberman, Yalom and Miles (1973) found that catharsis is not related to outcome, and that we must remember that often we cannot observe more intensely significant events. I make this point because I feel that some people misunderstand the music therapist’s use of free improvisation, thinking that the aim is to encourage catharsis. I believe that the important element in this way of working is to help clients understand more about themselves, and gain insight through the music therapy improvisation group process. This process can often take time, and inner changes may not at first be apparent to client or therapist. An intense experience of the here-and-now is provided by a music therapy group. Interactions are played out often within improvisations, and it is fundamental to this way of working that the therapist gets hold of this and does not avoid issues s/he perceives or hears. It is also important not to allow the activity of music-making to override the group therapy process in a way that would encourage defenses and avoidance of interpretation. I have heard music therapists in Britain dismiss interpretation and psychoanalytic concepts as too rooted in the past and not forward-looking towards therapeutic change. However, I would suggest that group music therapy is important. Approached in a confident way, free improvisation in a group provides an intense experience for transference and countertransference relationships to be dealt with between group members as well as with the therapist. In addition, feelings of members about the way others play and their degree of skill provide material which can be used by the music therapist to understand more about the group and its members. I also believe that the parental role of the therapist is one to be used, particularly in terms of carefully offering or not offering one’s own music. For example, I have found that in some cases, my harmonic input from the piano can inhibit clients from being able to work through their own problems. However, there are times when just the opposite is true and the basis for someone exploring a problem is that a musical dialogue with a supportive or more dominant role taken by the therapist is necessary. Supervision is essential for this kind of work. I see my role as making sense of whatever material comes up in the music, and in other ways, in terms of the group members and therapist. For example, in his first group experience. Brian asked: “Is it teaching or playing?” Then he tried to get me to play piano to the group because I am the “expert.” When I refused to play as he requested, he tried to teach one group member, Jane, to play a tune, as if she were his pupil. Thus, my refusal to take the role of “expert playing to the group” enabled him to interact with others, and to take on a controlling role himself. Afterwards, we looked at this in terms of something which he finds a need to do all the time. Later, he smoked, breaking one of the boundaries. He understood this in terms of “avoidance of discomfort.” Finally, Brian allowed a group improvisation to develop, and curbed his urge to both smoke and control the group with his tunes. He felt pleased with himself, and surprised at what came out musically. Jane began talking of isolation, and Brian became more able to focus on his issues in relation to me and the group, because his music was understood. My theory is that if I had become the teacher or taken control, this could have kept the group in its paralyzed beginning stage rather than allowing the group to begin its own process.

Background Information Brian was born in 1950 and is the second of three boys. Little has been learned from Brian about his early childhood, and he has always been reticent to discuss his family and personal history. What is known will be summarized here. Brian was diagnosed with schizophrenia in 1973. At the time he was living in the South West of England, where he was attending a university but failed to complete the degree. All three boys went to university. Brian’s father was a major in the army who died of a stroke in 1981; his mother is 74 years old, and well. Owing to his father’s profession, the family had lived in several different parts of the world. After his father left the army, Brian had three admissions to a psychiatric hospital. During these, his father was diagnosed first as having schizophrenia and later manic depression. After his father died in 1982, Brian moved East of England to be with his mother. There he had several admissions to a psychiatric hospital. He later followed his mother to the village where he lives now. When things did not work out living with his mother (owing to tension in their relationship), Brian moved to Sheltered Accommodations. Brian’s elder brother also lives in the same area, and is married with three children. He is described as “successful.” Brian’s older brother died in a car accident in 1979 at the age of 23 years. In 1988, while living in sheltered housing, Brian was referred to the clinic because of his isolated existence and need for further psychiatric understanding. Upon coming to the clinic, the psychologist found him to be verbally aggressive and hostile. He refused to have anything to do with anyone; he refused verbal treatment; and he did not participate generally in the clinic’s program, attending the newcomers group only sporadically. He eventually had to be given a single room in his house, and it was generally believed that Brian was unable to settle in groups. Brian also seemed unable to make long-term aims or plans for his life. The referral stated that “his mental state seems to make him inaccessible to rational planning for the future.” Brian had shown an interest in the music therapy group, probably as a result of his ability to play the guitar and piano, rather than from a wish to explore himself in therapy. However, the main reasons for referring him to music therapy stemmed from a belief on the part of the psychologist and team that Brian may be more accessible to nonverbal media, and that this in turn may help him in his relationships with the outside world generally, and eventually allow him to return to work. Assessment My dilemma after the first assessment meeting with Brian was whether to involve him in the group or to take him for individual music therapy. The assessment session was with musical instruments: Brian immediately engaged himself in interacting musically with me, trying to instruct me what notes to play, and also becoming quite animated in a drum improvisation and a chordal, more structured guitar improvisation. Brian showed interest in who might be attending the group, and what he might gain from it. The decision to accept him for group therapy was based on a notion that if he was to work on increasing his ability/wish to socialize in the world, it would be through music. I also

felt strongly that a very regular therapy group with firm boundaries may help Brian feel able to interact with others, and realize something of his effect on others. It was therefore worth a period of assessment in the group. In our initial contact, Brian presented as an angry, rather sulky man, with a capacity for being challenging and argumentative, juxtaposed with a sensitive musical expressive side that seemed to represent his wish for contact and togetherness. He was very reticent about acknowledging anything about his life and difficulties, but his energy to challenge, abuse and debate gave me some optimism for his beginning group music therapy Treatment Brian has been attending the music therapy group for two years. After an initial settlingin period, when he attended alternate sessions, Brian made a commitment to coming regularly on a weekly basis, and when unable to attend, letting the group know the reason. Throughout his involvement in the music therapy group, Brian was not involved in any other formal therapy. He occasionally attended activity groups (e.g., creative writing), and he saw a psychiatrist regularly for consultation regarding his medication. The two year period can be divided into three main phases. The first two were six months each in length, and the final was twelve months. Looking back, these periods seem to reflect different developments for Brian. The main features in Brian’s therapy during each phase will be described, with some detailed examples of sessions. Phase One: Testing and Establishing Himself Brian presented a challenge to me from the very beginning: he constantly criticized the group, its members, and me. In the first few weeks, he was often monosyllabic, and seemed confused and sometimes thought-disordered. I felt that it was important to constantly interpret some of his behaviour, whilst remaining receptive and nonjudgmental. He was often angry, and this meant that I had to constantly reflect upon the feelings this conjured up in me, in order to understand him without driving him away or letting him abuse the group. During the first six months of his attendance, the group itself was beginning, and Brian was part of this beginning process. Its membership included Dorothy, Brian, Peter, and three other individuals who attended sporadically, and were eventually discharged. Thus, the group was small, with a core of four members most of the time. An important feature during this phase was the difference in Brian’s behaviors when the group was larger, and when he and Dorothy were the only members present (which happened on occasion). On one occasion, he acknowledged that he preferred a smaller group, and on another, he stated that he would like to “have me to himself.” I have found that the best way for the group to function is to allow things to develop, and to provide musical structures at times when this seems appropriate. I provided such structure much more frequently in the first phase of the group process than in later ones, for at the beginning, the group was in the process of finding out about possibilities of using instruments, and some members could participate only with rhythmic or harmonic support

from me. During the later phases, I played less because the group was able to improvise without so much involvement from me. A description of three sessions follows, each showing Brian’s progression from a rather rigid non-acceptance of his own part in the process to some acknowledgement of his integration into the group, and an ability to acknowledge others and him within it. Session 5. During this session, Brian was challenging throughout, criticizing everyone and their music. Eventually however, he allowed himself to “let go” on the metallophone in a free improvisation during which he seemed very absorbed in the music. After it had ended, Brian denied that the group had any therapeutic value, and then accused me of being a bad therapist because I would not “prescribe.” I suggested to him that, even when I did musically provide structures (e.g., rhythmic blues chordal progression), he could not join in because it was not “right for him.” In this session, and throughout much of this phase, Brian seemed to want to destroy the group. It was also quite noticeable that he avoided disclosing anything about his life, at least until the 11th to 15th sessions. Session 12. We began with a series of integrated improvisations on the pentatonic scale, all sounding as if they had no ending. Brian was quite critical of this afterwards, and joined in with loud cymbal crashes or loud chord solos on the piano. The more I commented on the fact that he seemed to want to criticize, interrupt, and possibly to be “told off like a child, the angrier he became. Following my strong instincts that he really needed to have his behaviour understood and contained, I further suggested that he acted as though he were disinterested in Dorothy or Stephen. An exchange followed, which seemed to be a turning point in therapy when Brian asked about Dorothy’s family. A long interchange took place between Dorothy and Brian about their families. Brian talked for the first time about his father dying eight years previously; he also shared that his mother lives in the same area as he and that her job is in catering. Dorothy talked about her parents dying, and Brian became interested in Dorothy’s father’s job in a cement works. In this shared acknowledgement of their losses, the three group members seemed close to each other for the first time. Session 13. Brian showed an interest in Dorothy when she arrived, and gave her instruments to play, showing some awareness of her condition for the first time. (Although no one had ever commented on it before, Dorothy has no fingers on one hand, and also has a wound on her upper arm where she stuck nails into it). Brian seemed desperate for help, and asked me to help him get more sleeping tablets from his doctor. He actually agreed, in response to my suggestion, that perhaps in looking after Dorothy and pleading to me, he was showing that he wanted love and attention for himself. He commented on Dorothy being helpless, and she seemed pleased with all the attention. Then he asked Dorothy what she was doing for lunch “today” and “tomorrow.” In the improvisations, Brian played rich piano chords and also used drums and metallophone in an expressive way with Dorothy. It was significant that he did not need my support to do so. Session 15. This was one of the sessions leading up to a summer break, during which Brian was going on a holiday for the first time with people in the sheltered house where he lived. This itself reflected a change in that he could contemplate being in a close-knit situation with others for an entire week.

Brian entered very interested in getting started. He seemed less angry and gentler, yet able to express how he was feeling. He became very frustrated that my music was not exactly what he wanted. Several times he challenged me: “Can you play octaves? Your music is a bit thin.” I purposely did not want to influence or intrude. Then Brian began his questioning of the value of the group: “We’ve had ten minutes and not done anything!” Then later, when I was trying to explore silence, he said: “Silence is noise.” Brian started drumming and then stopped to write down some dates in his diary concerning cancellations of the group. Dorothy accompanied throughout, and he paid little attention to her. Eventually, Brian was very willing to express himself and let go—after the awkward silence at the beginning, and after challenging me further: “What about taping some records and having a proper music therapy group?” After the first improvisation (Brian on drums, Dorothy on xylophone, myself on piano), he said “it was fun, but still not quite good enough—your hands are too small.” Dorothy, however, commented on how pleased she was that Brian was very involved in the improvising. Near the end of the session, Brian asked Dorothy for the first time what was “wrong” with her arm. Dorothy replied that she had stuck nails in it. Brian seemed shocked and said in a thoughtful way: “You must have been very angry.” In this session, Brian showed more involvement than ever before, albeit in a challenging way: continually trying out pieces, wanting me to play in a certain way, etc. He agreed that he worried about not knowing what might happen next in the group. He seemed much more open. When I suggested that the group was feeling more in touch with each other, Brian agreed, but then added: “It’s monotonous, and I’m trying to change things.” His music was much more fluid and flexible, often within a structured rhythmic framework, but towards the end, he used drums and cymbals in a free dialogue improvisation with me. Six Month Summary. During this period, Brian was able to gradually make a commitment, and attend more regularly. After three months, he attended every week, and would always let the group know if he could not come. This is of major importance, as Brian’s previous history showed a difficulty in making relationships and keeping commitments. At first, he found it very difficult to take into account anyone else’s needs. He did not even talk directly to other members of the group, apart from to me as the leader. He was very keen to control others, and his initial interactions with members of the group were commands or derogatory comments, such as “Your music sounds abominable!” Part of his wish to control others seemed to be manifest in a need to keep him in control. He often became angry with me because I did not tell everyone exactly what to do. Often, when things became difficult, Brian would express a dire need to smoke, and because the group had established the boundary of not smoking, he would have to leave the group to do so. Gradually, with help, Brian began to acknowledge his need to challenge authority. He also became better able to relax and to allow himself to get to know others and even understand their needs. He began to stay for the entire hour. As these changes occurred, they showed in his music. He became able to improvise more freely and to follow others–in addition to expressing himself through music which often had very loud, structured beating as its main feature. Previously, Brian had been dominant to the point of being often abusive to others, but as this became less frequent, he began to notice and listen to others more, allowing them the time to talk and play their own music. A turning

point was when, in addition to feedback from others, Brian listened to a tape of the group improvising, and heard he was “drowning” other people’s music. When he was angry, he often benefitted from being able to release some tension and aggression by playing loudly and freely in improvisations. It also seemed useful for Brian to receive feedback from others about how he made them feel when he was organizing or criticizing them. He also benefitted from positive feedback from others about his musical skills on piano and percussion. By the end of this period, the group had helped Brian integrate with others in a more positive way than before his referral. He was more sensitive and trusting of others. He seemed to feel more confident and “good” about himself, better able to organise his time, and more amenable to spending time with others. He seemed to benefit from the regular support and insight possible in the group, and had begun to make links for himself regarding his personal difficulties and how he might change. His psychotic traits seemed to be disappearing and his mental state seemed more settled. Phase Two: Trusting or Not - In or Out This phase showed Brian really grappling with whether or not he wanted to be close to others in the group and explore things further for himself. He had his only admission to hospital in the middle of this phase. It did not last very long, and was more for the purpose of the psychiatrist monitoring him more closely rather than because everything in his life was breaking down. In fact, he continued to attend the group during his admission, coming to the clinic from the ward in a taxi. His group therapy seemed quite central to his fairly quick discharge. After his discharge, he moved to a smaller sheltered housing situation run like a therapeutic community where his case manager and other team members felt he would fit in better. He is still settled there, and has remained more stable ever since this move. Leading up to his admission, Brian did stop taking his medication and generally because confused. However he also used the group to deal with some of his feelings concerning relating closely to others. He went through a pattern of sitting in silence for whole sessions at a time when five members were present. He acknowledged that it was easier for him to relate to one or two people at once. Twice, when only he and Stephen were present, Brian said he wanted me to himself. During this phase, he began to explore his relationships in more depth, and asked me more personal questions, such as: “What do you do on the weekends?”, and “Can you come for a drink afterwards?” However, he did not seem ready to try to understand some of these desires, and would either play music in order to avoid talking, or not attend the group after a particularly insight-oriented session. It seemed difficult for him to acknowledge his wish for contact, and he appeared to run away whenever he moved nearer to understanding something. However, the fact that he continued to attend the group throughout this phase is significant, and following many weeks of angry silence, he began using the instruments expressively again towards his discharge time. He desperately wanted me to help him be discharged, and we agreed together that I would give my opinion in ward rounds, after discussing it with him beforehand. My opinion was that if he moved to the new housing, where there was more psychiatric follow-up, he was well

enough to go at any time. In fact, I had not really felt his admission to the hospital was essential in the first place, although in some ways he seemed to benefit from the overall attention he received. His admission also convinced him that he did not want to identify too much with longterm, institutionalized clients. All of these issues were examined in the group towards the end of this six-month phase, as he was settling into the new community house. At this time, his music became more adventurous and expressive. Phases Three: Hard Work During this one-year phase, there were three new members in the group making six regular attendees. Brian’s music because much more complex and intense, and he really became involved in the group. He began to mention people by name, show concern if they did not attend, and acknowledge how he hurt others by his criticisms. This seemed to be particularly possible with two new members, Stephen and Anthea, with whom he was constantly supporting or criticizing. The following two examples illustrate how Brian tried to deal with his competitive feelings towards others through interactions with Stephen and Anthea. He also tried to come to terms with the consequences of his criticisms towards women particularly. Overall, these examples show how much Brian was changing, now being able to consider his “place” in the group rather than angrily deny his involvement as he did in the past. Example 1. Near the end of this session, a fifth improvisation took place, with Brian very much leading on piano with strong chordal, rhythm patterns, and Stephen beating loudly on drums as if competing with Brian. Peter and Anthea were rather lost in directionless playing. A dialogue followed: Stephen: I thought the last piece was OK. Brian: I thought it came off quite well, but it carried on after I had finished. Stephen: I stopped when you stopped. Brian: Oh well, somebody didn’t. Can’t remember who was making the best accompaniment. Me: It seemed quite important to you that people stopped when you did, Brian. I thought Stephen that you wanted to let Brian know that you think of him as a leader. Stephen: Brian had finished his piece, so I stopped playing the drums. Me: (Sensing much underlying anger between Stephen and Brian). It seemed, Stephen, that earlier in the group you felt at home in coming to your first group and being a leader too. (I later suggested that there was some competitive tension between them, which they both seemed to acknowledge). Example 2. This session was four months later, and the first session after Brian and Peter had been on holiday together with a group from their house. They both seemed able to discuss it in the group, which was a new development. They also improvised a gentle melodic duet during which some intense listening and “give-and-take” took place.

