Bruscia, Kenneth E. - Case examples of music therapy for bereavement (2012, Barcelona Pub.)

Case Examples of
Music Therapy in
Bereavement
Compiled by
Kenneth E. Bruscia
Case Examples of Music Therapy in Bereavement
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: 978-1-937440-26-8
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Table of Contents
CASE ONE
Bringing Light into Darkness: Guided Imagery and Music, Bereavement, Loss
and Working through Trauma
Leslie Bunt
CASE TWO
Music Therapy in Working through a Preschooler’s Grief: Expressing Rage and
Confusion
Kerry Burke
CASE THREE
Our Path to Peace: Songwriting-Based Brief Music Therapy with Bereaved
Adolescents
Robert E. Krout
CASE FOUR
Where Have All Our Flowers Gone? Music Therapy with a Bereaved Mother
and Widow: A Case Analysis
Chava Sekeles
CASE FIVE
Bobby Laments His Grandfather: A Case Analysis
Chava Sekeles
CASE SIX
Mother, the White Dove: A Case Analysis
Chava Sekeles
CASE SEVEN
The Grief of the Therapist over Patients Who Passed Away
Chava Sekeles
CASE EIGHT
Feelings of Doubt, Hope, and Faith
Henk Smeijster
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 ebook describes various ways that music therapy has been used to help individuals
experiencing loss and grief. 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 grief and loss about the potential benefits of music
therapy.
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, re-creating, improvising, and composing music. These will be described in
more detail in the next few paragraphs; however, it is important to explain immediately
that clients do not have to be musicians to participate in or benefit from music therapy.
In fact, because most clients have not had previous musical training, the music activities
and experiences used in therapy sessions are always designed to take advantage of the
innate tendencies of all human beings to make and appreciate music at their own
developmental levels. Of course, in clinical situations, music therapists may encounter
clients who have physical or mental impairments that interfere with one or more of
these basic musical potentials. Therefore, care is always taken to adapt music therapy
experiences to the unique musical capabilities and preferences of each client. Music
therapists also screen clients who may have adverse psychological or
psychophysiological reactions to participation in music.
Four Basic Music Experiences Used in Therapy
To understand how music therapy works, it is necessary to examine the unique
nature of each of the four types of music experience—listening to, recreating,
improvising, and composing.
In those therapy sessions that involve listening, the client takes in and reacts to live
or recorded music in the style preferred by the client. The client may respond through
activities such as relaxation or meditation, structured or free movement, perceptual
tasks, free-association, story-telling, imaging, reminiscing, drawing, and so forth. Music
listening experiences are used with clients who need to be activated, soothed, or further
developed—either physically, emotionally, intellectually, and/or spiritually—as these
are the kinds of responses that music listening elicits.
In those therapy sessions that involve re-creating music, the client sings or plays
pre-composed 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
experiencing loss and grief, 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 experiencing loss and grief, 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
loss and grief are as interested in this question as scientists and researchers. Their
interest is in whether grieving individuals in their own lives can derive the same benefits
of music therapy as the client in this case did.
Scientists or researchers can also glean other very important information from
case studies. Because clinical cases provide rich descriptions of the therapy process,
they usually provide myriad ideas for what needs to be studied scientifically. By
describing what seemed to work and or not work for a particular client, a clinical case
reveals to the researcher which clinical protocols and therapeutic outcomes warrant
further research, while also suggesting specific hypotheses that might be tested.
Moreover, because events unfold naturally in a clinical case as they do in real life, and
because variables cannot be controlled as in laboratory research, the clinical case gives
very important information on what specific variables must be considered when doing
research, not only the most likely independent and dependent variables that are likely
to be related, but also what extraneous variables need to be controlled.
Of course, a research case can provide the same insights, to some degree, as a
clinical case; they too offer valuable information on potential independent, dependent,
and extraneous variables to consider. The greatest advantage of the research case is not
only that it provides objective evidence of what works or doesn’t work in therapy, but
also because it can reveal the “effect size” of the therapeutic change. That is, a singlecase 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 Bereavement
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
experiencing loss and grief. Additional case examples have been written, which further
elaborate how individuals experiencing loss and grief can derive therapeutic benefits
from music. Here is a list of selected writings on the topic.