The mood changed during the last improvisation, when all members played feely (Brian on piano, Peter on metallophone, Stephen on xylophone, Anthea on glockenspiel, Melissa on gato drum and Dorothy on maracas). Brian suddenly shouted: “It would help if you told Anthea what notes to play!” The women all immediately stopped playing, and Anthea left the room. For the next 30 minutes, I tried to help the group understand what was happening. Brian’s comment, and this session, was significant in that, by the end, Brian had actually regretted pushing Anthea out. For the first time, I found my countertransference towards him had been useful in that somehow we were able to recognise together that he needs to be destructive and abusive. I tried to help him see something I had been feeling for a long time-that he needed to be this way to avoid the fear of being hurt himself, and that he desperately wanted to be looked after, too. Since that time, a main focus of his work in the group has been to contain his rage, criticisms, and denial of the benefits of therapy. It became clearer that his fear of being hurt and avoidance of what others are feeling manifested themselves in Brian’s attempts to squash many improvisations by the group. He did this by being critical of others, by suggesting or playing complex harmonies that others could not follow, and by denying the value of any music other than the precomposed pieces of his own choice. I am still convinced that at some level Brian has been hurt and needs repairing, but we have not explored this yet in any depth. Discussion and Conclusions Brian’s history, and rather fixed schizophrenic disposition, may lead everyone connected with him to feel despair. He has not held down a job for 20 years, yet is intelligent and talented. He does not now exhibit particularly bizarre, psychotic behaviour (which was seen mostly while he was in hospital), but rather maintains a constant disposition of hatred towards the world and other people. He could be experienced as quite passive-aggressive at times. In the entire two years, he has admitted only twice that he has any problems, and often states that he is forced into attending the group. The reality is that he has the ultimate choice, and has often brought himself along to insult me and others, week after week. So, of what value is the music therapy? Why are we all still meeting? The reasons are complex, but to summarize finally, I will briefly mention some essential points. Brian’s only motivation to relate to others in the last three years has appeared to have been through the group. Before attending it, he was reported never to speak to anyone in his home or at the clinic; likewise, he did not even venture into the drop-in room. He now interacts with others in the drop-in room, and joins in community life more in his house. I cannot be sure that this is related to his music therapy, but what I have experienced is Brian gradually realizing over a long period of time, that his destructive instincts can be tolerated and perhaps understood. Brian has also begun to trust and enjoy the freedom of improvising with others, and the music has served the function, I believe, of making a link between his internal, destructive paranoia of being “cut-off and the way that others respond and react to him, which is something he has been forced to acknowledge and understand, and perhaps even want to understand. Yes, his prognosis overall is not hugely encouraging, but perhaps through constant trials and struggles to understand and contain his more psychotic and destructive instincts

(partly through music providing a different way of communicating these things), he can interact more easily with the world. Now he seems stable and quite relaxed, and last week, when a new member joined the group, he even acknowledged him by name. Two years ago, he sat for weeks without even using anyone’s name, and not showing any wish to be anything other than critical and destructive. Last week, he did attack the new member initially with: “I don’t know why you’re here if you can’t play anything.” But then, after half an hour of improvising said: “Gosh, your drumming was really sensitive and I like it.” He laughed when I ventured to suggest that perhaps he was able to welcome the newcomer after all. There is probably still much to understand and grapple with, but this is long-term work. Brian has still not verbalized very much about himself, but he has communicated to me through his musical and nonverbal behaviour, and I have attempted to understand as much as possible. The constant weekly commitment and sense of boundaries are important, as is the belief that something is changing. What would be lost if therapy were to stop? Brian has a huge investment at present and hardly ever misses a session. His music is becoming more relaxed and less rigidly fixed. For someone like him, all these phenomena seem important in helping him maintain his present quality of life, and hopefully preventing him from admission to hospital and repeated breakdown, even if his capacity for insight and inner major change is small. Glossary Countertransference: The therapist’s unconscious reactions to the patient, especially to the patient’s own transference. Hysteria: A neurosis with principal features of emotional instability, repression, dissociation, physical symptoms, and vulnerability to suggestions. Manic Depression: A severe mental illness causing repeated episodes of depression, mania (obsession, compulsion or exaggerated feeling for), or both. These episodes can be precipitated by upsetting events, but are out of proportion to the causes. M.E. (Myalgicencephalomyelitis): A diagnosis, which is fairly recent, often thought of as postviral. There are disputes as to whether it is a psychosomatic disorder or a medical condition of muscular inflammation and other symptoms, producing lethargy and depression. Personality Disorder: Severe maladjusted patterns of behaviour, deeply ingrained and lasting for many years. For the diagnosis to be made, these patterns cause suffering to the person, or others, or both. Schizophrenia: A severe mental disorder thought to have a strong genetic component, but which can be brought on by stress. Characteristics include psychotic traits - loss of contact with reality, a disintegration of the process of thinking at times, delusions, and hallucinations. Social

withdrawal can occur, and the patient often feels that his/her thoughts and actions are controlled or shared by others. Transference: In analytic therapy, this involves the patient’s unconscious wishes. Within the relationship with the therapist, “infantile prototypes re-emerge and are experienced with a strong sensation of immediacy” (Laplanche & Pontalis, 1973). References DeMare, P. & Kreeger, L. (1974). Introduction to Group Treatment in Psychiatry. London: Butterworth and Company Ltd. Laplanche, J., & Pontalis, J. (1973). The Language of Psychoanalysis. London: Hogarth Press. Lieberman, M., Yalom, I., & Miles, M. (1973). Encounter Groups: First Facts. New York: Basic Books. Odell, H. (1988). A music therapy approach in mental health. Psychology of Music, 16, 52-61.

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

CASE SEVEN Integrated Music Therapy with a Schizophrenic Woman Gabriella Giordanella Perilli Abstract A comprehensive approach to music therapy was taken with a 20-year old woman diagnosed as residual schizophrenic. The 18-month treatment period was divided into four developmental stages in order to formulate goals and develop the most effective strategies. Techniques include: singing and playing pre-composed pieces, action songs, improvisation, song-writing, and projective listening experiences. Background Information At the time of therapy, Mary was 20 years old, and had been diagnosed as having residual schizophrenia in remission, with no organic damage. She was taking a minimum dosage of Serenase, a neuroleptic drug. Mary was her mother’s fourth child, and her father’s first. Her mother had already had three sons from a previous marriage; her mother’s first husband had died. Mary was born 15 years after her three brothers. As a child, Mary had disturbing dreams which caused her great anxiety. She also had early eating disorders. At school, she demonstrated several problems, including deficits in attention and memory, and hyperactive behavior. When she was three years old, she broke one leg while playing with another little girl. This turned out to be quite a significant event, not only because it frightened her so much, but also because she did not grow or gain weight for one full year. Her family was both overprotective and critical of her at the same time. They were also of the opinion that it was impossible to cure Mary’s mental illness, or to modify her disruptive behavior. At the time Mary was referred to music therapy, she lacked many adaptive, self-help and social skills, and had poor contact with reality. She had been in verbal psychotherapy for eight months, receiving three sessions per week. Nevertheless, her condition seemed to worsen, and her psychiatrist and parents decided to refer her to music therapy to see if a nonverbal approach might have an effect. Mary demonstrated various forms of thought disorder, including delusions, fantasies, loosening of associations, poor reality-testing, and difficulties in concentrating, thinking, and

remembering. She was unable to stay on-task for sufficient periods, and shifted topics of conversation from one moment to the next. Generally speaking, any kind of ordered behavior posed a challenge. Mary also had difficulty making decisions, not only because of her disturbed thinking, but also because she lacked interest and motivation. She was filled with ambivalence, and she rarely derived pleasure from anything she did. Her affect and mood ranged from dysphoria, depression, and anxiety, to agitation and hyperactivity. She cried frequently. Mary also had disturbing nightmares, and a decreased need for sleep. Her sense of self was also disturbed. She felt worthless, and she often yelled out self-criticisms. She was generally withdrawn from others, and avoided interpersonal contact. She often exhibited hostility and anger towards others. Method Given the wide variety of problems that Mary presented, and the etiological complexities of schizophrenia, it became essential for me to clarify my own theoretical position and methodological approach as I began to work with her. We know that the schizophrenic process distorts the person’s entire reality system, and disrupts important links between the ego and outside world (Andreasen, 1985). We also know that one of the most devastating symptoms is the deterioration or inadequate development of basic psychological functions, including those pertaining to thinking, affect and interpersonal relationships (APA, 1987). I have found that many of these psychological functions can be approached in an integrated fashion through cognitive methods of psychotherapy. The works of Ellis (1962) and Kelly (1955) are particularly relevant. Taking Ellis’ perspective, Mary presented two irrational beliefs or dysfunctional ideas: (1) “I am an incompetent person,” which leads to feelings of inadequacy, depression, and lack of pleasure; and (2) “I cannot bear it,” which leads to anger, hostility, aggression and inactivity. Taking Kelly’s perspective, Mary does not have an adequate “personal construct system “for adapting to the world and changes therein; she therefore has an ongoing dread of what the future may bring. From a cognitive point of view, Mary’s problems formed a vicious circle: (1) she was terrified by demands from the environment, such as “You must be good in order to satisfy others,” or “You must go to school and do well.” (2) This led her to react with anxiety and selfdeprecation: “I have no control over what happens to me;” “I can’t do what everyone expects;” “I am incompetent, no good;” “I hate myself.” (3) With these ideas, she would fall into depression: “What’s the use, why bother to do anything?” “Life is miserable and meaningless;” “I can’t enjoy anything.” (4) The depression then led to blame and hostility towards others: “It’s not my fault, it’s yours;” “You are bad and incompetent.” “I am angry at you, leave me alone.” (5) Then, suffering the consequence of her inadequate behavior and the reproaches of her parents, Mary would feel punished and powerless: “I cannot do anything to stop what is happening to me.” (6) This completed the circle in that she now would become terrified by demands being placed upon her. When I work with psychotic patients, I divide the therapy process into four stages. With Mary, these stages helped me to formulate goals and to devise appropriate therapeutic interventions. The first and second stages are considered rehabilitative in nature and the third and fourth are reconstructive. The main priority for the first stage is to establish contact and to

gain rapport with the patient. The second stage is aimed at stabilizing current adaptive functioning while also restoring previous levels. In the third stage, specific problems are targeted for resolution. In the final stage, efforts are made to restructure the personality so that therapeutic gains can be maintained, and some degree of independence can be established. Because my aims in therapy address the whole person, and integrate cognitive, affective, physical, and interpersonal functions, I use a variety of music therapy techniques, as also recommended in Unkefer (1990). In my work, I integrate active and receptive techniques and use both structured and free musical experiences. Some are creative and some are recreative. Some require perception, others require projection. I also shift the amount of interaction that is required. For these reasons, I call my approach integrated. Using the full gamut of music therapy in this way allows me to gear the techniques to each stage of therapy and its corresponding goals. In this way, the client’s needs are kept in the forefront. The following are the main techniques I used (and modified at the different stages) with Mary: playing and singing pre-composed music, action songs, improvisation, song-writing, and projective listening activities. Treatment Process Stage One: Contact For the first three months, I met Mary four or five times per week, each session lasting one hour or more. I felt that we needed to have frequent contact because of her disintegrated state. The sessions were held in my private office, a room large enough to accommodate Mary, my assistants (a musician and a social worker) and me; and one that would permit free body movement. Most of the sessions were tape-recorded. Establishing contact and gaining rapport with Mary was quite difficult. She did not like her previous (verbal) therapist, and in fact, described him as “awful.” She experienced him as being very frightening and intrusive, and even had nightmares and fantasies in which she imagined that the therapist was threatening to terrorize or kill her. So at the beginning, I tried to approach Mary on neutral ground and on equal terms. I wanted to lower her anxiety level by respecting her deep inner space, and by not asking her questions about her maladaptive behavior, her past life, or her present life problems. I avoided any talk about her small stature and how it made her feel, her particular behavior towards people, and her hostility at home. In musical experiences, I was very accepting and nonjudgmental of everything that she did, and I found that this approach greatly increased her willingness to work on her own problems. In our improvisations, my role was: to mirror her musical behavior, to give her feedback so that she could hear her own music, to help her stabilize and control the various musical elements, to encourage her to reproduce patterns, and to help her to express her negative feelings through music. I also improvised or composed songs with lyrics aimed at giving her an opportunity to become more aware and accepting of her body (e.g., I’m playing the drum, while touching my head, I’m playing the triangle while touching my arms, I’m playing the harp while moving my body, etc.).

We often had rhythmic dialogues. Mary often entered the room confused, agitated, and anxious. On one occasion, after finishing the welcome song, I asked her to play a duet on the drum. I began to play very ordered rhythms in 4/4 meter, and Mary responded with incoherent and disorganized beats. I let this continue for about three minutes, and then suggested that we take turns leading and following. She agreed, and as we went back and forth, her playing became stronger, more ordered and responsive. Patterns began to appear. Whenever we would match each other accurately, Mary smiled, and this seemed to relieve her tension a great deal. We ended with calming rhythms, and then listened to the tape-recording of our duet. I asked Mary what she thought about it, and she said that she was satisfied. We then talked about the process of making music, and I pointed out that first comes confusion, then attention to what is happening, then organization of ideas, and finally interaction. By this time, Mary was much more relaxed and was able to not only understand what I said but also repeat it. Mary also did solo improvisations on various themes. In one particular session during this stage, Mary improvised two very different pieces on the piano. The first one was organized and coherent, and after hearing it, she said that its theme was “The Death of My Piano Teacher.” During the improvisation, she demonstrated very good concentration, and was in contact with her ongoing feelings of sadness and discomfort. The improvisation was a study of the relationship between the various music elements: the use of the rest as a moment of reflection and an opportunity for progressing and developing her ideas in a logical and consistent manner; collaboration and integration between the right hand and the left hand; the use of regular rhythmic accents; and a perfect synthesis of thoughts and feelings within musical creativity. The second improvisation was characterized by a lack of organization and coherence. This theme she decided in advance, “The Happy Country Woman.” In this one, there was an absence of awareness and reflection; the music was confused and she made little effort to relate ongoing ideas to previous ones. Her concentration was poor and she did not pay attention to details such as accents, meter, rhythmic patterning; there was no unifying idea or sound quality; there was no homogeneity in the expressive material, and as a result there was no emotional coherence; momentarily, Mary would express her obsessive thoughts and anxious feelings through perseverative playing; there were no moments of rest or relief; and when dissonances occurred Mary seemed not to know how to resolve them. Overall, the improvisation sounded like a spasmodic search for something unknown which eventually began to bore her. Based on the feelings that I experienced as I listened to Mary’s improvisation, combined with a cognitive analysis of the musical structures themselves and Mary’s verbal selfdeprecations (I am stupid, I do not have any ability, etc.), I came to a better understanding of her inner state. Coexisting were intense feelings of depression and a pervasive confusion due to ego anxiety. These feelings of depression and confusion formed the basis for planning sessions for the next stage. I wanted to organize her personal construct system, lower her anxiety, and let her experience positive emotional states. Stage Two: Stabilization and Rehabilitation

Goals for this stage were: to help Mary to focus her attention, and especially in tasks requiring perception and memory; to lengthen her in-task behavior and attention; to increase goal-directed behavior and perseverance; and to help Mary gain greater awareness and acceptance of her body. To accomplish these goals, I used a variety of structured listening and imitative tasks. These included: having Mary compare two musical patterns and describe how they were similar or dissimilar; having her imitate rhythmic and melodic patterns that I presented; having her vary the same patterns in systematic ways (e.g., louder/softer, faster/slower, louder and faster, etc.). Two kinds of improvisations were used: ones that focused on here-and-now experiences, and those that explored a particular feeling or issue. Mary also told stories and drew to different pieces of music and made connections between them. Finally, we played a musical game which combined singing and matching instruments to various body parts. The following is a transcript of a session which typifies this stage of therapy. Mary arrives complaining that she is unable to think. She feels terrible because this prevents her from being able to understand when people talk to her. She also gets confused about how to do things. Her face shows how tense and upset she is. Given her state, I try to comfort and calm her through a listening activity. I ask Mary to tell a story, and she begins: Laura is a young woman who lives in a castle; she is in the garden taking care of the flowers. There are animals and birds in the garden. She is somewhat uncomfortable there because it is not as orderly and calm as she would like it to be. Two Princes arrive, and Laura joins them in the castle. She tries to explain to them how desperate she feels because she cannot take care of the flowers by herself. They quarrel. The Princes are eventually persuaded to cooperate with her, and they prepare lunch and all eat together. I help Mary to finish the story, and then wonder to myself whether I should proceed in a structured or unstructured way. I decide to invite her to select instruments to describe the main elements of the story. After making her choices, she begins to improvise on the drum (representing the castle) and plays a strong, steady beat. She then goes to the cymbal and sistrum (representing the Princes) which she plays in a loud and confused way. Changing to the autoharp (representing Laura), Mary begins to play soft, delicate arpeggios, followed by a steady beat on the hand-drum (representing animals), a simple rhythm on the triangle (representing birds), and scales on the xylophone (representing flowers). She then returns to the cymbal and sistrum and resumes playing in a loud and confused way (Princes). I then took up the autoharp (Laura), and accompanied her with the delicate arpeggios until she ended. I then asked: What is happening to Laura now? Mary replied: “She feels happy, but still worried that she will not be able to find herself.” Surprised by how personal this statement is, I asked Mary what she could do to help Laura. Mary answers: “Sing a song.” She begins the lyrics with “Laura is unable to take care of the flowers.” I then question her, “Will these words help Laura?” Mary replies negatively, and I ask “What would be more helpful to tell Laura?” Mary begins again and sings: “Laura is able to take care of the flowers.” Feeling more comfortable with this solution, I begin to sing the

same words with her, and as we repeat the verse over and over, I ask her to dance together. As we finish, I ask Mary what she thinks about her song, and she replies, “Nice!” I then ask her how Laura feels, and Mary says: “Happy... because she now understands that it is her task to take care of the garden.” I then ask if Laura will be able to find herself doing that, and Mary replies, “Yes, I think so.” I then invite Mary to play Laura’s instrument (autoharp) and accompany herself singing the song. She decides that it is not the right instrument, and selects the xylophone instead. We sing the song again, with Mary playing a xylophone accompaniment. When I ask about it, Mary says that she is pleased with the instrument change. I ask her why and she says that she thought the autoharp was sad. I answer: “Sometimes I feel like that: the autoharp seems sad and quiet at times; it seemed more suitable to Laura when she was talking to the quarrelling Princes, but when Laura is working, she is lively and strong.” Mary agrees, and I comment: “Mary, you have thought about and understood what has happened to Laura in a very clear way. As you can see, when you decide to focus your attention, you can do it...you can think very clearly.” Mary says, “Yes, I am really o.k.” I then begin to summarize: “You understand that Laura, the most important person in your story, was sad because she did not realize what she was capable of doing, but when she did, she became....” Mary inserted: “Happy, because she took care of the garden.” I continued: Yes, she felt more self-confident because your song told her that she was able to do what she wanted.” Mary agrees, and I ask her “Is it possible for you to say that you are able to do something?” Mary: “Yes, I am able to do something!” I ask her for an example, and Mary says that she can play something. I then ask her to say the full sentence, and she does: “I, Mary, am able to play the piano.” As the session ends, I ask how she feels, and Mary smiles with the reply: “Better than before!” Stage Three: Problem Solving By the third stage, Mary was more present in the here-and-now, and her cognitive functioning was much better. The goals were: to decrease her distractibility, to build problemsolving skills and logical thinking processes, to help her become more aware of her feelings in different situations, and to help her formulate some goals that she would like to accomplish with regard to herself (e.g., self-management). Each session began with a welcome song, and after a discussion of whatever Mary presented that day, we went into either song-writing or telling stories with background music. After this activity always followed a review and discussion of what she had done, and how she felt about it. I would then give her homework assignments which made her practice and put into effect things we had worked on during this session. (Prior to this stage, she was not ready for these homework assignments). The sessions always ended with a summary of everything she had accomplished and explored, and a good-bye song. As evidence of her increased cognitive abilities, she worked on the same story over several sessions. It was called “The Vegetable Garden.” When she finally completed the various chapters, Mary exclaimed: “This is my life!”

Stage Four: Reconstruction In the fourth stage, the main concerns were: changing some of her irrational beliefs, improving her coping and social skills, clarifying her interests and needs, and trying to integrate various aspects of her personality. Sessions during this period began with a welcome song, and a verbal discussion of any issues or problems on Mary’s mind. Then, based on this discussion, I would engage her in one of the following musical experiences: 1) Composing lyrics and music to a song. This was done to work on her irrational fears or beliefs. 2) Playing or singing pre-composed music in different ways, or with different interpretations. This helped Mary to gain some insight into her own traits and characteristics when making music and in other daily situations. It also helped her to see that there were different ways to perceive and interpret things. 3) Improvising with or without a verbal theme, and with or without the therapist. These experiences were aimed at making Mary aware of how the music changed with the various feelings she was trying to express. 4) Projective listening activities (e.g., storytelling). These were used to help her integrate cognitive and affective components, and personal needs and goals through her musical experiences. 5) Listening to and discussing several musical pieces and then putting them into a hierarchy according to personal preferences or some other characteristic. This activity was aimed at helping Mary to adapt to changes in the real world, and to recognize how her own perceptions and preferences influenced her orientation to the world around her. After the musical experience, came a period of feedback and review. If Mary produced a song, improvisation or performance, I would tape it, and then we would play it back and she would react to it. Following this, we would talk about how Mary’s music or the way she went about making it related to herself and her daily life. Based on this, I would give Mary a homework assignment. Usually, this involved rehearsing the songs she had written, and then using them throughout the week to guide herself into more functional and adaptive behaviors. At the end of each session, we would summarize what we had accomplished and close with a good-bye song. The songs that Mary composed during this stage provide good examples of the issues and problems she confronted during this period. The songs were originally written in Italian; English translations are given below. Some of these were set to existing tunes (e.g., “I Accept Myself” was set to the Scout’s “Farewell” Song); others had melodies especially composed by Mary. I DON’T WANT TO BECOME REASONABLE I don’t want to become reasonable,

It’s too exhausting; It’s more comfortable not to work at it, Anyway, I do not have the ability; It takes time, time; time. I decide to make an effort, I think it’s more convenient to have a better life; I go step by step to be sure: Exhausting obligation becomes joyful, Joyful, joyful. —– SPRINGTIME TEARS These are life’s tears that I feel in myself I feel in myself. When I am happier than now, the smile will come And glow again. Joy gets down into my heart, Life creates love. The joy will come from pain; Soon merriment will come again. I’d like to do easy things, Within the need for toil. I can try hard so that I am happier Joy gets down into my heart And life creates love. Joy will come from pain; Soon merriment will come again. —– I ACCEPT MY SELF I don’t accept myself As I’m afraid that other people don’t love me anymore. I am unsatisfied Because I think that I am unable to do anything. But why? But why do I want to suffer? I can accept myself as I am; I am a worthwhile person, too. Discussion and Conclusions If we analyze the whole therapeutic process, we can see how music therapy played a positive role from beginning to end: it permitted Mary to overcome her resistance to therapy and to the therapists; it motivated her to play an active role in her own process of change; it helped me to reach Mary on the nonverbal level, avoiding the negative effects of verbal therapy; at the same time, it helped to integrate the verbal and nonverbal aspects of her problem, so that Mary could transfer the musical insights (i.e. irrational beliefs) and skills (e.g.,

problem-solving) outside the therapy session into her daily life (e.g., self-care, home activities); it allowed Mary to have multisensory experiences which helped to integrate fragmented aspects of her personality; it worked well when combined with other expressive arts to give Mary physical boundaries, and to move her from one kind of symbolic representation to another; it enhanced long term memory functions which were very poor; it increased Mary’s symbolic cognitive abilities; it was useful in focusing Mary’s attention when she was confused; it helped to modify some of her stereotypic behaviors; it provided a noninvasive way to address her needs, preferences, and goals; it gave Mary joy and pleasure and motivated her to be more playful; it facilitated social interaction, and lessened her feelings of inferiority; it provided tangible products that rewarded her hard work; and finally it provided an opportunity for her to develop a sense of pride in herself, and especially when sharing her musical accomplishments with her parents. The advantages of music therapy are further underlined by how it compared to previous treatment using a verbal psychoanalytic approach. In response to the verbal approach, Mary lost contact with reality, and her condition worsened. This did not occur within the music therapy, except when sessions were interrupted for some reason (i.e. summer holidays), or when I inappropriately evaluated Mary’s readiness and introduced verbal interventions prematurely. Clearly, Mary had difficulty with a verbal approach, and whenever she was not ready to approach her problems at the verbal level, it was necessary to return to music therapy activities alone. Throughout the various stages, Mary’s music changed considerably, going from confused to ordered, and from being disengaged or disinterested in the musical process to recognizing how her own feelings and personality were reflected in it. Her participation was at first whimsical, later music was a means by which she could enter into a personal problemsolving process, either alone or with the therapist’s help. My evaluations of her progress in the area of adaptive behavior were later confirmed by objective observations made by her parents and by Mary herself. Also, her psychiatrist reduced her medication to a very minimal dose. Mary’s social and coping skills are now quite adequate, and permit her to be involved in more satisfactory relationships with others. She is also more self-reliant, and has even decided to attend a pottery school. She is able to do a little cooking, and she now enjoys taking part in parties, trips and various recreational activities. Her thinking follows more logical sequences, and this permits her to follow a conversation, story or movie, and to express her opinions and emotions more easily. Although I have presented the treatment process as if it occurred in four clearly defined stages; in actuality, sometimes a session would contain elements of one stage exclusively, and at other times, a session would contained elements of several stages. This would depend on how Mary’s readiness changed from one week to the next. Thus, during each session it was possible to consider peripheral or central issues, more specific or general ones, and to use simpler to more complex procedures. It was also possible to use a technique for assessment purposes at one time, and then later for treatment and evaluation. In some cases, the same technique (e.g., music combined with other expressive arts) was used at two different stages (e.g., first to develop particular cognitive functions [perception, memory], and then later to analyze thinking modalities (e.g., loosening of

associations) or to learn a problem-solving skill. Moreover, techniques such as song-writing were useful not only during the therapy session itself (e.g., to express and overcome a depressive state), but also as a homework assignment (e.g., to rehearse more functional selfstatements or to develop a new self-management skill). It is important when working with individuals like Mary that the therapist be always present as a guide and/or partner. The therapist must always have a flexible attitude, and be ready to modify the planned program or session to meet any needs that arise unexpectedly or to accommodate any shifts in the person’s readiness to forge ahead in the therapeutic process. I have also found that having assistants was very helpful, and in some cases, essential. They were particularly important when we would play out a story with many characters, as their personalities would help to teach Mary about the complexities of social interaction and the many aspects of her own personality that she could call upon in various situations. In conclusion, I believe that integrated music therapy achieved such good results with Mary because it is a nonverbal, multisensory, joyful approach. As a result of the various techniques, Mary is now more aware of herself in relation to the real world; she can integrate different aspects of herself; and she is better able to verbalize her needs, resolve conflicts, process information. Now she is discovering the meaning and purpose of her existence, and has begun hear a new melody of life: “I accept myself as I am--I am a worthwhile person, too.” Glossary Delusion: A fixed, false belief. A delusion involves believing things that are not real, and are frequently persecutory, grandiose or somatic in nature. Dysphoria: A mood state which causes discomfort (e.g., anxiety, depression). Loosening of Associations: Disorganized thinking and speech. Personal Construct System: A psychological concept developed by George Kelly (1955) to describe how a person construes the world, and organizes his/her constructs into themes which permit anticipation of future events, and prediction and control of interactions with other people. Reconstructive Stage: A period or phase of clinical treatment aimed at producing cognitive, emotive, or behavioral changes needed to achieve a more integrated personality. Rehabilitative Stage: A period or phase of clinical treatment principally planned to regain previous levels of cognitive functioning or reality adjustment. Residual Schizophrenia: A type of schizophrenia in which there are: a history of schizophrenic episodes with psychosis prominent, a current clinical picture without any psychotic symptoms, and continuing evidence of illness, such as blunted or inappropriate affect, social withdrawal, eccentric behavior, illogical thinking, or loosening of associations (APA, 1987).

References American Psychiatric Association (APA) (1987). Diagnostic and Statistical Manual IIIR (DSM IIIR). Washington, DC: Authors. Andreasen, N.C. (1985). The Broken Brain: The Biological Revolution in Psychiatry. New York: Harper & Row. Ellis, A. (1962). Reason and Emotion in Psychotherapy. Secaucus, NJ: Lyle Stuart. Kelly, G.A. (1955). The Psychology of Personal Constructs (Volumes I and II). New York: W.W. Norton. Unkefer, R.F. (Ed.).(1990). Music Therapy in the Treatment of Adults with Mental Disorders: Theoretical Bases and Clinical Interventions. New York: Schirmer Books.

Taken from: Priestley, M. (1994). Essays on Analytical Music Therapy. Gilsum NH: Barcelona Publishers.

CASE EIGHT Analytical Music Therapy and the “Detour Through Fantasy” (The Case of Curtis) Mary Priestley This essay is based on a talk originally given at the 1979 Conference of the British Society for Projective Psychology and Personality Study. Its title contains a phrase, “The Detour through Fantasy,” which captured me as I was reading Heinz Hartmann’s Ego Psychology and the Problem of Adaptation (1958). Here is the complete quotation: “Taking our point of departure from pathology, from the psychology of neuroses and psychoses, we come to overestimate the positive developmental significance of the shortest pathways to reality, and it is only when we set out from the problem of reality adaptation that we recognise the positive value of the detour through fantasy.”(Hartmann, 1958) A phrase like that tends to capture us when we have a body of experience which cries out to be neatly clothed in its verbal skin. The body of experience was, in this case, some work in my private analytical music therapy practice which constituted a detour---in fact several detours---through fantasy. We, the patients and I, took these detours without any conscious knowledge that this might be the best way as regards reality-adaptation; we took them because they seemed to be the only routes open to us at the time. In the case that follows it was necessary for me to enter the patient’s fantasy world because she was unable, at that time, to enter the challenging world of more generally accepted reality. I wondered what it would be like to make this detour purposively, and decided to call on a colleague to make an improvisation with me to the title of this chapter. As the therapist, she sat at the hospital Steinway grand piano and I sat, as the patients do, behind a battery of instruments comprising an alto chromatic xylophone, a 16” tom-tom, a gong and a cymbal. There were other smaller instruments nearby: a melodica, double naqqaras, a chordal dulcimer - that sort of thing. (At home I also have a home-made bell-tree with bells from all over the world). We started playing, and immediately I found myself in a leafy jungle running for my life with a horde of angry psychologists after me. I was thudding along on the xylophone and annihilating the strident sounds of my colleague’s pianistic cacophony with the drum and cymbal. It was a slightly paranoid impression of my talk to the Projective Psychologists and a timely warning to me not to get too defensive at question time. My colleague felt that the title gave her carte blanche to pull out all the stops of musical creativity and fantasy. Having made this experiment with myself as patient, I felt confident to try it out on my patient.

Curtis (as I will call him) was referred to me by a consultant psychotherapist with the words: “It is either music therapy or nothing!” Curtis was a tall, pleasant but anxious-faced 32 year-old man of medium build. He had recently been hospitalized with schizophrenia and was still falling into catatonic states and finding speech difficult. He lived then with his parents, being recently divorced but without children. His father, with whom he had a poor relationship, was a professional man and Curtis had been studying for the same profession until he cut loose, left this country, married a dancer from the Continent, taught English, and studied singing, only to be told that he had insufficient talent to become a professional musician. At the time therapy commenced, he was working behind the scenes with people in a commercial concern, a job that his mother had helped him to obtain. (How he coped I could not imagine. Certainly there had been a very poor report on his work just before we started therapy). He had a sister some years older who was married and had five children, and Curtis had a good relationship with that family. He was quite cut off from any of his former friends and led a restricted life working, chatting sparsely to his parents, watching television, and retiring to bed early. Here he listened to the radio (what else he did he did not say); certainly he was unable to read at that time. Curtis came for treatment in early spring. I had comprehensive notes on his case from his consultant psychiatrist and the referring consultant psychotherapist, but I always like to have the patient’s own version of his story to see how it has been edited for me and how it felt from the inside. I wrote in my notes that he seemed dim and faint; his hold on reality seemed as fragile as a soap bubble. He could not initiate speech but answered monosyllabically when asked a question, seemingly in some distress. After a brief history-taking we moved quickly on to the instruments. We played together for 10 timed minutes. He played quietly but with interest, mostly on the xylophone. Afterwards I explained that we were going to record the next improvisation and the microphone would not pick up such quiet playing. We then improvised on his imagined “Mountain Climb.” He made a quiet start, and then came rain and thunder on the drums, the sun coming out with cymbal and glissandi on the xylophone, climbing up and crossing the stream, and resting under a tree. I thought that this symbolized this stage of his life when he was protected by his family. Then he went on and climbed to the top but imagined no view. When he told me about his visualization he spoke clearly, his face flushed and his eyes much brighter. There was a countertransference of sadness. The “Mountain Climb” theme was an exercise used by Dr. R. Assagioli (1965) to discover a patient’s life aspiration. I decided not to discuss the possible meaning of Curtis’ fantasy in reality terms. I felt that he was too frail to make such connections for the moment, just as in our talk, I had to be the model for a fluently communicating person rather than subjecting him to the stress of long, tense silences when his words would not form themselves. Fifteen months later, I was sometimes empty and silent to receive his verbal flow, and sometimes responding and amplifying, too, like a good musical instrument. For the first eleven sessions (once-weekly for an hour), we vacillated between fantasy and reality in our titles. There were, in fact, five fantasy titles and six reality titles. The fantasy titles were: “Mountain Climb” (he chose to do this title three times, each time differently), “The Castle of the Self,” and “The Dream at Work.” These titles were fruitful in that they seemed to cause a release of energy and expression in music and more especially in words. But, possibly

because I thought we ought to be exploring the shortest pathways to reality, they were interspersed with titles of: “The Artist versus the Professional,” “Mother,” “Holiday,” “Father,” “Conversations at Work,” and “Dr. F” (his consultant psychiatrist). These last, though fruitful, seemed to stop the flow of free verbal expression and to block him and give him a sad, perplexed look as if he had been deprived suddenly and inexplicably of something that he loved. If fantasy was what released him and set him free to communicate, then I decided that we would resolutely turn our explorations that way and see where it led. I was interested to provide a title that might lead to the exploration of his aggressive and sexual drives. In his 12th session he told me that he was now able to deny accusations at work. His speech was more fluent with fewer of the former helpless gestures which had pleaded to be magically understood like the preverbal baby with the good-enough mother who preserves just a little of his illusion of omnipotence. We took the title “Finding the Dagger in the House.” He imagined going up the front stairs, standing waiting in front of the door, then going downstairs into a room looking out on to trees, seeing a jewel-encrusted dagger and a bowl of fruit. He thought of eating the fruit but left both fruit and dagger and came away. I said that living at home was rather like eating the fruit and leaving the dagger. His music started in a rapid quaver 4/4 beat which sounded first urgent and then questing as he changed to crotchet and quaver beats and lead finally into a stale repetitive pattern. This seemed to point to his domestic situation where the home comforts (breast/fruit) with mother demanded the sacrifice of the use of the dagger/penis of tough thinking. I hoped for something more archaic, and in the next session, after we had played our 10 minutes untitled duet and an improvisation in the Aeolian mode, we improvised with the title “Finding the Sword in the Forest.” His music started out in a brisk 6/8, it was lively and rhythmically varied with drumming, careful use of cymbal and free xylophone glissandi. He imagined going up a hill to the forest, hearing birds singing, seeing flowers blooming, and coming to a river where the sword lay dirty and out of its scabbard. He cleaned it and buckled it on to himself and went on his way. The countertransference was of madness which I played while he continued as his determined and purposeful self. Next session our title was “After Getting the Sword.” He imagined that he went uphill to a deep forest with rocks sticking out of the ground and found a white, turreted castle where a White Lady lived with her maidens. They gave him a meal and in some mysterious way he pledged his services to her (this bit was played very quietly, almost reverently). He also glanced at me when he said this as if I were the lady in question. The music was full of purpose and most moving with an almost sacramental intimacy in places. He came an hour early for the next session. His 10 minute improvisation took on an eager speed; he improvised a song about a flower that grew and grew while I drummed on the tambour. Next we took the title “After the White Castle.” He imagined that he got up, had breakfast, and the White Lady told him to fetch the stag from a mountain forest. He found the way up the mountain, and in a clearing saw the herd with playful fauns. He lassoed the stag and on the way home it swam the river ahead of him. The music was at first a nonchalant, pleasant 6/8 but became more urgent in the middle of the piece and had more emotional range. He looked sharper and more in focus when we finished. All these vivid inner experiences contrasted sharply with his apathetic everyday appearance and experience.

In the next session we did our 10 minute improvisation in an ABA form as I thought he needed some conscious creativity to balance the fantasies. Our title was “After the Stag.” The White Lady told him to go to a tower and fetch the book inside. He had to cross a river and the tower was guarded by a dragon which he discouraged with a wooden pole. He brought the book back without looking in it. The music started with gentle downward glissandi and had dynamism and character. He told his story with fluency and conviction. The dragon seemed to represent the negative aspect of the White Lady, an archetypal smothering, all-devouring, and womb-imprisoning mother. He could well have connected this with his infantile fears regarding his own mother as he looked so shocked and pained when I asked if he had killed it. I remarked on the suppression of his curiosity regarding the book and wondered privately if his epistomophilic instinct was in the service of his mother rather than himself. During this time Curtis attended his hospital one evening a week for a Social Skills group; he always spoke about this and we incorporated the teaching into our work where it seemed relevant. I thought that this strong outpouring of unconscious material should be subjected to as much conscious scrutiny as possible (thinking of Jung’s recommendation to this affect); and in the absence of a qualified art therapist I asked him to make some coloured pictures of the story so far, the accent being more on the effort to bring these images into the world of everyday than on the end product. In the seventeenth session he arrived with the first three of the chalk drawings of the tale; they were primitive but quite strong. We played “After the Book.” He imagined that he set out from the castle to find the bugle that was the horn of an animal. There was a storm in the night. He came to an encampment and played draughts with a man and won the horn. He blew it and brought it back. His speech was enthusiastic and fluent. He had been to concerts and theatres in his holiday and looked well. At the next session we finished this personal myth. It seemed to come to a natural end. We improvised “After the Bugle.” The White Lady read in the book that he was to take the stag to another herd where it must fight the existing leader and take over. And this was done. The music was quite stormy and emotional and there was some interesting musical dialogue, which seemed to indicate that I had suddenly become a separate person for him to play with and not just a part of his larger self. There was a countertransference of anger which I expressed freely, and he drummed acceptance of it. It is interesting how patients accept countertransference expression if the moment for the transmission of the emotion from the unconscious is right. Either they freeze at the sound of a melody which expressed their deepest, most secret self and play pianissimo while it lasts, or they play along with more turbulent music if it seems somehow right to them. In the first case they will usually remark on the tune afterwards. One patient said: “That music was me.” But such happenings are rare and very beautiful. The second kind of acceptance is more common. But to return to Curtis and his detour through fantasy: This personal myth enabled him to begin to come to terms with his sexual and aggressive drives which were never expressed crudely but always wrapped in the symbolism of the sword, the tower, the stag with erect horns, and the bugle made from an animal’s horn. Overcoming his father, in the Oedipal sense, was symbolized by the winning of the game of draughts, the vanquishing of the stage leader and taking the phallic sword from the genital river in the archaic forest mother’s depths. The

mother/wife was split into the White Lady--quite a demanding woman in her way--and the dragon guarding his access to the book of knowledge in the tower; which he overcame with the aid of a long pole. The pledging of his service to the White Lady had the quality of a sacrament, there was an almost tangible feeling of deep mystery while he played this passage. I wondered if the music made the myth possible or did the myth produce the music, or were they mutually creative? I am inclined to believe the last. Being firmly lodged in reality and relationship through our music, Curtis could safely have access to and share his fantasy. This fantasy indeed resembled a psychic nature reserve, as Freud described in his Complete Works (Volume 16): “The mental realm of fantasy is just such a reservation withdrawn from the reality principle” (p. 372). As the therapist I played the part of a super-ego milder than his own, which allowed him to contact this inner world. I made almost no interpretations because I felt that his ego was as yet too fragile to tolerate them. Transference interpretations, in particular, I believed would have jarred him too brutally out of his world of fantasy and perhaps made it difficult for him to distinguish the boundaries between his inner and outer worlds. Nevertheless there was a link, through music therapy, between his fantasy nature reserve and the world of outer reality. To quote Freud again: “There is a path that leads back from fantasy to reality--the path, that is, of art.” At that time, positive idealized mother transference was casting the White Lady projection on to me, but I was ready and willing to be cast in the role of the obfuscating dragon at any time. Curtis was unable, at the start of this therapy, to work out a man-to-man relationship with his father. He had totally abandoned all competition with him through his original profession but through fantasy he felt that he was able to master the tasks of manhood and that gave him more confidence in reality in connection with his work and relationships. His music had been changing too; he was bolder rhythmically, more creative with melody and more adventurous in expressing a wider range of emotion. But it still had mainly a synthetic or synthesizing function, keeping his psyche together while he experienced this tenuous connection between inner and outer worlds. Three months after the myth ended, Curtis moved out of his parents’ home and into a mixed hostel and was cooking, shopping, washing, and ironing for himself and loving it. For his aggressive impulse towards his parents, expressed in the vanquishing of the stag and dragon, he made reparation by taking on spare time voluntary work taking an old lady out in her wheelchair. He regained his gentle sense of humour; he was able to read once more and filled the rest of his leisure with the pursuit of the pleasant, in the form of visits to films, plays, concerts and art galleries and dining out with one or two friends. Altogether I felt that his detour through fantasy had returned quite generously to reality.