Bailey, Valerie. (2009). Using techniques of music therapy: Lyric and journal writing as a
form of expression for adolescents during grief: A comprehensive literature
review. Dissertation Abstracts International: Section B: The Sciences and
Engineering, 70(5-B), 3160.
Brooks, M., & O'Rourke, A. (1985). Grief and music therapy. A study into the application
of music therapy with the dying and bereaved. Annual Journal of the New Zealand
Society for Music Therapy, 7(2), 16-24.
Choi, Y. K. (2010). The effect of music and progressive muscle relaxation on anxiety,
fatigue, and quality of life in family caregivers of hospice patients Journal of Music
Therapy, 47(1), 53-69.
Cortes, A. (2006). Occupational stressors among music therapists working in palliative
care. Canadian Journal of Music Therapy, 12(1), 30-60.
Cox, Gerry R. (2010). Using music and poetry to manage grief. Illness, Crisis, & Loss, 18,
355-371.
Dalton, T. A., & Krout, R. E. (2006). The grief song-writing process with bereaved
adolescents: An integrated grief model and music therapy protocol. Music
Therapy Perspectives, 24(2), 94–107.
Hilliard, Russell E. (2001). The effects of music therapy-based bereavement groups on
mood and behavior of grieving children: A pilot study. Journal of Music Therapy,
38(4), 291-306.
Hilliard, R. E. (2006). The effect of music therapy sessions on compassion fatigue and
team building of professional hospice caregivers. The Arts in Psychotherapy,
33(5), 395-401
Lindenfelser, Kathryn J, Grocke, Denise & McFerran, Katrina. (2008). Bereaved parents'
experiences of music therapy with their terminally ill child. Journal of Music
Therapy, 45(3), 330-348.
Krout, R. (2002). The use of therapist-composed songs to facilitate multi-modal grief
processing and expression with bereaved children in group music therapy.
Annual Journal of the New Zealand Society for Music Therapy, 21-35.
Krout, R. E. (2005). Applications of music therapist-composed songs creating participant
connections and facilitating goals and rituals during one-time bereavement
support groups and programs. Music Therapy Perspectives, 23(2), 118-128.
Krout, R. E. (2006). Following the death of a child: Music therapy helping to heal the
family heart. New Zealand Journal of Music Therapy, 4, 6-22.
Lorenzato, K. (1999). Grief: Experiencing the death of a favorite patient. Music Therapy
Perspectives, 17(2), 102-103.
Magill, L. (2007). The spiritual meaning of music therapy after the death of a loved one:
A qualitative study of surviving caregivers. Dissertation Abstracts International
Section A, 68(1),22-23.
Magill, L. (2009). Caregiver empowerment and music therapy: Through the eyes of
bereaved caregivers of advanced cancer patients. Journal of Palliative Care,
25(1), 68-75.
Magill, L. (2009). The meaning of the music: The role of music in palliative care music
therapy as perceived by bereaved caregivers of advanced cancer patients.
American Journal of Hospice & Palliative Medicine, 26(1), 33-39.
Magill, L. (2009). The spiritual meaning of pre-loss music therapy to bereaved caregivers
of advanced cancer patients. Palliative & Supportive Care, 7(1), 97-108.
Magill, L. (2011). Bereaved family caregivers' reflections on the role of the music
therapist. Music and Medicine, 3, 56-63.
Mandel, S. E. (1993). The role of the music therapist on the hospice/palliative care team.
Journal of Palliative Care, 9(4), 37-39.
Mayhew, J. (2005). A creative response to loss: Developing a music therapy group for
bereaved siblings. In M. Pavlicevic (Ed.), Music therapy in children's hospices:
Jessie's fund in action (pp. 62-80). London, UK: Jessica Kingsley Publishers.
McFerran-Skewes, Katrina. (2000). From the mouths of babes: The response of six
younger, bereaved teenagers to the experience of psychodynamic group music
therapy. Australian Journal of Music Therapy, 11, 3-22.