Taken from: Meadows, A. (Ed.) (2007). Qualitative Inquiries in Music Therapy: A Monograph Series, 3 (1).

Changes in Images, Life Events and Music in Analytical Music Therapy: A Reconstruction of Mary Priestley's Case Study of "Curtis" Lillian Eyre Abstract This study is a reconstruction of the case study of "Curtis," a client of Mary Priestley who participated in Analytical Music Therapy (AMT) with her for 119 sessions over the course of three years from 1978 to 1981. Curtis, a client in his early thirties who had schizophrenia, was the subject of Priestley's chapter entitled "Analytical music therapy and the 'Detour through Phantasy'" which appeared in her Essays on Analytical Music Therapy (1994). The present study integrates and elaborates on the clinical data from Priestley's published writings about Curtis and her unpublished clinical data about him found in the Priestley archives at Temple University’s Paley Library. This includes Priestley's diaries and recorded clinical improvisations of her work. The purpose of this study was to determine if significant changes occurred during the course of AMT with Curtis and if so, to understand how these changes were manifested in the client's images, life events, and music improvisations. References to Curtis in Priestley's published and unpublished sources were coded for images and life changes. Five improvisations were selected from seven audiotapes and were structurally analyzed and interpreted in a psychodynamic context according to the Improvisation Assessment Profiles (IAPs) developed by Kenneth Bruscia (1987). These improvisations can be heard at www.barcelonapublishers.com, The research led to the conclusion that there were changes evident in all three dimensions of images, life, and music over the course of therapy. Introduction The purpose of this reconstructive case study was to determine if significant changes occurred during the course of Analytical Music Therapy (AMT) for an individual ("Curtis") with whom Priestley worked, and if so, to understand how these changes were manifested in the client's images, life events and music improvisations. Subordinate questions were: 1) what changes occurred in the images during his three years of therapy; 2) what changes transpired in Curtis' life during this period; 3) what changes occurred in Curtis' improvised music; and, 4) how were the images, life changes, and improvisations related. AMT is "the analytically-informed symbolic use of improvised music by the music therapist and client. It is used as a creative tool with which to explore the client's inner life so as to provide the way forward for growth and greater self-knowledge" (2: p. 3). (See separate references for Priestley works at end of case). Within the context of this study, an image is defined as a memory, descriptive title, story, metaphor or symbol. Changes in life events

include interpersonal relationships, psychological insights, and life circumstances that are the result of changes initiated by the client, and improvisation is defined as the extemporization of sound or music while playing or singing. Mary Priestley is a co-founder and major proponent of AMT (2, 3), which uses music improvisation as the primary method of therapy in conjunction with verbal dialogue within a psychoanalytic framework. During an improvisation in AMT, images may arise spontaneously, or they may be stimulated by verbal discussion with the therapist; images are also used as titles for improvisations specifically intended to access the unconscious. Improvisations may be nonreferential (i.e., with no extra-musical title or theme), but most often they are referential (i.e., based on an extra-musical title or theme chosen by the therapist). The referential improvisation is preceded by a verbal dialogue in which "some kind of picture of the [client's] internal situation will develop in the therapist's mind. Something will cry out for investigation" (3: p.120). The purpose of the title or theme of the improvisation is to provide an emotional container for the client to explore therapeutic issues. Following the improvisation, the therapist and client will listen to the taped improvisation, discuss the meaning of the music improvisation, and relate the experience to the client's life. This paper elaborates upon the published case study of Curtis, a client in his early thirties who had schizophrenia and with whom Priestley worked for three years. The present reconstruction will attempt to integrate and elaborate on the clinical data from Priestley's published writings about Curtis (2) and her unpublished clinical data about him found in the Priestley archives at Temple University’s Paley Library, which includes Priestley's diaries and recorded clinical improvisations of her work (1). The first year of treatment in this case study was documented by Priestley in various chapters throughout Essays on Analytical Music Therapy (2) and more specifically in the chapter, "Analytical Music Therapy and the 'Detour through Phantasy'" (2: pp. 199-206). The following two years of Curtis' treatment were documented in Priestley's personal diaries. Of particular interest is case material about Curtis that arose from the images that occurred during his sessions, changes that came about in his life events, and his improvisations during the three years of treatment. In her case study of Curtis, Priestley wrote about the relationship between the images that Curtis used in the improvisations and his significant life changes. However, she did not write about how these life changes were reflected in Curtis' music, nor did she publish an account of the images and life changes that occurred in the last two years of treatment. In reading Priestley's diaries and listening to her improvisations with Curtis, I was fascinated by three aspects of Curtis' developmental process. These were: 1) the shift in imagery in Curtis' titles and themes for his improvisations, 2) how the images in the improvisations reflected life changes, and finally 3) the developments that occurred in Curtis' music over the course of therapy. Literature Review Aside from this case study, no writings or research studies were found that deal specifically with the relationship between images, music, and life changes over time with clients with schizophrenia. Most case studies by Priestley and her followers tend to focus in depth on

two of these three cornerstones of AMT. Discussions of the music describe salient characteristics of the music, but there has been no study to date that provides a detailed analysis of the music as it relates to images and life changes. There are no studies describing work in AMT with persons with schizophrenia. There are a number of examples in Priestley's writing that describe how changes in the client's images reflect changes in the client's life. One such example is the case study of a depressed client (2: pp. 225-229). In a seminal session, the client had images of "knives" that Priestley used as a title for a dyadic improvisation. Interpreting knives as a symbol of the client's split-off aggression, this improvisation helped the client to confront a significant person in her life and to use her aggression positively to express her needs. No information was provided about what the music sounded like, or how the music expressed the knives. In other case studies, Priestley alluded to the music and discussed life changes but did not write about the images that occurred in the improvisations. In the case study of Z.O. (2: pp. 235-236) Priestley stated that she heard the image of the "bright shadow" in the client's music even though there was no evidence of it in his life. However, after three years of therapy, positive life changes that the client had brought about bore witness to the bright shadow that Priestley had heard earlier. Priestley did not reveal how the bright shadow was communicated in the music, nor did she reveal the client's imagery. In the case of a client with communication problems (3: pp. 202-203), Priestley described how she interpreted images in the client's poetry such as "desolation," "deserted peaks," and a "throat of dried hopes" as symbols of her client's internal struggles, and used these as titled images for her improvisations. Expressing these images in the improvisations improved the client's verbal communication; she began to speak in complete sentences and to initiate conversations with others, all significant life changes for this client. Priestley demonstrated the connection between images and life changes, but the details of how the images were expressed in the music were not included. The last illustration of how images, music and changes in the client's life unfold in Priestley's case studies is taken from the many examples in Priestley's chapter that describes techniques for accessing the unconscious (3: pp. 129-136). Priestley relates how a client used her aggression to fight a battle with an imaginary lion as she played the drum, and in so doing, she began to understand how she had turned her aggressive impulses against herself and how she could utilize them as a resource in the world. In this example, Priestley focused on the image but she neither described the music nor recounted how her client's insight provoked further life changes. The case studies that have been written by Priestley's followers demonstrate a similar trend in that the focus is on some aspect of the music, imagery or life changes, but not on the relationship among all three. In some studies the client's images are not discussed, while in others, life changes are not indicated. Where references to the music occur, they are phenomenological descriptions of a particular moment or moments and are used to illustrate an aspect of the dyadic relationship or to demonstrate how salient characteristics in the music reflect images or life changes. References to the client's music do not describe detailed changes in the music over time and do not consistently relate them to the images and life changes, nor are there any structural, methodical analyses of all the musical elements.

Pedersen's (2002, 2003) case study of the Sea Urchin is perhaps the most complete example of a discussion of the relationship between images, music, and life changes in Analytically Oriented Music Therapy (AOM), a term given by Pedersen to her practice of Analytical Music Therapy. Pedersen described how a client created improvisations based on images that arose in his dreams and paintings in order to gain insight and initiate life changes. Detailed information was provided about the images, the musical relationship between client and therapist, and the client's insights and life changes. However, only an informal description of changes in the music over the course of therapy such as alterations in color and tone were described. There was no formal analysis of the musical elements. Purdon's (2002) account of her work with children demonstrated how a six year old girl improvised a hymn which served as a symbol of connection to her dead grandmother. In another case study, a four year old symbolically acted out the trauma of a long hospital stay and separation from her family by inventing a musical story with songs using instruments and a doll. In both case studies, Purdon described the images, the role of the music, and the psychological process that occurred in therapy, but she did not comment upon the music itself or on how the psychological insights that were gained had an impact upon the child's life. In a case study of a young man with depression, Scheiby (1998) created metaphors to describe how she and the client were relating musically during a dyadic improvisation. Descriptions of the music focused on significant moments in the improvisations and their meaning, but Scheiby did not explain how the music changed over time, nor did she explore either the client's images or his life changes beyond the fact that his depression was alleviated. In the case study of a young woman suffering from unresolved grief, Scheiby (1991) described how her client's music and images represented feelings that related to her dead father. She provided a phenomenological description of some segments of music that accompanied selected images and noted that the client's images of her father changed over time, but she neither analyzed the music structurally, nor described changes in the music over time, nor recounted how the psychological shift evident in her client's imagery affected her life. From this representative literature review, it is evident that images, music, and life changes are reflected in AMT case studies to varying degrees. All studies include references to either the client's images, or brief phenomenological descriptions of the music, or changes related to the client's life. However, neither structural analyses of the musical elements, nor the relationship between changes in the client's music, images, and life events, have been described consistently over time. The purpose of this case study of Curtis was to understand how changes in images, life events, and music unfold in the course of AMT. In order to do so, I have examined how Curtis used images over the course of three years of therapy, and I have analyzed the elements and structure of the music from significant stages throughout his therapy to uncover changes in the musical content and changes in the dyadic musical relationship. I have connected Curtis' images to his music within the context of life changes that were concurrent with them. Method Participant

This historical reconstructive research is based on the case study of Curtis, a client of Mary Priestley with a diagnosis of schizophrenia who had music therapy with her on a weekly basis for a period of three years. The name of the client has been changed in accordance with the name used by Priestley in her published case study in order to protect the client's anonymity. Materials Data includes Priestley's published case study and references to Curtis (2) and archival materials that have been recently acquired by Temple University's Paley Library. The archival materials consist of 119 weekly entries in Priestley's diaries from 1978 to 1981 (1) in which she commented on client improvisations. There are also seven audiotapes of improvisations by Curtis. Information relevant to Curtis, such as the date and the title or theme of the improvisation, along with Priestley's comments about the session, was extracted from her diaries and entered into Microsoft Word on a PC computer in a file under the client's name. Original session tapes were made by Priestley for every session from the first one on March 17, 1978, to session 37 on January 29, 1979. There were no recordings made from session 38 on February 5, 1979 to session 115 on March 2, 1981, and recordings were resumed for session 116 on March 9, 1981 to session 118 on April 6, 1981. The cassette recordings were converted to digital files using the program "Peak" on a Macintosh computer and were burned onto a CD directly from the Peak files using the program iTunes. All the above work was carried out at Temple University. The Individual Assessment Profiles (IAPs) developed by Bruscia (1987, pp. 403-496), are "a model of client assessment based upon clinical observation, musical analysis, and psychological assessment of the client's improvisation" (p. 403). The IAPs provided a structured and comprehensive method with which to analyze all the musical elements in the improvisations and to interpret them in a psychodynamic context. Design This qualitative study was based on a hermeneutical approach in which I considered all the above materials as different interpretive sources. I established integrity by maintaining thoroughness in extracting all material related to imagery, life changes, and Priestley's comments that appeared in her diaries, and by comparing her diary entries to her published work to find every reference to Curtis. Using a technique of triangulation applied to these various audio, print, and analytic sources, I identified correspondences among them and I integrated their content. I considered these multiple perspectives within the theoretical framework of the AMT model, psychodynamic theory, and my clinical knowledge of the challenges and problems faced by persons with schizophrenia who deal with issues similar to those experienced by Curtis, the subject of this study. The analysis of musical elements in the improvisations using the IAP method was interpreted according to psychodynamic concepts. A psychodynamic interpretation is particularly suited to therapy using the AMT model because AMT is based on theoretical foundations of psychoanalysis and employs psychodynamic concepts. Implied in a

psychodynamic interpretation of the musical elements analyzed in the IAPs, is the belief that musical elements are symbols that have meanings which extend beyond pure sound. Priestley, too, interpreted images and musical events symbolically and attributed interpretive meaning to them. Therefore, the psychodynamic interpretation of the IAPs is aptly suited to decipher and interpret meaning from Curtis' music. Procedure I began by coding all the material gathered from Priestley's diaries (1) and Essays in Analytical Music Therapy (2) for references to images and improvisation titles, life changes, Priestley's comments on the music, and other interpretations by Priestley regarding her client. I listened to Curtis' complete audio files to determine if I could hear changes in his playing that occurred over time. I divided the diary entries into seven sections where I discerned a shift in the images or life changes. I listened again to the audio files several times to determine if the changes in his life and imagery were congruent with changes in the music. Based on these findings, I reduced the sections to four periods that reflected major changes in images, life, and music. By a process of triangulation, the four periods were constructed as follows: Period I: March 17, 1978 to August 18, 1978 (18 sessions); Period II: August 25 1978 to November 06, 1978 (11 sessions); Period III: November 20, 1978 to July 02, 1979 (29 sessions); and Period IV: July 09, 1979 to termination, April 27, 1981 (63 sessions). I then selected six improvisations that demonstrated emblematic changes for a structured musical analysis. The IAPs were used to analyze and interpret the musical elements of the improvisations (Bruscia, 1987, pp. 423-455). The IAP analysis consists of three steps: clinical observations of the client while he or she is improvising; a musical analysis of the improvisations; and an interpretation of the data (p. 403). Step one could not be carried out in the context of this historical study, but steps two and three were completed. Two improvisations were selected from the first period; one improvisation each was selected from periods two and three, and two from period four. Because an IAP analysis of the second improvisation chosen for period four determined that there were no significant changes from the first, it was not included in the final analysis. Once the improvisations had been selected, they were segmented so that an IAP analysis of musical elements could be undertaken. Segments were selected for their characteristic representation of the various musical elements found in the improvisation. The variety of musical changes determined how many segments were chosen and the repetition of these elements determined when I had reached saturation. It should be noted that Priestley did not record the improvisations from February 5, 1979 to March 9, 1981, which meant that half the improvisations from period three and all but three improvisations from period four were not recorded; therefore, the choice of improvisation was somewhat limited in scope for period three and more limited for period four. The two improvisations selected for period one were Conversation at work (April 21, 1978), a reality theme from session four, and after getting the sword (June 30, 1978), a fantasy theme from session 11. There were two selections for this period because Priestley heard differences in Curtis' music between the fantasy and reality improvisations, and she considered both types of referential improvisation to be significant (2: p. 201). Conversation at work lasted 15 minutes and 28 seconds and for this analysis, two segments were used; the first was the

beginning of the piece from 00:10 to 03:00, and the second, from 08:40 to 10:30. After getting the sword had a duration of 12 minutes and 05 seconds. Four segments were selected: 1) 00:00 to 2:50; 2) 3:18 to 4:30; 3) 5:30 to 6:40; and 4) 10:00 to 12:05. Down under the sea occurred in the 27th session (October 23, 1978), which was the penultimate session in period two. The improvisation lasted 11 minutes and 44 seconds. Four segments were used for this analysis: 1) 00:00 to 3:00; 2) 5:30 to 6:00; 3) 7:50 to 9:30; and 4) 9:31 to11:44. The improvisation chosen for period three was The Fracas, from session 37 (January 29, 1979). It was nine minutes in length and has been divided into five segments for analysis. These have been determined according to the thematic description of events as described in Priestley's diary of the same date (1). These segments were: 1) quiet eating music, 00:00 to 1:45; 2) the argument, 1:46 to 2:12; 3) tense eating as if nothing had happened music, 2:13 to 3:06; 4) Curtis' conversation with his roommate afterwards, 3:07 to 4:30; and 5) conversation that took place a few days later with one of the persons involved in the fracas, 4:31 to 9:00. IAPs were analyzed for segments one through four. In segment five, Curtis began a process that ushered in changes in his playing that were developed in period four where they became more obvious; therefore, these elements were presented in the IAP analysis of the improvisation in period four. Nightscene print occurred on March 23, 1981 during the third to last session, and lasted for 12 minutes and 46 seconds. There were two segments in this improvisation, segment one from 00:00 to 1:10 and segment two from 4:00 to 6:04. The IAP analysis and the psychodynamic interpretation of the IAPs were then integrated with Priestley's diary entries (1) and comments from her published work (2). Together, these sources provided a complete case history that included significant changes in images, life events, and music improvisations as they unfolded in AMT throughout the course of Priestley's work with Curtis. Results For each of the four periods, I will present a summary of the images and life changes as they appeared in Priestley's diaries (1) and published source (2). A music analysis will follow in three parts: 1) a short general description of the music in each period and comments about the music from Priestley's written sources where applicable; 2) a short description of the selected improvisation and a summarized IAP analysis of the musical elements, and 3) a psychodynamic interpretation of the IAP analysis. The definitions of the IAP scales and profiles appear in Appendix 1. Curtis' History Curtis, a young man of 32, had been recently hospitalized with schizophrenia when Mary Priestley began to see him. Before his illness, he had spent time in France studying voice, though he abandoned his studies when he realized that a professional career would be unlikely (1:5-7-79). He turned to the study of law, the same profession as his father, and at some time during this academic pursuit, Curtis became ill with schizophrenia and his marriage