McFerran, Katrina, Roberts, Melina & O'Grady, Lucy. (2010). Music therapy with
bereaved teenagers: A mixed methods perspective. Death Studies, 34, 541-565.
O'Kelly, J. (2008). Saying it in song: music therapy as a carer support intervention.
International Journal Of Palliative Nursing, 14(6), 281-286.
Popkin, K., Levin, T., Lichtenthal, W., G, Redl, N., Rothstein, H., Siegel, D., et al. (2011). A
pilot music therapy-centered grief intervention for nurses and ancillary staff
working in cancer settings. Music and Medicine, 3, 40-46.
Register, D., & Hilliard, R. E. (2008). Using Orff-based techniques in children’s
bereavement groups: A cognitive-behavioral music therapy approach. The Arts in
Psychotherapy, 35(2), 162-170.
Schwantes, M., Wigram, T., McKinney, C., Lipscomb, A., & Richards, C. (2011). The
Mexican corrido and its use in a music therapy bereavement group. Australian
Journal of Music Therapy, 22, 2-20.
Smeijsters, H., & van den Hurk, J. (1999). Music therapy helping to work through grief
and finding a personal identity. Journal of Music Therapy, 36(3), 222-252.
Stewart, K., Silberman, J., Loewy, J., Schneider, S., Scheiby, B., Bobo, A., et al. (2005). The
role of music therapy in care for the caregivers of the terminally ill. In C. Dileo, &
J. Loewy (Eds.), Music therapy at the end of life (pp. 239-250).
Cherry Hill, NJ:
Jeffrey Books.
Tyas, R. (2010). A death in the family. The British Journal of Music Therapy, 24(1), 22-29.
Tyson, Edgar H. (2012). Hip-hop healing: Rap music in grief therapy with an African
American adolescent male. Hadley, Susan [Ed], Yancy, George [Ed]. Therapeutic
uses of rap and hip-hop. New York, NY, US: Routledge/Taylor & Francis Group,
US; pp. 293-305.
Wexler, M. (1989). The use of song in grief therapy with Cibecue White Mountain
Apaches. Music Therapy Perspectives, 7, 63-66.
Wlodarczyk, Natalie Marie. (2012). The effect of a single-session music therapy group
intervention for grief resolution on the disenfranchised grief of hospice workers.
Dissertation Abstracts International Section A: Humanities and Social Sciences,
72(9-A), 3051.
References for Introduction
Bruscia, K. (1993). Music Therapy Brief. Retrieved from temple.edu/musictherapy/FAQ.
Case Examples of
Music Therapy in
Bereavement
Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case
Study Perspectives. Gilsum NH: Barcelona Publishers.
CASE ONE
Bringing Light into Darkness: Guided Imagery and Music, Bereavement,
Loss and Working through Trauma
Leslie Bunt
Introduction
This is the story of a courageous woman who used a series of 17 Guided Imagery
and Music (GIM) sessions to bring light and healing into very dark and troubled places.
Fiona was originally referred for bereavement support following the loss of her partner,
but as the case narrative unfolds it will become apparent that working through this
specific loss triggered exploration of earlier losses and traumas resulting from periods of
childhood abuse. GIM can provide a safe setting for containing the expression of some
of the complex feelings associated with the grieving process, including sadness,
isolation, guilt and anger, and can also assist a client to strengthen the inner resources
required to allow other deeply buried losses to be recalled and moved into the light of
consciousness. Given sufficient ego strength (as was the case with Fiona) it is then
possible for further mourning of these earlier losses to be reconstructed and worked
through in the present moment. Reflecting on Fiona’s entire journey benefited from
insights gained during discussions with my supervisor, a Jungian analyst. The chapter
continues with some background to GIM and concepts central to the approach adopted,
before introducing Fiona and the main stages and themes of the unfolding therapeutic
process. Words taken from session transcripts are in italics.
Foundational Concepts
The GIM method adopted in this context is the one pioneered by Helen Bonny
(2002) and defined by the Association of Music and Imagery (AMI) as “A music-centered
exploration of consciousness that uses specifically sequenced classical music programs
to stimulate and sustain a dynamic unfolding of inner experiences” (AMI, n.d.). The
individual hour and a half to two hour session is divided into four interlinked phases:
1) Prelude: generally verbal in nature, although drawing and other non-verbal
media may be used.