disintegrated (2: p. 200). At the beginning of his music therapy treatment he was living with his parents and working in a routine job in a department store. Priestley noted that he sometimes fell into catatonic states and that he was finding speech difficult (1: 3-17-78; 2: p. 200). He had recently given up singing in a choir, he communicated very little with others, and he had no social engagements outside of work (1:3-17-78). Period I: March 17, 1978 to August 18, 1978 (18 sessions) Images: Reality is Opposed to Fantasy The first period, from March 1978 to August 1978 is the subject of Priestley’s Chapter 19, “The Detour Through Phantasy” (2: pp. 199-206). Themes for improvisations alternated between fantasy and reality titles, and Priestley noted that the improvisations based on reality themes “seemed to stop the flow of free verbal expression and to block him and give him a sad, perplexed look as if he had been deprived suddenly and inexplicably of something that he loved” (2: p. 201). She decided to use fantasy to stimulate his expressive abilities, beginning with titles that would “lead to the exploration of his aggressive and sexual drives” (2: p. 202). In a series of improvisations over six weeks (1:6-16-78 to 8-11-78), Curtis explored his personal images by developing the following myth. In a forest, he found a sword in a river and cleaned it and buckled it onto himself; he came upon a “White Lady” in a turreted castle and performed three services for her: he pursued a stag in the forest; he crossed a river and confronted a dragon with a wooden pole to fetch a book for her; and he took the stag to another herd and witnessed his stag win a battle against the existing leader. Priestley interpreted the images of the dagger, sword, tower, and stag as symbols of Curtis’ sexual and aggressive drives (2: p. 204). Taking the sword from the river, overcoming the dragon with his pole, and taking over the herd with his stag were symbols of the Oedipal struggle with his father, with whom he had a poor relationship. The river symbolized the female, and the mother/wife was present in the White Lady, whom he was able to please by channeling his aggression, which resulted in successfully completing his difficult tasks (2: p. 204). The reality-based improvisations that Curtis did during the first nine sessions explored such themes as: conversations with people at work, holidays, and people in his life – mother, father, and doctor; others were based on non referential improvisations using a pentatonic scale (1:3-17 to 5-26-78). Priestley did not report any specific imagery as a result of these improvisations. At the beginning of therapy the most significant images and the greater psychic investment was evident in the fantasy as opposed to reality improvisations (2: p. 202). Priestley did not interpret Curtis' symbols to him at this time, but being aware of the qualitative difference between the fantasy and reality improvisations, she asked Curtis to draw the images he accessed in the improvisations so that they could be externalized and explored (2: p. 204). Life: Creating Internal Dialogue and Interpersonal Communication When Curtis began sessions with Priestley, he had difficulty communicating; his speech was flat and monosyllabic, and he could not initiate dialogue (1:3-17-78; 2: p. 200). He stated

that he had no thoughts about the past or the future; Curtis' world was an eternal present in which his memories and hopes, if he entertained them, were not expressed (1:5-12-78). As the images in his fantasy improvisations allowed him greater access to his inner life, he began to interact more with the world and his speech became more expressive and spontaneous (1:7- 478; 7-13-78). The tasks of manhood that Curtis mastered symbolically in his myth gave him more confidence in work and relationships (2: p. 205). Previously, he had received a poor work report (2: p. 200), but after a few months of therapy he began to recount positive personal changes at work; he conversed with his colleagues more and perceived himself able to stand up for himself when needed (1:6-16-78; 2: p. 202). He continued to live at home with his parents. He had no social engagements, was unable to read, and he passed his time watching television. Music: Emergent Musical Dialogue Priestley stated that the music of this early period consisted of "taut, tonal, repetitive rhythmic phrases which every now and then he would alter by changing into another rhythm" (2: p. 128). Priestley also noted an emerging musical dialogue as Curtis began to relate to her as someone with whom he could play, as opposed to relating to her as a part of his larger self (2: p. 204). Two improvisations in this period have been selected for analysis using the IAPs: a) Conversation at work, and b) After getting the sword. A) Conversation at Work: Reality Improvisation Conversation at work was recorded in Curtis' fourth session, April 21, 1978 (1). According to Priestley, her piano part in this improvisation represented "the room and other people," while Curtis played the wooden xylophone to represent his "conversation." Priestley felt that her playing expressed Curtis' unconscious, which she experienced through countertransference as being "very remote and dreamy"(1). Based on the IAP analysis, the salient musical elements were the fusion of the rhythmic figure to its rhythmic ground and the fusion of the melodic figure to its tonal ground. Curtis' playing was characterized by perseverative single tones repeated in groups of three or six with occasional forays into duple groupings. Melodic movement consisted of ascending and descending scale patterns in a narrow diatonic range. The subdivisions of the beat created tension resulting from the unpredictable instability of the meter which was affected by an occasional change from a triple to a duple figure; instability also resulted from the sporadic addition of a single note that was added to a metrical grouping which slightly distorted the pulse. Phrasing, timbre, and volume were rigid and did not vary. As a musical partner, Curtis resisted Priestley in changes in volume, tonality, and rhythm. In the second segment there were slight tempo changes, minor rhythmic figure variations, and slight volume changes that resulted in more flexibility. In addition, Curtis employed a new melodic and rhythmic figure in the form of a glissando alternating with a dotted figure that added some variability. Curtis was less resistant to Priestley, allowing her to follow his pulse more often. Psychodynamic Interpretation of the IAPs

Curtis' repetition of the same fused melodic and rhythmic figure suggests that he did not feel free to follow his own impulses and to vary them to achieve his own goals. At the same time, the close relationship of the rhythmic figure and rhythmic ground and the perseveration of this figure met his need to avoid any change that would result in his separation from his physical holding environment. The repetitious and restricted melodic elements resulted in a lack of melody that suggests that there was a fundamental bodily and emotional dependency in this music that stemmed from the first developmental stage (0-18 months) and the following developmental stage (18-36 months). The occasional instability of the rhythmic ground, changing from triple to duple figures, was a reflection of the unpredictable physical holding environment that Curtis experienced. His attempt to maintain a steady rhythmic figure through perseveration was likely a compensatory mechanism; he was attempting to provide holding for himself through predictable repetition. However, the disruption of the rhythmic figure and the occasional slip in the rhythmic ground rendered this attempt unsuccessful and indicated that Curtis was not able to successfully achieve the holding on his own. The presence of these rhythmic tendencies throughout so much of the music may point to issues of trust, physical safety, lack of trust in his own body, all originating in Curtis’ infancy. The constant fusion of his melody with the scale and tonality signified that he had not individuated and was embedded in the emotions, goals, and impulses of his holding environment, specifically with his mother. The invariability of phrasing, timbre, and volume may be other indicators of Curtis' inability to establish his own physical and emotional separateness and identity. He seems unready to organize his own impulses and feelings into meaningful expression in the phrasing, unable to change his identity in the timbre, and unwilling to take or vary his own power in the volume. Transference issues would most likely surface with regards to Priestley holding the rhythmic ground firm and avoiding any attempt to provoke him to disembed from the rhythmic ground and establish his own musical ideas, for this would represent separation from his mother, a task which Curtis was not yet ready to attempt psychologically. To work through the transference, Priestley would first have to gain Curtis' trust by allowing him to depend on her so that he could feel secure enough to begin to develop his autonomy. In this improvisation, she accomplished this by supporting and following his perseveration; whenever he deviated, she followed him to create a stable holding environment. She stated, "I did not feel it was right to interfere with this musical expression of his naturally self-healing process in any way" (2: p.128). It seems that this strategy had an impact on Curtis' transference even within this improvisation, which was evident in the changes he made in segment two after he had worked through some of his initial anxiety. Priestley followed him rhythmically to create a secure holding environment, and once he felt more secure, he was able to enter into a relationship with Priestley by allowing her to play in the same pulse as him, rather than resisting her. He also began to be more aware of his own emotions and impulses and to express them in the melodic glissando and dotted rhythmic figure. The perseveration and embeddedness of Curtis' rhythmic and tonal elements and the invariability of his phrasing, timbre, and volume created considerable tension in the listener, mostly in the form of uncomfortable boredom. One might wonder if another aspect of

Priestley's countertransference was boredom with Curtis' music, fuelled by continuous hopes and anticipations for her to be set free by his independence. The musical elements most resistant to change would likely be the melodic, rhythmic, and phrasing elements, since these were the most salient. Therefore, a breakthrough in the transference would be more likely to occur first in those elements that were not salient, such as volume and timbre. B) After Getting the Sword: Fantasy Improvisation Priestley noted the emergence of a musical dialogue in After getting the sword, an improvisation done in their eleventh session on June 30, 1978 (1). Curtis' rhythm became bolder and the melodies were more creative and adventurous, with more expressed emotion. During After getting the sword, Curtis imagined that he went uphill to a deep forest and found a white turreted castle with a White Lady living with her maidens. They gave him a meal and he pledged his services to the White Lady (1). Priestley's interpretation of this improvisation was that Curtis was coming to terms with his aggressive and sexual drives which were presented in the symbolism of phallic objects, which in this improvisation was the sword. Curtis was also projecting the positive idealized mother transference onto Priestley through the image of the White Lady (2: p. 205). She described the moment of the pledge to the White Lady in her diary, "This bit was played very quietly; he also glanced at me when he said it as if I were the lady in question. The music was lovely and most moving" (1). She added, "The pledging of service to the White Lady had the quality of a sacrament; there was an almost tangible feeling of deep mystery while he played this passage" (2: p. 205). In the four segments chosen for analysis in this improvisation, parts one and four were played on the wooden xylophone and resembled Conversation at work, in that Curtis used a similar rhythmic-melodic figure of repeated notes in ascending and descending scale patterns while adhering to one tonality. Segments two and three were selected because of their noteworthy exploration of timbre and volume. In segment two, Curtis used the drum and in segment three, he used the cymbal in addition to the wooden xylophone. According to the IAPs, the salient elements in this improvisation were the variability in timbre, primarily through a) changes in instrumentation, b) contrasts in volume, and c) a stable, more flexible tempo. Elements in his playing that resisted change were the fusion of the rhythmic figure and the melodic figure to their grounds, and a dependent intermusical relationship that was evident by Curtis' reliance on Priestley for the overall direction of the improvisation. Psychodynamic Interpretation of the IAPs Throughout this improvisation, Curtis was over-reliant on structure and was embedded in it, both physically and emotionally. This was demonstrated in his rhythmic perseveration on the subdivision of the beat and in his sequencing of the three-note descending melody by which he provided himself with his own holding environment. However, by exploring different timbres, Curtis began to establish his own identity separate from Priestley (mother) while modeling it closely on hers.

Clinically speaking, the way for Curtis to make progress with his dependent identity issue would be through the timbre, because when the timbre changed, he also began to play more responsively with regards to volume and rhythm. By following Priestley's changes in volume, Curtis was beginning to experiment with his own power. The subtle changes in rhythm indicated he was also discovering the energy available in his impulses. However, when he returned to playing the xylophone in segment two, his rhythmic perseveration indicated that he still felt physically and emotionally unsafe, causing him to be extremely dependent on creating a stable holding environment for himself. Curtis' short excursion into the exploration of his own identity with the drum timbre had an effect on the music that followed in segment three. When Priestley became bolder in her melody and accompaniment, Curtis became responsive to her on the cymbal, as if he was waiting for his mother to lead so that he might get out of his own world. He became more responsive to Priestley's volume changes that allowed him, by imitation, to play with his own power. This reflected a positive transference. At this time he could not maintain this psychological dynamic of responsiveness for long, so he reverted to the safety of his repetitious rhythmic melodic figure on the xylophone. Perhaps Curtis' inability to tolerate intimacy and power, as he demonstrated when he stopped playing the cymbal and reverted to the xylophone, was a manifestation of his organic problems which caused him to become overwhelmed and to seek retreat to defend himself against mental or neurological overstimulation and chaos. Throughout, Curtis continued to hold himself rhythmically, as though he could not trust anyone to hold the rhythm for him. This might suggest that his early holding environment was so chaotic that he could not surrender control even though he reached out desperately to Priestley for intimacy by following her and imitating her musical expression. Priestley found that Curtis' improvisations that were based on fantasy titles caused a release of energy and expression in his music as well as in words (2: p. 201). It is interesting that in the two examples analyzed here, the fantasy improvisation indicated a direction that would help to break through his transference of dependence and enmeshment that was entrenched in the reality improvisation. The fantasy improvisation revealed a glimpse of a musical partnership with Priestley as Curtis allowed himself to follow her lead and explore the musical elements with greater flexibility. Period II: August 25 1978 to November 06, 1978 (11 sessions) Images: Self is Explored Through Reality and Fantasy Having concluded the myth based on fantasy that he created in period one, Curtis indirectly explored issues in his life that he wished to work on using titles such as Dependence/independence (1:8-31-78); Love (1:9-15-78); Hate (1:9-18-78); Gateway (1:9-2578); and What sort of person I am (1:10-9-78). Following these improvisations, he developed a narrative based on images related to a boat trip. He explored his illness symbolically by entering a cave mouth and finding a bear, and he attended to his feelings when he found a horse after going through a gateway. The White Lady made an appearance in one of his trips down the

river, and he engaged in creativity through play with porpoises when he dove under the water (1:10-9-78 to10-23-78). A more profound exploration of his psyche, symbolized by the image of a deep dive into the water in Down under the sea (1:10-23-78) was a continuation of the previous river theme. His last improvisation in this period explored a deserted room in a house that included the images of a harp that he played, fruit that he ate, and a window through which he saw a garden. Priestley interpreted these symbols as an indication of the feelings that he had been neglecting. In order to be able to do more in the world, he needed to be able to comfort himself more, which she felt he was doing in the images, in his life, and in the music (1:11-6-78). Life: Reaching Out to Others and Rediscovering Interests Curtis’ speech was becoming more spontaneous and expressive, and he was able to carry on dialogue with greater ease. He still found it difficult to concentrate, could not read books, and spent his evenings at home with his parents (1:10-16-78). In therapy, he had resisted talking about anything that was difficult in his life, stating that he could only cope with pleasant things (1:8-11-78), though in this period, he began to symbolically explore biographical material related to his past in a tentative manner through images and music (1:9-18-78; 10-23-78; 11-678). During this period, Curtis increased his awareness of and attention to his feelings as he worked on issues of autonomy versus dependence in the images and in the dyadic improvisations with Priestley (1:8-31-78). He maintained his job in the department store, began to attend a social skills group, and found a mutual interest in betting on horses with one of his work colleagues (1:10-30-78). It is interesting that the image of the horse, a symbol of feelings, had made a few appearances in his improvisations by this time. His new-found excitement of betting on the horses was coincidental with “betting” on his feelings in the imagery and music. Music: Awakening Creativity and Expression According to Priestley, during this period, Curtis' rhythm became somewhat bolder and the melodies were more creative and adventurous, with greater expressed emotion (2: p. 205). Although change was indicated by rhythmic and dynamic alterations within the improvisations, his music played the role of a "synthetic or synthesizing function of carefully balancing and holding together his lately disintegrated psyche" (2: p. 128). Down Under the Sea This improvisation occurred in the twenty-seventh session that was the penultimate session in period two (1:10-23-78). In her diary, Priestley stated that Curtis engaged in creative play when he dove into the sea where he played with a porpoise, then found a wreck and some old jewelry that he brought up to the surface. She interpreted the porpoise as a representation of herself; as a porpoise, she had come under the water to meet Curtis, but she stated that he had to do the work himself. Priestley saw the wreck as a symbol of his last illness, and the jewelry as a symbol of the values that he possessed, but had not yet used. Priestley's

countertransference also took on a symbolic form, that of a huge water snake, which she put into the music (1:10-23-78). Curtis used the xylophone almost exclusively throughout the improvisation with the exception of two sections where he used the cymbal for approximately fifteen seconds each. Based on an IAP analysis, the rhythmic ground controlled the rhythmic figures in all four segments and the meter subdivision ranged from stable to variable throughout three segments. The variability of the rhythmic figure was closely related to the variability of the melodic figure, both salient elements. Segments two and four introduced a change in the melodic and rhythmic figure, while segment three was notable for the change primarily in the rhythmic figure. The phrasing was stable, and it was congruent with the rhythmic and melodic elements. While the volume was undifferentiated because Curtis did not manipulate this element to create different part relationships, he nevertheless demonstrated greater flexibility in subtle volume changes throughout the four sections. In terms of musical autonomy, Curtis continued to alternate between roles of dependent and resister, but there were moments when he took the initiative and became a partner to Priestley. Psychodynamic Interpretation of the IAPs Throughout this improvisation, Curtis was resolving transference issues related to trust and dependency. At times, his defensive control of his environment through rhythmic and melodic perseveration resulted in him using all his energy trying to provide his own security. He was timidly following his impulses, but he didn't yet trust himself to invest in them. He had a symbiotic relationship with Priestley (mother) in which he depended on her for his feelings in the melody and he resisted her when she tried to get him to venture beyond his known world. It was as if he could still not trust that his environment could hold him if he allowed his attention and impulses to waver from the fixation of holding himself. Priestley created a holding environment for Curtis while encouraging him to explore new experiences she offered in her harmonic, rhythmic and melodic space. Through a positive transference, he was able to begin to internalize the secure, holding environment that Priestley offered and follow her invitation to play with his own power in the volume changes. He began to venture out into new experiences of his identity in the cymbal, which led to an emotion that he held on to in a fixated manner. He freed himself from this fixation by developing his instinctual drives into organized, cohesive goals in the phrasing. The final segment demonstrated that Curtis was beginning to develop his autonomy. Having experienced, to some extent, a secure internal holding environment, and having resolved some of his unconscious conflicts with Priestley, he was less fused with her and therefore less defended against her, which opened the possibility to following and leading in dynamic play with her in the volume. Thus, he began to liberate himself from having to hold on to his environment and he reduced his dependency on her. This was the meaning of Priestley's statement that though she came to meet him and play with him as a porpoise, he, alone, had to do the work of discovering his unexploited potential symbolized by the jewels he discovered during this improvisation (1). Period III: November 20, 1978 – July 02, 1979 (29 sessions)