2) Relaxation induction: assisting the client to enter an altered state of
consciousness (ASC) and moving to the point when the therapist provides an
opening focus for the client’s imagery ‘journey.’
3) Music listening: in which the client shares with the therapist the various
feelings, body sensations, insights, memories, connections with the music,
images, colors etc. that arise while the therapist supports with a range of
verbal and non-verbal interventions aimed at holding, containing and
deepening the client’s inner experiences and process.
4) Postlude: the therapist assists the client to return to the ‘here and now’ and
to make further verbal connections between imagery and issues. Other nonverbal media may also be used. (For more detailed elaborations of each
phase see Abrams & Kasayaka, 2005; Bonny, 2002; Clark, 1991; Goldberg,
1995)
GIM provides a supportive and safe containing therapeutic space for the
facilitating and gradual uncovering of the bereavement process (see, for example,
Creagh, 2005). Listening to music in a very relaxed state with the witnessing support of
the therapist provides opportunities for clients to find, at their own pace, the internal
resources and strength needed to work through the shifting emotions associated with
grieving. As shall be seen in Fiona’s story, time is also needed for sufficient trust to occur
with both the music and the therapist before there are sufficient inner resources to
enable the specific loss to be addressed (for further exploration of the complex
relationships transferred between music, images and therapist see Bruscia, 2002).
Sometimes the music listening evokes the additional presence of inner helpers to
support this unfolding process. We shall see in Fiona’s story the importance of such
figures as guardian angels. Support from these kinds of helpers has been reported by
other therapists using GIM in grief work (Smith, 1997).
The choice of music is also crucial in this early unfolding stage. Music of a highly
supportive, predictable, and nurturing quality was used in the early sessions as Fiona
began to connect with the feelings associated with the presenting loss. But, as
uncovered in these early sessions, the loss of her partner was the trigger for the gradual
unraveling of a more obscured loss, that of her own childhood innocence due to a
sustained history of abuse by family members. Once she had gained sufficient strength
to work through some aspects of her bereavement process, she was able to bring
memories of this darker material into the light of the present moment in order to reexperience these earlier losses and traumas. In this phase of the work stronger, more
challenging music was used to hold and contain these complex and difficult memories
and emotions.
In reviewing the case material retrospectively with my supervisor, it became
clear that the gradual unfolding and expression of this traumatic material echoed the
three-stage ‘recovery’ process elaborated by Herman (1992). Having established ‘safety’
and trust in the ‘first stage’ of the work, opportunities for the ‘second stage’ of
‘remembrance and mourning’ of the earlier losses arose before leading to a ‘third stage’
of ‘re-connection to ordinary life’ and the making of future plans (Herman, 1992 p.155).
Ventre (1994/1995) used Herman’s stages to frame a ‘two-year GIM process’ that aided
a 32-year-old woman to heal the ‘wounds’ from childhood periods of traumatic abuse.
Later Moffitt co-published, including drawings, a journal ‘reflections and poetry choices’
from her client, a study that incorporated aspects of Herman’s stages into the recovery
process from the long-lasting effects of sexual abuse from family members (Moffitt &
Hall, 2004). These studies contribute to a developing literature of using GIM to address
the complex issues of loss and trauma. How GIM can begin to help the abused client to
acknowledge deeply buried feelings of anger, fear, sadness and resentment was
discussed by Borling (1992). Also see Pickett, 1995, for a further case study example of
the use of GIM to aid recovery from trauma.
The gradual accumulation of fear and anger associated with periods of abuse can
lead to physical tensions kept locked within the body and the manifestation of a
primitive ‘freezing’ response (Rothschild, 2000). This can be viewed as a means of
defense, as can any resulting state of desperate ‘helplessness’ (Levine, 1997). There are
examples of such freezing in the early parts of Fiona’s narrative. There are also later
moments when these deeply rooted and locked-in memories were given physical
expression and release.
A review of Fiona’s GIM journey provides examples of rich symbolic content
existing in the liminal spaces between conscious and unconscious realms, between
lightness and darkness. Romanyshyn (2007, p. 27) echoes this when, referring to Jung,
he notes that one of the functions of a symbol is to exist in this space between what
remains hidden deep within the psyche and what is brought into the ‘light’ of conscious
awareness. Symbols such as swans accompany Fiona at various stages throughout her
journey. Other archetypal figures also occur, for example the appearance of a wise old
woman, as does the exploration of younger parts of Fiona’s self. A Jungian framework
was used by Tasney (1993) in a GIM case study that investigated archetypes including
the hero and shadow. Bringing light to illuminate the darker and more shadowy aspects
of Fiona’s psyche also relates to the Jungian emphasis on the union of opposites, active
use of the imagination, and living through the experiencing of the images (Meadows,
2002; Ward, 2002).
The Client
Fiona was in her early fifties at the time of the referral. She had lost her partner
Robert recently from cancer. She was referred to GIM to support the bereavement
process but, as mentioned above and can be read in this following narrative, the loss of
Robert connected to earlier experiences of death and other traumas. Fiona’s father was
dead but her mother was still alive, although during the course of the sessions she was
becoming increasingly unwell. Fiona worked as a volunteer career. She was interested in
art, meditation, and loved nature. Although she talked of spending time with her
friends, she was rather a shy and anxious person who lacked confidence.
The Opening Assessment Phase (‘Taster’ and Sessions 1-3)
The opening sessions of a course of therapy regularly introduce themes that
permeate the entire therapeutic process. Working through the loss of her partner
occupied some of this process for Fiona. But exploring this particular loss became part
of a gradual unfolding of traumatic memories of child abuse with Fiona reporting that
she had moments of not speaking during her childhood. Since the environment provided
by her own parents was not safe she would often look for alternative mothering from
her mother’s sister. This pattern of seeking out different secure attachment figures has
been observed in people suffering from early trauma (Körlin & Wrangsjö, 2004).
Although Fiona presented with some of the features of ‘Complex Post-Traumatic Stress
Disorder’ (Herman, 1992, pp. 119-122), such as feeling guilty, she had a strong sense of
self with extant coping mechanisms and defenses. This strong enough ego enabled
Fiona to withstand explorations of these early memories (see Rothschild, 2000 for
further psychobiological discussion of trauma and Korlin, 2002 for neuropsychological
perspectives related to GIM).
Bringing light to illuminate a pathway was there from the start as the focus to
the short introductory ‘taster’ session. Fiona felt supported during the opening two
pieces of Bruscia’s Pastorale1 program: Debussy’s Prelude à l’après- midi d’un faune and
Liadov’s The Enchanted Lake (see the Appendix A for an outline of each session). She
was walking by a river with her well-trusted dog and saw two swans – so white, pure
and untouched. She wished (not without some sadness) to be as strong, free, fearless,
proud, and confident as these beautiful creatures. The complex symbol of a swan points
to ‘the complete satisfaction of a desire’ with a ‘swan-song’ also holding connections
with death (Cirlot, 1971 p. 322). There was much beauty in this introductory session,
beauty that she could smell and touch as she moved with the swans and her dog into a
sunlit garden. Suddenly scared by someone jumping out, she felt protected by her dog
and the swans who told her no one will come out and hurt you. She felt stronger, finding
it hard to leave the garden.
During the next three sessions she began to trust more and to bring the light to
move further away from safe pathways into denser and darker woods, a symbolic
gradual unfolding of hidden subconscious material. The smell of Lily of the Valley
reminded her of a favorite perfume on her bedroom table when a young child. She had
been sent to bed for something she had not done. Too frightened to go downstairs to
the bathroom she eventually was calmed to sleep at a synchronous moment with the
music, being cradled and rocked during the Shepherds’ Cradle Song from Bach’s
Christmas Oratorio (from the program Caring).