Images: Fantasy Evokes Memory and Serves Reality The alternation of fantasy and reality images that had been established in the first eight months of work continued throughout this period. The deepening of Curtis’ self-communication and access to his imagery supported his burgeoning engagement with life and vice-versa. During the first part of this period, Curtis' images were closely related to life issues. As a result, many improvisations were reality rehearsals in which he imagined having conversations, meeting new people, and sharing meals with others or going on outings (1:12-18-78). For example, while improvising, he thought about what to say to each person in his social skills group (1:1-15-79) and imagined conversations he might have with an old friend who had contacted him (1:3-5-79 & 3-12-79). Before moving into a hostel, he did a number of improvisations in which he imagined moving there and participating in the chores and routines of daily life (1:11-27 to 12-11-78). After a number of reality rehearsals, Curtis' imagery again became based on fantasy. He imagined a Volcano (1:11-20-78), then improvised a series based on a sea voyage. He sailed to a desert island where there were no inhabitants, which Priestley interpreted as Curtis beginning to unfurl his sails as he visited a new part of himself (1:2-19-79), then he returned to the desert island to discover a spring where natives were eating and feeding fish to the parrots (1:2-2679). In Parrot and turtle he imagined joining the natives to cast nets for fish (1:3-19-79). Priestley interpreted the natives and parrot as the part of him that was searching for a more meaningful and richer life (1:3-19-79), and stated that he possessed both a thick-skinned turtle part and a rarer, but more flamboyant parrot part that was the singing part of himself (1:2-2679; 2: p. 140). Following the sea voyage series, Priestley encouraged an exploration of Curtis' past life events in reality-based improvisations with titles such as Separation and Autobiography (1:5-779 & 6-4-79). These images evoked memories of his early vocal studies (1:5-7-79) and his time spent in France (1:6-4-79), and brought up emotions related to the loss of his wife at the dissolution of their marriage (1:5-14-79). Interestingly, after having explored these memories through reality-based titles, he began for the first time to explore images that integrated life memories with fantasy elements (1:6-11-79 to 7-30-79). In subsequent improvisations, Curtis developed recurring images of the sailboat, water, and the voyage. These images sparked more memories of actual adventures he had had in France. He set off to sea on a moonlit night and arrived in a port where he had a meal (1: 6-1179). He found colorful bales of cloth and perfume that he loaded on board (1:6-18-79) then sailed back to England where he exchanged the cloth and perfume for fruit (1:6-25-79), and finally, he arranged a feast with dancing (1:7-2-79). Each of these improvisations also evoked memories related to his trips and to the time he spent abroad. Priestley interpreted these images as the colorful part of himself that he had left in France that he was now going back to reclaim (1:6-18-79). She stated that the boat was a symbol of his psyche holding him together as he sailed over the sea of quiet emotion (1:6-11-79). Life: Enacting Major Changes

Curtis made enormous changes in his life during this period of treatment in the areas of work, leisure, and interpersonal relationships. The fantasy improvisation entitled Volcano (1:11-2078) brought up sad feelings of how he had lost his sense of spontaneity, and perhaps served the purpose of motivating him to break out of the monotonous patterns that he had established in his life. The first major change he enacted was that he moved out of his parents’ home into a hostel (1:1-2-79). There, he met new people, cultivated a friendship with his roommate, began to cook for himself (1:11-27-78 & 6-25-79) and participated in leisure activities such as going to movies (1:1-8-79). He enjoyed doing the shared tasks of community living at the hostel and took on a part-time job as a volunteer for an elderly lady who was handicapped (1:5-7-79). Priestley noticed that he had more expression and spontaneity in his speech and body language (1:1-8-79). Although at first he found it difficult to keep up conversations with others, he used the musical dialogue he created with Priestley and the imagined conversations during reality rehearsal improvisations to practice connecting to others emotionally and verbally (1:1-22-79). These social skills helped him to become reacquainted with an old school friend who was now a doctor, and the old friend was able to feel comfortable enough with him to maintain this relationship (1:3-12-79). His new-found confidence motivated him to go to the cinema, dinners, concerts, and art galleries both alone and with new friends from the hostel (1:4-23-79). He stated that he was once again enjoying reading (1:4-2-79). He began to renew his relationship with his niece and nephew (1:12-4-78 &12-18-78) and experienced satisfaction in his ability to enjoy visits and a holiday with his family (1:1-2-79). With increased awareness of his feelings, Curtis was able to articulate the aspects of his life that were unsatisfactory. He stated that he felt anxious in the morning, and often had a sense of indistinctness or “not being definite” and that he was not able to remember things, though this was much better than it had been previously (1:4-23-79). The fantasy images that followed helped Curtis to rediscover memories through association. He recounted his youthful experiences at a boarding school (1:12-4-78) and followed his memories back to his first interest in studying singing at the age of 13 (1:5-7-79). He explored images and emotions related to the loss of his wife and briefly reminisced about the time they spent together in France during his vocal studies (1:6-4-79). In these images, he began to come to terms with the unraveling of his life at the onset of his illness. It seems that the process of revisiting the difficult memories of his time spent in France through imagery based on fantasy allowed him to recover happier memories and the excitement that also belonged to that time in his life. Music: Deepening Creativity and Expression During this period, Curtis explored his musical ability to express his feelings about internal and external events. He became more inventive with his use of musical elements; for example, his rhythms became adventurous (1:1- 8-79) and he developed greater autonomy in his playing (1:1-15-79). He continued to use improvisations to rehearse events that would occur in his life (1:2-12-79) and also used the improvisations to re-experience the success he felt after having engaged in these life events (1:3-12-79). He created desires and goals by imagining what he wanted, for example, his "ideal home" (1:4-2 & 4-9-79).

Curtis accessed the deeper regions of his psyche with fantasy improvisations that were based on his memories of life events and on an imaginative elaboration of these events (1:6-1179 to 7-19-79). Rather than being divorced from reality, these fantasy improvisations served the purpose of reclaiming the energy and emotions associated with his pre-morbid functioning, which stimulated his desire and awoke emotions related to his life in the present. An example of the vivid expression of emotions he experienced in the present occurred in the improvisation, The fracas. The Fracas This improvisation occurred in the thirty-seventh session (1:1-29-79). During an evening meal, Curtis and his roommate witnessed a violent exchange at the hostel that involved threats and a knife, though no one was physically harmed. Curtis chose to replay this event in an improvisation in which he and Priestley described the thematic sections as: 1) quiet eating music, 2) music depicting the argument, 3) tense eating as if nothing had happened music, 4) music that portrayed the conversation with his roommate afterwards, and 5) music depicting the conversation that took place a few days later with one of the persons involved in the fracas. The entire improvisation lasted nine minutes. The five sections can be identified by shifts in instrumentation and playing style. Although the xylophone was predominant for all sections and was used exclusively in sections three and five, Curtis also used the drum and cymbal at various moments in the improvisation. The eating music consisted of cymbal and xylophone; in the argument scene, Curtis used the drum almost exclusively apart from two beats of cymbal crashes. In the eating as if nothing had happened music, he used only the xylophone, while music that depicted the conversation with his roommate after the event used the xylophone, the drum, and the cymbal and drum together in three balanced segments, and in the final section, conversation a few days later, Curtis again used the xylophone exclusively. Priestley wrote in her diary, "it was the most expressive improvisation he’d ever done and he put much more expression into the music than into his words" (1). The animated use of the drum and cymbal with the xylophone added the dimension of timbre to the music in a dramatic way which indicated a new development in Curtis' playing. Summarizing the improvisation in IAP terminology, the timbre and tension were the salient elements and they contributed to other musical elements with varying degrees of prominence, depending on the segment. This variability in timbre, that was used cyclically from section to section, contributed to the tension. Tension was also derived from changes in volume that created variability in the drum and cymbal timbres. The meter, subdivisions, and tempos were also all variable among sections, and programmatic changes were identified by shifts in timbre, tempo, meter, and the rhythmic or melodic figure. In the sections that used the xylophone exclusively, Curtis used his characteristic melodic figure based on six ascending steps in a scale, but he varied the melodic figure by changing its direction or by introducing short motives based upon the main theme. He also employed variations in the tempo as well as greater variability in the rhythmic figure. The rhythmic ground was stable throughout the improvisation. In addition, Curtis developed more

autonomy and became a musical partner with Priestley, both following and initiating changes in volume, tempo, phrasing, and in the rhythmic and melodic figure. Psychodynamic Interpretation of the IAPs Based on images emanating from a real-life event, this improvisation provided Curtis with the opportunity to explore his own character from different vantage points. Old identities and old ways of being were juxtaposed with new aspects of his character that he was discovering. For example, in the eating as if nothing had happened segment, Curtis played the xylophone in a rigid way reminiscent of his early improvisations to express the denial of feelings (as if nothing had happened), while Priestley played the repressed feelings attached to the event. This suggests that Curtis associated the rigid way he played the xylophone when he began therapy with repression or denial. The difference now was that because of his internalized experience of a secure holding environment, Curtis had the liberty of choosing to play rigidly or not while he remained congruent with Priestley's contrasting music. Curtis' ability to create a stable rhythmic ground for himself without having to devote all his energy to the task of holding allowed him to develop the concept of object permanence and to separate from Priestley. His burgeoning sense of identity resulted in less anxiety and this gave him greater access to his emotions, freeing him to invest his energy in following his instincts in the rhythm, in recognizing his emotions and desires in the melody, and in directing them towards a goal in the phrasing and volume. Using the image of the argument, Curtis projected the more aggressive and powerful parts of his character onto the persona of his housemate, thereby discovering his own untapped potential for commitment, strength, and intensity. He developed his own power through his capacity to recognize, organize, and express his feelings and instinctual energy. His impulses and emotions were organized and congruent with each other and his feelings were consistent with the intensity of his urges. A stronger identity freed Curtis to cultivate greater intimacy in his contacts with others without having to inflexibly maintain his boundaries by blocking others out. This nascent responsiveness can be heard in the last two segments of the fracas. In the music, Curtis was able to leave space, listen to, support, and follow Priestley, and to respond to her spontaneously. Curtis' increased capacity for intimacy was possible because of the crystallization of his core identity through his experience of having had a secure holding environment in the musical transference. The reconstruction of Curtis' psyche fortified his ego, dissipated some of his anxiety that had been attached to defenses of repression, and freed him to become more connected to himself in the moment. The process of establishing intimacy with others and the recognition and expression of his emotions and drives continued in his work with Priestley throughout the last period of his treatment. Period IV: July 09, 1979 to April 27, 1981 (63 sessions) Images: Fantasy and Reality are Integrated The last part of the treatment was a period of consolidation of gains for Curtis as he continued to integrate fantasy and reality images. Reality-based images were imbued with the

richness that he formerly reserved for his fantasy improvisations and he consciously used these images to help him to concretize his wishes, to reclaim the excitement he had felt in his past, and to prepare himself psychologically to embrace a more challenging future. For example, Curtis used reality rehearsal techniques to prepare himself for a move into an apartment by improvising on images of preparing dinners (1:8-13-79); chatting with his roommate (1:8-2079); decorating his new home (1:2-11-80); inviting guests (1:8-13-80); and putting in a garden in his new flat or apartment (1:2-18-80). He also used imagery to prepare himself for the role of being best man at his friend's wedding (1:1-7-80). Curtis’ images not only prepared him for the future, but also acknowledged the transient joys of his recent past. At the beginning of his treatment, he used fantasy to bring meaning to his life which he found uninteresting. Now, pleasant, everyday experiences, such as a walk in a public garden with a friend (1:9-3-79) or an evening at the cinema (1:1-8-79), theatre (1:10-29-79), or concerts (1:12-31-79) became a theme in improvisations that permitted him to savor the memory through the images and the music. He imagined visiting France again; this led to more memories of his previous time in France (1:1-14-80 & 1-21-80). In a reciprocal manner, new discoveries in life sometimes served as a catalyst for images, such as the improvisation on the theme of Starry night that was inspired by his new interest in astronomy (1:12-1-80). As opposed to the purely concrete images or the fantasy magical thinking that typified the first period of treatment, Curtis was developing his ability to use metaphor consciously in his images. For example, a physical injury to his legs prompted improvisations based on themes of exploration of where his legs would take him (1:10-15-79 & 10-22-79). Another example of the use of images as metaphor occurred in an improvisation after Curtis saw the film Les enfants du paradis. He improvised on a beggar character in the movie who pretended to be disabled though he was actually a gold expert. Priestley wondered if Curtis was communicating that he was hiding behind his illness, and brought his attention to the fact that he was now finding his identity in being a well man, which was represented by the beggar’s gold treasure (1: 6-9-80). Similarly, after attending the musicals Sleeping Beauty (1:10-29-79) and Cinderella (1:118-81), Curtis improvised on images associated with these personas that were related to awakening and transformation, a process that he was undergoing in his life. In the last year of therapy, Curtis consciously used images as symbols to intensify intra and interpersonal communication. In an improvisation on Pandora’s box, he heard Hope’s voice after he let out the bad objects, and decided to keep Hope in the box, which Priestley interpreted as an attempt to control his persecutory objects (1:3-31-80). After an improvisation on the image of a Cross journey, Curtis said that the cross was his illness; this was one of the few times that he directly expressed feelings about his illness (1:12-10-79). He also used the image of Renoir’s Girl in blue watering a plant to express the feelings he had about his relationship with his niece (1:1-5-81). Finally, Curtis communicated that he was beginning to think about leaving therapy through an image of an uneaten meal for two people (1:10-27-80). Five months later, he expressed this more directly in an improvisation entitled Nightscene print, based on an image of a print he had purchased depicting a prince leaving at night (1:3-23-81). Thus, in the final stage of therapy, Curtis used his images to increase his quality of life and to meet new challenges through reality rehearsals; he used his memory to relive pleasant daily experiences, thereby reinforcing his motivation to continue to grow; and he used images

to evoke past memories that helped him to make sense of his experience, to reconnect to the qualities possessed by his pre-morbid self, and to integrate them with his present self. Curtis' psychological functioning became more abstract. He used metaphors to explore his unconscious and he used symbols to communicate with others and to intensify his intrapersonal communication. Life: Consolidating Gains and Ending Therapy In his life during this period, Curtis made major changes that demonstrated his growing ease with people and his increased autonomy. The reality rehearsal improvisations that he used as preparation to move into a flat with his roommate were qualitatively different from those he played in the earlier stages of therapy. For example, when Curtis was first preparing to move out of his parents' house (period three), the function of the reality rehearsals was to quell his fears and help him view the move to the hostel as an attainable goal, whereas now, his images were ego-driven with the emphasis on his desire and the confident creation of a pleasurable future (1:8-18-80). Curtis communicated more easily and established a mature, autonomous relationship with his family, taking a vacation with them (1:8- 4-80); visiting them (1:10-15-79 & 3-31-80); and cultivating an avuncular relationship with his niece and nephew (1:3-17-80 & 10- 6-80). He reached out to people to widen his circle of friends (1:12-79; 9-22-80 & 9-29-80), and his confidence in his social skills increased to the point that he accepted weekend invitations with his old school friend, participated in joint ventures with his friend and his friend’s fiancée (1:24-80), and efficiently carried out all the duties of best man at their wedding (1:4-28-80). Weekends became a time for creative adventure, whereas at the beginning of treatment, they were a time of anxiously trying to fill up the hours (1:9-15-80). He continued to work at the department store, but took on a more challenging volunteer job reading and helping to mark papers for a blind professor of French (1:5-14-80). Memories of his previous time in France revealed to him some of the things that he presently missed in his life, such as cultivating his interest in art (1:1-21-80). He wanted to have a greater knowledge of painting and he craved more clarity of thought (1:11-26-79). His memories of France (1:1-14-80) incited him to join the French Institute (1:6-16-80) and to enthusiastically pursue his interest in art with visits to galleries and purchases of prints and books on painting (1:12-31-79; 2-11-80 & 8-4-80). Although Curtis reclaimed his memories of the years he spent in France, he resisted exploring the difficult memories both verbally and in the music (1:10-1-79 & 12-10-79). Priestley felt that Curtis could not get to a depressive position about his losses (1:4-28-80 & 514-80), though she noticed more fleeting expressions of both sadness and joy in his music (1:24-80; 3-31-80 & 10-20-80). As he prepared for separation from Priestley and faced the end of his music-making with her, his musical pursuits became focused on attending concerts (1:1-21-80; 2-18-80 & 3-3-80) and learning to play the guitar (1:9-1-80). He used this newly acquired skill for musical expression and social interaction as he accompanied himself while singing popular songs (1:106-80; 1-13-80 & 1-5-81). Curtis stated that he felt he was becoming more thoughtful, better at planning, and had a “wider attitude towards life” (1:4-14-80).

In summary, during the last 22 months of therapy, Curtis worked on consolidating his gains by defining his goals, developing his creativity, and cultivating interests that would bring him a greater quality of life. Psychologically, the overall theme was that of awakening to life after illness. He gained greater access to past memories, and as he did so, he identified with his healthy, functional, and creative capacities that made it easier for him to focus on living in the present and to prepare for realistic goals in the near future. Achievement of goals and new interests gave him a sense of competence in the world. Finally, he successfully completed the tasks of separation and transition from the therapeutic relationship by finding fulfillment in the development and maintenance of his life relationships, and by bringing his music-making into a developmentally appropriate, functional sphere of life. Music: Becoming a Musical Partner and Creating Meaning The three recorded improvisations of this period reveal that Curtis' music became more expressive and creative. He was also acting as a musical partner with Priestley. This was evident in his autonomy and leadership in proposing musical ideas, and in the quality of his listening and sensitivity to Priestley in following her musical ideas. Nightscene Print This improvisation occurred in session 118 on March 23, 1981 (1). This was the third last session Curtis had with Priestley. The theme was based on a Japanese print that Curtis had bought depicting a young prince leaving at night. Priestley wondered in her diary if Curtis was thinking of leaving therapy at that time. She also stated that this improvisation was very mysterious and unusual and that his playing was more creative (1). An IAP analysis revealed that all the musical elements in this improvisation were salient. The timbre was salient in the opening of the improvisation when Curtis used the cymbal. However, after the first segment, he played the xylophone exclusively for the remainder of the improvisation. In the xylophone playing, Curtis began with his usual melodic figure of five ascending notes, then he proceeded to vary this theme rhythmically and melodically throughout the improvisation, creating a form of theme and variations. Curtis' expressivity was evident in all the musical elements: volume, timbre, phrasing, rhythm, and melody, which were all variable. Curtis initiated changes in tempo, volume, meter, and musical character. He was also sensitive to changes that Priestley made and complemented them, taking on a balanced role of both leader and partner. This improvisation demonstrated a significant development in sensitivity and creativity in Curtis' playing, particularly as compared to the rigid improvisations he did in period one. The rhythmic figure, which was integrated with its ground, was variable and was more developed in character and more flexible than in previous improvisations. Tempo changes and volume changes as well as beat subdivisions and metric changes were used in a variable way for expressive ends with frequent use of rubato, accelerandos and ritardandos. The phrasing was variable as it conformed to the changes that occurred in the rhythmic ground and in the rhythmic and melodic figures. The melodic figure, which was integrated with its ground, was variable, because Curtis employed changes in melodic direction, some intervallic leaps, and

melodic motives of different character and length. Accents and phrasing conformed to the variability in the rhythmic and melodic figures. Psychodynamic Interpretation of the IAPs It is difficult to listen to this improvisation without feeling awe at the changes in Curtis' music that had occurred since his first improvisations. The core of his identity as it was expressed in his first sessions was still heard in the ascending repetitions on a five note scale, but the rigid and perseverative theme of the early improvisations had become enriched with rhythmic and melodic variations as well as fluidly-changing dynamics. The positive transference with Priestley freed Curtis to be adventurous and to interact with her spontaneously; he was able to move both towards himself and towards her in the music. The dyadic musical relationship with Priestley had the quality of equals exchanging intimate feelings and tenderly supporting each other. Psychologically, Curtis was now able to establish intimate, authentic relationships with others, and to act in the world in a way that would fulfill his desires and advance his goals towards accomplishments. Secure in the knowledge that his instinctual forces would not become overwhelming to him, he could organize and direct his impulses towards the achievement of personal goals and desires. Unconscious conflicts that had kept him rigidly defended and fixated were no longer blocking the energy and creativity in his life. He was able to experience the flow of energy in his body, recognize the many emotions that were carried by this flow, and express these feelings in his music. Connection to his inner life gave him a stronger sense of his identity and freed him from needing to maintain his psychological integrity by creating rigid boundaries between himself and others. He was able to play with his own power, experimenting with using his energy to lead and create, or using it to be sensitive and responsive, while leaving space in which he could dialogue with others. It is interesting that Curtis chose an image from a print that he had bought as the theme of this improvisation. One of the aspects of his life that had changed over the course of therapy was his renewed interest in art and music; both were passions that he had abandoned when he became ill. At the beginning of therapy, Curtis used the fantasy myth of the maiden and the romantic quest to gain access to his psychic energy and his emotions, whereas now, he gravitated towards an object which he found in the world that reflected a psychological problem that he was grappling with. Curtis used the image with its message of stealing away to help him deal with the separation from Priestley that he knew was inevitable, and also used it to communicate to Priestley that he was thinking about termination of treatment. Thus, Curtis was able to use both abstract and concrete thinking, and fantasy and reality in the service of his imagination, feelings, desires and will, with the goal of self-expression and communication in order to achieve his objective of continued growth. Discussion Personal Bias Influencing my Approach to this Study