Younger and older parts of Fiona began to emerge. At the start of the second full
session she recalled being frozen with fear on encountering some steers on a recent
walk and the instant connections with suffocating childhood fears. Adult Fiona asked to
find ways of taking care of her younger self and began to take young Fiona by the hand
into the GIM journeys. During session three an older woman, who could connect to the
Jungian archetype of the wise woman, showed Fiona a beautiful, warm, and sunlit
house and garden. Older Fiona revealed this house (too grand for me) to younger Fiona.
This is what it should have been like and was taken from her. She was entitled to this.
The older Fiona became angry (another reaction to the freezing response; Levine, 1997)
before this turned to pain and sadness….She’s been in the dark for so long, she has the
light now, she’s so lovely, such a good person, her body’s getting old.
At this integration of younger and older parts of self, Fiona seemed strong
enough for the appearance of the first significant image of her dead partner. It was as if
up to this point she had been gathering her personal resources, preparing the safe
ground herself. Robert appeared during another musically synchronous moment, during
the opening bars of Duruflé’s In Paradisum from his Requiem, a piece not known to
Fiona. Robert floated past wearing a long gown, appearing like a merman or fish and
smiled as if to say ‘Hello.’ Fiona felt he had moved on and she was happy about this.
The Therapeutic Process
The Loss of Robert (Session 4)
The first anniversary of Robert’s death occurred near the time of the fourth
session. Fiona was terrified to think of Robert’s bones rotting in his dark grave. She
asked for the focus for the session to be at his graveside and that the music (the
program Grieving) could help her to look into the grave, again using light to look into a
dark place. The image of a broken skull connected with one of a broken doll in the cellar
at her childhood home. She wanted to put the bones in the right order and the image
kept shifting between Robert’s body and her doll. She went into the nearby church to
light a candle. She felt calmer. Everything was o.k; the bones were all clean, white, pure
and untouched (as were the earlier swans). Fiona saw a white shadowy figure, full of
light. She was not alone and felt better. She too had been waiting for someone to bring
her out of the dark. The light drew her between graveside and the church, the same
light for Robert and for her. Robert’s spirit is in the church, in the light. The bones aren’t
important. They can look after themselves. The session culminated with the appearance
of four big strong angels whose wings are like swans (again). They were gentle, kind and
understanding and Fiona felt that she had known them for a long time--they’re not
strangers and like a nice family--mother, father, auntie, uncle (my supervisor noted a
possible connection with the four archangels). Fiona felt vibrations in her body at the
reply when she asked the angels to look after Robert. The angels invited her to move on,
to go beyond the pain. They told her: You must trust, if you trust we will never let you
down. Fiona ended the journey by placing flowers on the grave in glorious sunlight.
The Childhood Traumas (Sessions 5 – 8)
Fiona was beginning to feel safer and more trusting of the GIM process. The
mourning and some healing of Robert’s memory provided a kind of catalyst to allow
some of these early memories to take more shape. Glimpses had occurred from the
outset with the untouched swans, the taking care of younger Fiona and the co-existence
of the broken doll/bones in Session four. In allowing these earlier memories to surface it
was as if she was beginning a grieving process for her own losses.
Stronger music used during these pivotally central sessions enabled her to
explore the symbolic potential of such fearful images as:
•
•
•
•
•
•
Hiding in a smelly upstairs cupboard during one of her mother’s terrifying
rages;
The boarded-up fireplace and door in her bedroom;
The room where her grandmother died;
Both her grandfather and her father returning home drunk in the middle of
the afternoon;
The cellar where she was often thrown;
A dark and gloomy bricked-up well (glimpsed as early as Session two) that
frightened and angered her parents.
So many of these images were concerned with hiding, being in the dark or with
something blocked up. Fiona needed to find ways of protecting and defending herself,
of distancing herself from suffering and pain. During the orchestral arrangement of
Bach’s Passacaglia and Fugue in C minor (Session six), her guardian angel gave her the
strength to look down into the well, finding life in the trapped water. Fiona began to
realize her father was the weak one, controlled by her mother and who did anything to
keep the peace. She became no longer scared of her father but began rather to pity him.
Fiona began to feel freer and have more control. The well scared them more than me. I
took their fear on.