The purpose of this study was to determine if it was possible to see changes in Curtis' imagery and life and to hear changes in his improvised music over the course of his therapy. This purpose determined my approach to the study and it was influenced by a personal bias that changes in music or imagery should facilitate and reflect positive life changes. This bias stems from my clinical work with persons with chronic mental illness. Therefore, I was particularly interested to discover if there were parallels among the changes in Curtis' music, images, and life over time, and if so, what meaning these changes had and whether they altered Curtis' quality of life significantly. Changes related to Curtis' life and images were recorded in Priestley's diaries; however, deriving meaning from the music improvisations necessitated a method of analysis that would consistently reveal not only changes in the musical elements, but also, the symbolic significance and meaning of these changes. In the music therapy literature, the most common approach to deriving meaning from the client's improvisations is to describe what one hears in the music in a phenomenological way and relate this to the salient aspect of the treatment that is being discussed. Because I had no direct contact with Curtis as a client, I did not have an intimate sense of his process throughout his therapy from which to draw upon. Thus, in this historical reconstruction, Curtis' recorded improvisations took on a primordial importance as the most direct link that I had with him that could help me to better understand him and his process in AMT. The written sources that I had access to – Priestley's diary entries (1) and her published chapter (2) clearly demonstrated the changes in Curtis' life events and his images, and I wondered if a systematic way of analyzing the music would yield similar detailed results. Structural analyses used to understand the formal aspects of occidental music, whether the music is in a classical, jazz, or popular style, are useful in comprehending the composer's construction of phrase, harmony, rhythm, melody, and form. However, subjective meaning is not usually extrapolated from such analyses. For this study, in which the personal significance of the music is a vital component, I considered a using a phenomenological approach that would allow me to infer meaning from Curtis' music. I was wary that without having had direct contact with Curtis, I might be unaware of a bias in my listening. Furthermore, I could not fully comprehend the context surrounding Curtis' creation of the music. In the IAPs, each musical element is presented with a number of scales within each profile and they include clear definitions related to the quality of each musical element. Further meaning can then be derived from the application of an interpretive frame of psychodynamic concepts as applied to the musical elements. I therefore decided to use the IAPs, which provided me with a more objective structured and systematic approach with which to analyze each musical element. I had expected that it would take considerable effort to become adept at using the IAPs and I was concerned at the interpretive skill involved in making psychodynamic interpretations. I discovered that in order to manipulate the many elements in the analytic tool of the IAPs, it was necessary for me to make subjective decisions to determine the salience of musical elements. Initially, I also found it difficult to avoid integrating a descriptive, phenomenological language into the IAP analysis, which seemed at the time to render the analysis more meaningful and therefore, more useful to me. I wondered what the structured IAP language could possibly yield in terms of making meaning of the changes in the musical elements that were brought to light by the IAP analyses of Curtis' improvisations.

Once I began to work on the psychodynamic interpretations, I discovered that I was afforded considerable clarity in grasping the essential meaning of the musical elements by virtue of having avoided phenomenological descriptions of the music. In contrast, the focused language of the profiles and scales of the IAPs as applied to the salience of each musical element revealed aspects of Curtis' music that I would not have been aware of in a more open listening approach. The psychodynamic application of the IAPs included guidelines with which to interpret each musical element within the profiles, thereby uncovering the meaning which lay at the heart of Curtis' music. Thus, with Priestley's diaries and audiotapes and the psychodynamic interpretation of the IAPs, it was possible to discover how Curtis made changes in his images, life, and music over the course of three years of therapy with Priestley. Implications for Use of IAPs Beyond this Study One result of having become more adept at using the IAPs during the course of this study is that they have also provided me with a new way of listening to my clients' improvised music. In turn, this has engendered a new means of understanding and making meaning of the way that a particular client uses or avoids each musical element. The acquisition of this analytical tool has provided me with an answer to a question that had long plagued me – how to listen to and analyze the clients' improvisations in a way that would provide me with some insight into their process and character and personal issues, and how to better guide the client to work out therapeutic issues in the music-making. I have found that similar themes have been raised frequently by students in improvisation class, for example: what is the significance that making music has for the client, and how can the therapist make meaning of the client's improvisations and gain insight from them. I now find that I am teaching in a different way, calling my students' attention to a close listening to the musical elements and their meaning within the psychodynamic interpretation of the IAPs. Ultimately, each music therapist will find his or her own answers to the question of how to make meaning of the client's music and each researcher will discover his or her unique language to present the music improvisations in a way that is significant to his or her research. Because of the discoveries I made in this study, I believe that the IAPs are an analytical tool that has the potential to provide much insight for clinicians and researchers alike. Thus, while the IAPs are not the only way to derive meaning from or to understand a client's music, they offer a structured, systematic method of analysis that goes beyond both phenomenological description and formal analysis. This implies that an introduction of the IAPs to the graduate music therapy curriculum would be useful in applications to research and clinical work by providing a systematic way to gain insight into clients' improvised music. Changes in Images, Life, and Music in the Case Study of Curtis The results of this study revealed that changes in all three areas did occur and that these changes were interrelated; changes heard in the music and seen in Curtis' imagery were congruent with changes that he enacted in his life. In the music, Curtis became more creative and expressive, demonstrating greater flexibility over time; he created a strong rhythmic pulse,

became rhythmically inventive, and he created melodic phrases. He explored new timbres and developed greater autonomy along with an ability to interact musically with Priestley in creative ways as an equal partner. One of the limitations of this study was the lack of recorded improvisations from session 35 (February 05, 1979) to session 115 (March 02, 1981). Clearly, there was an extended period of time during which there was no documentation of music. It was fortuitous that Priestley continued to document improvisation titles, images, and life changes in her diary entries during this time, and that she recorded the last three improvisations. These improvisations clearly demonstrated the musical changes that had taken place in the interim, and the seven extant audiotapes showed the process of gradual change that had begun in Curtis' music. Concurrently with the musical changes, Curtis made life changes that demanded greater autonomy and that were linked to his desires and to his creativity. These changes served to motivate Curtis to make more demanding life changes. Life changes included moving into more autonomous living situations, making new friends, rekindling an old friendship, taking on new responsibilities, and renewing his relationship with family members. As Curtis developed a stronger sense of self, he pursued interests and desires that were based on aspects of his identity that he reclaimed and developed during his work with Priestley. He embarked on creative ventures such as going to concerts and galleries, taking trips abroad, learning to play the guitar, joining the French Institute, and taking on volunteer work that he found to be interesting and fulfilling. When Priestley wrote the chapter, "Analytical music therapy and the 'detour through phantasy'" (2: pp. 199-206), she had been struck by the difference in Curtis' music when he improvised on reality as opposed to fantasy themes. Based on her reading of Heinz Hartmann's theories on ego psychology, Priestley stated that the use of fantasy in improvisations was often the only way to help her clients adapt to reality (2: p. 199). She theorized that in order for Curtis to have access to his internal drives and creativity, he first had to have greater access to his capacity for fantasy, for it was in the fantasy improvisations that Curtis was most easily able to release his energy in musical and verbal expression (2: p. 201). The use of fantasy and reality in Curtis' imagery and improvisation titles underwent a process of change during his therapy that paralleled his psychological changes and growth. Throughout the three years of therapy, Curtis used fantasy and reality improvisations differently. At the beginning, fantasy and reality were opposed to each other; the fantasy improvisations were based on unconscious and primary process material that Curtis could not consciously interpret, while the reality improvisations were more lacking in expression than the fantasy-based improvisations. Later, Curtis consciously explored his identity through reality improvisations, while he was able to use the fantasy improvisations to make connections between his inner life and desires and his images. In the third period, fantasy was intertwined with reality in his improvisations; the fantasy contained aspects of reality and served to evoke memory and increase his sense of self and reclaim aspects of his identity rooted in the past. Finally, in the last period of treatment, fantasy and reality became fully integrated; Curtis was able to use abstract thinking; he used symbols to deepen his understanding of himself and to communicate with others.

Thus, this study led to a discovery of how images, music, and life were related for Curtis throughout his course of AMT for three years, and how the changes in Curtis' improvisations reflected the changes he made in his imagery and in his life. References for Priestley Sources Cited in the Study 1. Priestley, Mary. (March 17, 1978 to April 27, 1981). Personal Diaries. Temple University Archives, Paley Library. 2. Priestley, M. (1994). Essays on analytical music therapy. Phoenixville: Barcelona Publishers. 3. Priestley, M. (1975). Music therapy in action. London: Constable. References Bruscia, K. (1987). Improvisational models of music therapy. Springfield, Illinois: Charles C. Thomas. Langenberg, M. (1995). From isolation to bonding: A music therapy case study of a patient with chronic migraines. The Arts in Psychotherapy, 22(2), pp. 87-101. Mahns, W. (2003). Speaking without talking: Fifty analytical music therapy sessions with a boy with selective mutism. In S. Hadley (Ed.), Psychodynamic music therapy: Case studies (pp. 5372). Gilsum, NH: Barcelona Publishers. Pederson, I. (2002). Analytical music therapy with adults in mental health and in counselling work. In J. Eschen (Ed.), Analytical Music Therapy (pp. 64-84). London: Jessica Kingsley Publishers. Pederson, I. (2003). The revival of the frozen sea urchin: Music therapy with a psychiatric patient. In S. Hadley (Ed.), Psychodynamic music therapy: Case studies (pp. 375-388). Gilsum, NH: Barcelona Publishers. Purdon, C. (2002). The role of music in analytical music therapy: music as a carrier of stories. In J. Eschen (Ed.), Analytical music therapy (pp. 104-115). London: Jessica Kingsley Publishers. Scheiby, B. (1991). Mia's fourteenth — the symphony of fate: Psychodynamic improvisation therapy with a music therapy student in training. In K. Bruscia (Ed.), Case studies in music therapy (pp. 271-290). Phoenixville, PA: Barcelona Publishers. Scheiby, B. (1998). The role of musical countertransference in analytical music therapy. In K. Bruscia (Ed.), The dynamics of music psychotherapy (pp. 213-248). Gilsum, NH: Barcelona Publishers. Wigram, T., Pedersen, I., & Bonde, L. (2002). A comprehensive guide to music therapy: Theory, clinical practice, research and training. London: Jessica Kingsley Publishers.

Appendix: Definition of Terms Used in IAPS i Types of Relationships • Figure-Ground Relationships: The ground is the basic matrix, environment, material, context, or underlying structure out which a figure is formed; the figure is the pattern, design, or entity that is created out of the ground. The figure is created to be heard against its background; it emerges from embeddedness as an independent entity to be attended. Figure-ground relationships are always simultaneous, and are most relevant to the rhythmic elements and the tonal elements. The integration profile is used to analyze figure-ground relationships. • Part-whole relationships: A part is any independent voice, strand, or configuration in the music that makes up part of the whole texture of the piece, because it plays a “role” in the music such as solo or accompaniment. For example: 2+ simultaneous rhythmic parts, or melodies, or instruments, or players, or any accompaniment pattern. Simultaneous part-whole relationships form the “texture” of the piece, and are analyzed according to the various integration scales. Successive part-whole relationships constitute the “form” of the piece, and are analyzed according to the variability profile. Levels of Relationship in Improvisation • Intramusical relationships: how the elements and components within one person’s music are related to one another. Includes only within-music-within-individual relationships. • Intermusical relationships: how the elements and components of one person’s music relate to the elements and components of another person’s music. Includes only between-music-between-individual relationships. • Intrapersonal relationships: how parts of the self relate to one another, for example, how the musical and nonmusical selves are related, how emotions are related to behavior, etc. • Interpersonal relationships: how musical and nonmusical parts of each person’s self are related to one another. Rhythmic Elements • Rhythmic Grounds: pulse, subdivision, tempo, meter • Rhythmic Figure: rhythm pattern or theme • Pulse: a division of time into equal, recurring segments that are marked off by equally significant events. • Subdivision: equal divisions of the pulse into shorter temporal units. • Tempo: the speed of the pulse. • Meter: the organization of pulse into numerical units • Rhythm: a sequence of sounds and silences of varying durations and emphases that relate in some way to one another and/or the rhythmic ground. Tonal Elements • Tonal Grounds: Modality, Tonality, Harmony. • Tonal Figure: Melody. • Modality: a delimitation of pitches that can be used horizontally (melodically) or vertically (harmonically). Also called “scale.” • Tonality: the means by which pitches are organized around a tonal center or resting point. • Harmony: A sequence of simultaneous combination of pitches (chords), which may or may not be organized according to intervals between the pitches (tertian, quartal, quintal), a modality, and/or tonality. • Melody: a sequential arrangement of pitches that move in different directions at different intervals from one another to form a contour. Sound Elements • Timbre: Identity or character of music-maker. • Volume: Power, strength, intensity, size of commitment.

Structural Elements • Phrase: The syntactical and prosodic structure for melody; the physical or motoric structure for rhythm; the element which unites the physical, emotional and cognitive. The temporal-physical boundaries for feelings and ideas. • Texture: Fabric: role relationships of the various musical parts, along with organizational strategies and hierarchies. • Register and voicing: where parts are in relation to one another; degree of intimacy. Spatial-physical relationships between psychological parts. The Six Profiles • Integration: Reflex organization, sensorimotor coordination, physical boundaries, figure-ground and partwhole perception, perceptual illusions, impulsivity, field-dependence, emotional individuation, role boundaries. The basic well-formedness of the individual. • Variability: Control issues; need for sameness or change, regression or progression, retention or invention; conservativism versus liberalism; preferred time zone; fear; ability to integrate past, present, and future. The openness of the person to the birth-death-rebirth cycle. • Tension: The origin, direction, aim and impact of both psychic and physical energy; location of conflicts and methods of resolution; reveals stress and anxiety in relation to the elements and profiles. • Salience: The need for attention, recognition, power, or control; the person's agenda; differentiates conscious and unconscious; hierarchy of concerns and values. • Congruence: Reveals latent or unconscious conflicts. • Autonomy: Awareness of self and other; identity issues, role boundaries, tolerance, aggression, need for control. Interpersonal stances are: toward self and other, toward self and away from other, toward self and against other, toward other and away from self, and toward other and against self.

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

CASE TEN Edwin, Who Murdered His Wife in a Psychotic Attack: A Case Analysis Chava Sekeles Set me as a seal upon thine heart, as a seal upon thine arm; For love is strong as death; jealousy is cruel as the grave; The coals thereof are coals of fire, Which hath a most vehement flame.” (“Solomon’s Song” Chapter 8:6) Introduction Edwin was a tall, handsome man in his late twenties when he was hospitalized in the psychiatric hospital in which I was employed. He referred himself to music therapy, presenting himself as a folk musician who could not live without music. After obtaining confirmation from his psychiatrist, I began to work with him simultaneously in both individual and group therapy. The process endured five years of ups and downs, regressions and progressions, deep depressions, and periods of flourishing creativity. Edwin had been a stranger in this particular country as I myself had been. We were both faced to cope with being immigrants; we both came from different language and musical cultures and had to contend with a new mentality as well as with the cultural gap between client and therapist. Individual Intake Edwin was diagnosed as suffering from schizo-affective disorder in which there are clinical symptoms present from both categories of schizophrenia and affective diseases. Edwin exhibited pathological signs in his early adulthood. He married when he was 19 years old, and his wife bore a baby daughter a year later. By that time, his condition had deteriorated. He was hospitalized and released home two years afterward. His relationship with his wife had been a complicated one from the very beginning. A cultural gap had existed between them, she hadn’t been able to cope with his illness and occasional aggressive outbursts, and he had always been suspicious of her and had a preset misgiving concerning the origin of his daughter. Schizoaffective disorder has schizo-depressive waves and schizo-manic waves. During one of the schizo-manic waves, Edwin had killed his wife with his own two hands, handed the baby over to a neighbor, and hospitalized himself. When I first met Edwin, he had already been hospitalized for a year (second hospitalization).1

The music therapy room was very spacious, furnished with ancient furniture. It had tall, narrow windows; a stony floor; a cage with midget parrots; and some flourishing plants. Musical instruments hung from the walls; huge, self-made pottery drums and an upright piano covered the floor; and ancient records and big cassettes sat on bookshelves. The room was an antithesis of a traditional hospital space and enabled both individual and group music therapy. In addition, I was technically able to build musical instruments there with the patients, thereby developing creativity as well as saving on budget expenses.2 Process. When Edwin first entered the room, he immediately chose the guitar and began to play and sing a spiritual piece. He sang in English and continued, moving from one song to the other. Half an hour passed as Edwin played. I listened and no word was uttered. In the meantime, the sun sank, the room darkened, and Edwin had to return to his ward. As he left, he said, “Next time, I’ll play my own composed songs.” Throughout the entire session, he had not expressed interest in the various possibilities the music room offered and had attempted only what he had felt comfortable with, singing and accompanying himself. His playing had been clear and fluent, his bass voice warm and beautiful, and it had been apparent to me that he possessed natural talent. His mood had been somewhat quiet and reserved. Group Intake The group was composed of three patients hospitalized from 20 to 35 years, plus Edwin. They were all from the same ward. The condition of the additional three group members was that of chronic patients. This was at a time when the psychotropic treatment (psychiatric drugs) was at an early stage of development, in comparison to the present. The three members of the group, Anton, David, and Donald, were diagnosed as schizophrenic patients. They were very passive, barely spoke, and expressed themselves through a kind of muttering-speech and sometimes through neologism.3 They moved about mechanically and suffered from uncontrolled movements and salivation, hallucinations, and disorders of thought, affect, and perception. Anton and Donald were especially paranoid4 and were certain that they were being eavesdropped on through the radio wires and that the FBI was after them. They all experienced side effects;5 David entered a catatonic state6 several times and most of the time seemed to be out of reach.” All members of the group participated in both individual and group music therapy. In addition, due to a tradition I had regulated at this hospital, they also contributed once a month to an open evening, in which music was presented and created in a free fashion. Patients (sometimes 100) and staff members participated in these evenings. This tradition helped us to make music a welcome guest at our hospital and easily celebrate holidays and other festivities. My view was that most of our patients considered the hospital their home. We therefore needed to integrate musical activities to enrich the entire community and not just those who participated in the music therapy sessions. For the open evenings, we occasionally invited wellknown performers or music students and at times attended concerts outside the hospital or took musical instruments to play-sing in nature. From this short description, it is probably clear that the patients attending the small therapy group knew each other from other activities, had individual music therapy sessions,

and were willing to take part in group music therapy. Consequently, the intake-observation session was as natural a process as possible for them. Initiatives. Edwin took the guitar, asked the others to choose musical instruments, and formed an improvisational group. The patients were obviously pleased that Edwin had taken the initiative and responsibility. Edwin played a South American rhythmical tune and the others joined in with drums, sticks, and rattles. As they were familiar with recordings, with their permission, we recorded the group improvisation and listened to it afterward. Although Edwin was the initiator, the leader, and the domineering figure throughout the improvisation, at the end of the session he himself suggested that next time they decide together what to do. In his next individual session, he said to me, “I apologize for assuming your role, but I know those people have no energy and I wanted to help you.” In the short conversation that ensued, I told him that his idea of sharing would be very helpful and encouraging for the entire group. A week later, it was obvious that Edwin was entering a schizo-manic wave. His mood became heightened; he began to speak of his talents in an exaggerated manner, had some paranoid thoughts, and sometimes lost control. It was easier to handle him in individual music therapy than within the group. From here on, after describing the music therapy settings in which Edwin participated, I would like to focus mainly on Edwin development as a result of both group music therapy and the individual sessions. When Edwin brought his own composed songs to therapy, I took note of several issues: • • • • • •

Edwin’s last song had been composed five years ago. The themes of his writing were nature, love, and, generally, sweet, “chocolate box” content. He could write songs in two languages, but preferred English. Edwin communicated through his songs but remained in the safe land of poetic beauty. Even when he wrote a love song, he generalized it and did not touch upon his personal feelings. Most of his songs had probably been written during schizo-manic phases.

Therapeutic Considerations The group was based on the ward psychiatrist recommendation. Edwin was much less regressed than the other members of the group. In a way, this position contributed to his selfconfidence, specifically due to his authentic talent and development in music. Through music, he was able to experience himself as strong, creative, and contributing. Paradoxically, this also created a problem that hadn’t existed in individual therapy, as he threatened the group members’ already limited ability to take initiative. This led them to become even more passive and to delegate the responsibility of action to Edwin. On the other hand, Edwin supplied the group with a natural leader, which Freud (1921) declared an essential condition of group therapy. Moreover, this provided an opportunity for constructive work within the group on sharing, cooperation, and mutual creation rather than eventually allowing the members of the

group to reject Edwin. I therefore planned to develop and maintain several organizational conditions concerning the group: • • • • • •

Set rules to enable continuity. Establish group tradition. Encourage individual development and functioning. Shift leadership. Build a supportive group. Get the group to contribute to the hospital’s community life.

As all members of the group participated in individual music therapy, I supposed that in this setting it would be possible to accentuate the work on weaker functions in favor of the group therapy. As aforementioned, Edwin had stated that he would try to be less domineering in the group, and I had to wait to see if he would indeed keep his word. In reality, he became less and less dominant and much more sociable. Approach and Technique 1. Warm-up (Movement). Throughout the years I worked as a music therapist with psychiatric patients, I always took care to invest the beginning of each session in preparing for whatever came afterward (“warming up” as employed in the terminology of dance-movement therapists). Indeed, this mostly included body-movement work, either active or receptive. With chronic patients, I found that receptive-meditative exercises may attain a negative result by intensifying the patient’s isolation and regression. I thereby employed mostly energetic movement techniques with gradual deceleration. These included guided movements (guided by music and by the therapist’s instruction) or improvisations stimulated by the music alone. Repeating these every session contributed to the continuity as well as to the establishment of traditional customs in the group. Chronic psychiatric patients require many repetitions and safe boundaries to strengthen their poor self-confidence and enable the development of trust both in the therapist and in the members of the group. In a way, this group often behaved as children, which makes it appropriate to quote Slavson’s (1952) words: In individual therapy, the client relates himself to the therapist; in group therapy, the intent is that the child should relate himself to the group as well as to the individuals in it. The therapist’s role is that of catalytic agent in this process. His attitude of acceptance, friendliness, and appreciativeness sets up like attitudes in the children toward one another. The group therapist is also a synthesizing influence for the group (p. 138). The opening of each session soon produced positive results. Those patients who were very passive most of the day became more energetic and began to use their bodies in new

ways. Edwin, who came from a culture that encouraged movement, had a natural way with movement and undoubtedly inspired the others. This introduction would last 15 minutes and was divided into instructed and free movement. 2. The Musical Circle. The following stage consisted of sitting in a circle and, after a short discussion and a mutual decision, making music. As for the verbal part, generally speaking it had been very poor. Many times, I felt that they had simply forgotten how to talk. Conversely, knowing that I was a foreigner to their language, they amazed me by trying extra hard to be clear. Edwin’s speech, on the other hand, was clear, but he lacked the desire to verbally share any content with the group. In his individual music therapy, I had the chance to work on this very issue. 3. Folk Songs and Singing. After the abovementioned segment of the group therapy, we moved to closing the hour. This was done by singing the members’ ethnic songs according to their choice. At first, they preferred to leave the choice to me, but it gradually became apparent to them that the hour was theirs and so was the responsibility. I decided to place books with folk music and texts in the center of our circle and to allow the patients to choose. Each chosen song was typed up afterward, allowing us to later form a book from the songs we collected over the years. The members of the group (including Edwin) chose songs from their childhood and adolescence. Those songs reminded them of a better era in their life and aroused nostalgic feelings. As music therapists, when we work abroad in a different musical culture, it is imperative to study the new culture and mentality and to attempt to understand and imagine its importance for the local residents or, in this case, for the patients. I would sit for endless hours learning entire song books, preparing myself for my patient requests. I believed, among other things, that it gave the patients a sense of “being honored.” Edwin added a colorful mood to the folk songs by bringing songs from his childhood and country and teaching us a few. Eventually, David said to me: “Bring songs from the Holy Land.” This request was very moving from a man who barely spoke. I indeed added a couple of Israeli songs to their collection that I translated to enable the group to sing them.7 The voice is the most natural musical instrument, the one we carry with us everywhere. Singing integrates physical operation (the use of organs that participate in this action: throat, vocal cords, diaphragm, lungs) with emotional expression by employing the natural musical elements that create emotionality: range of voice, volume, and tempo; socialization (togetherness, sharing, creating varied interactions, and group cohesion); and cognitive skills (the use of language). Randi Rolvsjord (2005), who wrote from her experience in psychiatry, listed the following features: Songs are a common form of expression; songs can be performed over and over again; songs can be shared; songs can be kept and stored away (p. 98). The singing of folk songs and the growing interest in facilitating the voice brought about a new development in the group. 4. Composing Personal Songs. Edwin brought his previously composed songs to his individual sessions and gradually began to work on new material. Though he touched upon more emotional issues through them, he never mentioned the circumstances that led him to murder his wife. Neither was this topic brought up by the other patients. The psychiatrist of the ward, who was also my supervisor, advised me not to touch on the subject unless Edwin elicited

it. In the meantime, Edwin’s songs began to emit a sad, tragic color: They described loneliness, hostility, disappointment, failure in relationships with women, and a feeling of not being understood. I sensed that this circumventing approach was his way of sharing personal material and of grieving for his wife and his son. At times, he would bring a song he composed to a group session and perform it. Once, Anton suddenly suggested writing a group hymn. Working on this hymn, a new gate was opened in which words began to play an important role. This held true for all the members of the group. Another phenomenon was that because Edwin and I had not yet mastered the language, the three schizophrenic patients took on a more active role. They would also at times introduce neologism, to which I agreed on the condition that the one responsible would explain the meaning of the word to the group. We performed this exercise by writing on a large board so that everyone would be able to contribute a word, an idea, a sentence, etc. We would discuss the content and try to agree on it. I was very pleased to witness the patients arguing over a word or an idea and to watch them emerge from their shells. Edwin became very active and was actually happy to learn the language, as in individual music therapy he wrote only in English. In order to stimulate and encourage the members to participate in the writing, I used word games, nonsense and/or descriptive sentences, word or sentence completion, the choosing of keywords, etc. (see Wigram, 2005, pp. 246-265). Composing the music was sometimes done after the text was prepared and at other times preceded the text. I assisted by accompanying the creation of the melody on the piano through different techniques, such as allowing each patient to improvise on one sentence and working on it until it became integrated in the song. It often took three weeks or more to finish a song, gradually becoming the project of our second book. 5. The Creation of a Musical. Edwin came up with the idea of composing a musical on the everyday life of the psychiatric patient and the manner in which the normal community perceived him/her. This idea frightened Anton, David, and Donald, but Edwin convinced them and so the work began. Brainstorming and Creation This stage lasted one month, during which we gathered topics of interest so that all members of the group would be able to participate and contribute. As in group composing, I used the school board in a way that required the participants to raise their heads, an act that is difficult for someone pumped up with medication and fatigued part of the time. These were the topics elicited by the group in their chronological order: Our pills. The nurses. The psychiatrist. Good morning, how are you today? Potatoes-animals on the plate. We want to get out, to be free.

We’re home? I wish I could stay in bed. I wish I would die. I feel lonely. My wife left me and took the children. I killed my wife and lost my daughter. I feel depressed. We are strange. We frighten people and they hate us. From this list, which was accompanied by slow, tiresome discussions, we were able to learn a lot about the patients. They were concerned with the enduring necessity to swallow pills, and, in the conversations, all four expressed the fear that the pills were poisoning them and that the nurses and doctors wanted to get rid of them. They also admitted that they sometimes threw the pills away. Indeed, a severe problem of compliance exists concerning psychotropic medicine. This was specifically the case at the beginning stages of psychotropic development. Many patients resisted, were afraid of the side effects, did not understand the correlation between the medication and its influence, held prejudiced notions regarding the subject, etc. Elizur, Tyano, Munitz, and Neumann (1990) claim that compliance consists of physiological, pharmacological, and psychological aspects that are of cardinal importance in psychiatry (p. 397). Understandably, the fact that the patients had permitted themselves to open up and discuss this issue had already provided them with a sense of relief. In addition, I invited their psychiatrist to one of our group sessions to broaden the discussion and moderate the anxiety. The song composed on the pills dealt with all of the aspects they had mentioned during the brainstorming, with Edwin serving as the main originator of the melody. Another subject was the nurses and psychiatrists (the medical team). The patients felt as though they acted as jail wardens, although I must say objectively that it was one of the most advanced and enlightened hospitals I have ever observed. This had, however, been their subjective feeling, and at that stage I had to contain it. Anton said that every morning when the nurse asked him, “How are you today, Anton?” he envisioned her as an inquisitor who wanted to harm him. Sometimes she looked like a black queen with long nails to him. Donald, who also had strong paranoid traits, said that he couldn’t stand certain foods because they turned to animals, beasts, or insects on his plate. This instigated a lengthy conversation on the misery of hallucinations and delusions, issues they mainly dealt with through denial. The second song that was created described the way they perceived the medical team and how they experienced the world. The music was gradually composed by all members of the group, with my harmonic support on the piano. Following these occurrences, they embarked on a phase in which they began to discuss their isolation and loneliness. Then, suddenly, Edwin raised his issue: “I killed my wife and lost my daughter.” It seemed as though the members of the group accepted this statement with no wonder or fear, as though they had previously discussed it. I knew from the psychiatrist that they all knew, but that Edwin had never mentioned his history. We agreed to work on it in

individual music therapy, but this never transpired. Edwin raised the topic and closed it in the same breath. It did, however, prompt him to talk about his loneliness, sadness, and anxieties. The last subjects, “We are strange,” “We frighten people and they hate us,” were easier for the group to deal with, as they tended to split their reality into them/the world and we/the inside prisoners. It was amazing how incredibly overloaded their emotional world was and that they were able to work on such topics though they were severely chronic patients, hospitalized for 20 or more years. Throughout this entire lengthy process, Edwin served as a member who could clarify what others had stammered or had muttered inaudibly with a few words. It was obvious that he gained much self-confidence from this process. My objective as therapist was to provide each participant a place of respect among the group members although their contributions were different or unequal. The musical was never completed. The group composed six songs in over half a year, but from my point of view, it was a great achievement mainly due to the process they had undergone and, in a way, also due to the results they obtained. I would like to take this opportunity to point out the importance of the products as well as of the therapeutic process, in light of the fact that as therapists we ought to not only work toward a psychodynamic objective but also strive toward rehabilitation as well. Even within the framework of a hospital, it is essential to pay our respects to the therapeutic products and to share them with the community. I have often heard therapists claim that the most important objective in therapy is the process, while the by-products or end products are secondary and less important. I completely disagree with this notion and believe that anyone who has ever witnessed a patient’s delight when listening to his recorded song and transcribed music would agree with me. The process is the road and the gate through which evolution and development bear a product. This gives the patient something to hold on to. Indeed, one of the strongest attributes of the art therapies is the opportunity they proffer to relisten to, reobserve, and reread the artistic creativity and thus to sense an increased productivity and normalcy. Epilogue This was a chapter on Edwin, but also on group therapy with chronic patients in psychiatric hospitalization. In order to understand Edwin, it was necessary to follow his development in both individual music therapy and in group music therapy. Individual music therapy provided him with the opportunity to further develop his natural creative talents, to progress from composing beautiful songs dealing with love and nature (while denying his tormented disposition) to more personal material dealing with grief and sadness. The group music therapy allowed him to feel part of a small community and to contribute to chronicpassive members and taught him to maintain modesty in order to gain friendship and acceptance. He not only gained the respect of the group members but also encouraged their involvement and even their speech. Irving Yalom (1985) wrote, concerning group therapy: “The greater the verbal participation, the greater the sense of involvement and the more the patient is valued by the others and ultimately by himself” (p. 385). In a group of chronic psychiatric patients, where each word was worth gold, this importance was doubled.

We never succeeded in working in depth with Edwin on the murder of his wife, but he did work on it in an indirect manner by expressing his mood, grief, and loneliness. He participated in concerts, gained much acknowledgment on the ward, and was released after six years of hospitalization to a sheltered housing complex in the community. Ten years afterward, I was informed that he had undergone a severe crisis and hanged himself. This was the last song he wrote in therapy (translated). It was written in a blues musical style: I am a deserter from birth Deserted my country Deserted my family Deserted my daughter. I am an eternal orphan I am a father of an orphan We are both orphans Lonely in our caves. Murdered in our caves. Notes 1) Schizophrenic patients are usually nonviolent. Statistically, there are fewer violent occurrences among schizophrenics than in the general population. On the other hand, there is a greater chance for short life expectancy due to the danger of suicidal tendencies (Elizur, et al., 1990). 2) The personal building of musical instruments is an activity that suits long-term hospitalized patients. In psychiatric hospitals, there are gardens kept partly by the patients. This provides the opportunity to plant gourds and other seeds, to observe their growth, and to then prepare a personal musical instrument. The therapist can consequently offer musical instruments made both of natural material and of metal, plastic, and junk material with personal designs. Besides the creative act and the patient’s pleasure, there is a great economical advantage to this activity, provided that the musical instrument is strong and of good quality. 3) Neologism is a typical phenomenon among schizophrenic patients that depicts the formation of sentences and words with personal meaning, incomprehensible by the listener (Dorland, 1982) 4) Paranoid schizophrenia is the most common type of schizophrenia. The general organization of the personality is higher than in other types. It is characterized by the presence of delusional thoughts of persecution, jealousy, and grandeur. The patient is tense, suspicious of the environment, hostile, and occasionally violent (Dorland, 1982). 5) The side effect of psychotropic drugs is an adverse reaction. It might appear in the form of sedation, dystonia, extrapyramidal phenomena, and others. 6) Catatonia in schizophrenia may present a psychiatric emergency in the stage of either stupor or excitement. With the new generation of psychotropic drugs, these phenomena are less readily observed (World Health Organization, 1996). 7) The cultural issue in therapy and in music therapy is a very important one. I live in a country that has absorbed immigrants from all around the world, in which the melting pot became

an idiom of negative as well as positive content. It was never enough to study the musical culture of your patients or music therapy students; it really required you to take a thorough look into the cultural mentality: language, history, customs, beliefs, etc. The folk song is just one example, though very important in our profession. In a symposium on the cultural background of the therapist and the patient, I once heard a prominent music therapist state, “If those immigrants came to my country out of their own free will, they must attempt to understand us.” I completely disagree. We as therapists should assume upon ourselves the responsibility of encouraging new immigrants to cope with the new reality, partly by studying the patient’s old reality and demonstrating respect for it, rather than attempt to erase his or her past. From this point of view, the group had fulfilled Edwin’s need to be respected through the mutual sharing of culture. References Dorland, W. A. (1982) Dorland’s Illustrated Medical Dictionary (26th Ed.). Toronto/Tokyo: Igaku– Shoin/Sounders International Edition. Elizur, S., Tyano, H., Munitz, M., & Neumann, M. (Eds.). (1990). Selected Chapters In Psychiatry. Tel Aviv: Papyrus Publishing House (Hebrew). Freud, S. (1921). Group Psychology And Analysis Of The Ego. In Elizur, S., Tyano, H., & Munitz, M. (Eds.), Selected Chapters In Psychiatry, 1990 (pp. 449–461). Tel Aviv: Papyrus Publishing House (Hebrew). Rolvsjord, R. (2005). Collaboration on songwriting with clients with mental health problems. In F. Baker & T. Wigram (Eds.), Song Writing: Methods, Techniques, And Clinical Application For Music Therapy Clinicians, Educators, And Students (pp. 97–116). London: Jessica Kingsley Publishers. Slavson, S. (1952). A Textbook On Analytic Group Psychotherapy. New York: International University Press. (1st ed., 1943). World Health Organization. (Ed.). (1996). The ICD–10 Classification Of Mental And Behavioural Disorders: Clinical Descriptions And Diagnostic Guidelines (1st ed., 1992). Geneva: World Health Organization. Wigram, T. (2005). Song writing Methods—Similarities And Differences: Developing A Working Model. In F. Baker & T. Wigram (Eds.), Song Writing: Methods, Techniques, And Clinical Application For Music Therapy Clinicians, Educators, And Students (pp. 246–265). London: Jessica Kingsley Publishers. Yalom, I. (1985). The theory and practice of group psychotherapy. New York: Basic Books.

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

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

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

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

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

Voice

• • • •

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

• •

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