But, tragically, this house held more horrors for her. She needed a lot of light and
support from her ever-important guardian angel to re-visit (Session seven--DeathRebirth) the recurring traumatic memory of discovering in the cellar the coffin of a
family member who had died at a young age in childbirth. Fiona also felt as if part of her
was in the coffin with the mother and child. During this journey she screamed for both
the child and herself to be let out. Subsequent to this session, the following questions
were explored in supervision. Was she mourning her own lost childhood? Was some of
this material a creative and metaphoric fantasy all needing to be released? How did she
feel at the threshold of her own adult life?
Fiona remembered how frightened she felt at the funeral, worried that perhaps
the baby was not dead. Fiona created a beautiful new grave and funeral for the child
and mother. Her last words of the session were: Now there is light. She hasn’t been
forgotten, she’s always with me, goodbye my love. They were evoked by the final bars of
Mahler’s Der Abschied from Das Lied von der Erde, a farewell described by Fiona as
perfect for the funeral. Was she symbolically saying farewell to her own childhood?
These central sessions were akin to the musical form of variations on a theme
with an ever-deepening cycle of grieving, letting go and some beginning of restoration.
By Session eight she had sufficient internal resources to confront the memories of the
most dreadful damage done to her by family members. One constantly crippling fear
was of dark buildings, church steeples, and towers, holding within them symbolically
very painful associations. She asked if she could use the music to face her terror of one
church steeple in particular. For the focus she opted to leave her friends at the end of an
enjoyable evening and moved towards the bus stop close to the dreaded steeple. After
gathering strength during excerpts from Elgar’s Enigma Variations (Positive Affect), she
moved towards the steeple, terribly scared but aware that her guardian angel was with
her. During the singing in Mozart’s Laudate Dominum the angel seemed not to
understand. At the start of Barber’s Adagio for Strings the angel looked sad. As the
music moved towards its intense climax there was a clear transformational matrix of
working relationships: Fiona’s connections to the music, the unfolding images, and to
my guiding. The images unfolded thus:
The angel can feel Fiona’s pain, is hunched up, holding her stomach.
The angel weeps.
The angel understands and holds Fiona’s hand, giving her strength.
The angel stands up and let’s go of her stomach.
She puts her arm around Fiona.
They look up at the steeple together (during the general pause after the loudest
moment).
Fiona realizes that the steeple represents the family abuser.
The angel asks what is to be done with him.
Fiona replies: Let him go, let him flow away, take him out of the church steeple.
The steeple is now just an empty, narrow passage, just stone.
The steeple is a pointed ridiculous object.
Following the Barber the know-it-all tenor and self-interested chorus in the
Sanctus from Gounod’s St. Cecilia Mass annoyed her. They did not understand; only her
angel did. She felt stronger when the voices disappeared during the excerpt from
Strauss’ Death and Transfiguration. Here Fiona and her angel were drenched in
cleansing and very healing rain. The overwhelming dark object had lost all of its
symbolic potency. As a child this fear had petrified her. She was speechless and unable
to tell anyone. Now she could see the steeple for what it was – it had been cut down to
size. After the session she went to look up at this steeple and at the start of the next
session reported that it no longer had the same horror for her.
Releasing and Reconciliation (Sessions 9-14)
Fiona often brought objects or paintings relating to her GIM journeys to
subsequent sessions, including bird feathers (relating to the swans), a drawing of one of
the angels at Robert’s grave, and, after the powerful work with the steeple, a painting of
a black steeple now covered with glitter and white feathers. She began to talk about
becoming freer, released from some of the memories and able to move on. She was
aware that nobody was pulling her back, no Robert or abusive family figures.
Sessions began to oscillate (at her request) between those focused on quiet,
reflective healing and restoration and those where working programs with stronger
music were employed to connect again to more fearful feelings. But now there was
more integration with Fiona feeling less abandoned and frightened than before.
Some of the journeys were magical in flavor, as in her very happy travel in a
snowy landscape (Session nine – Quiet Music). A silver-clad lady took her (during Holst’s
Venus) on a ride on a carriage pulled, on this occasion, by a clean, white swan. Fiona was
certainly using the music in its full liminal and transcendent capacity to enter through
new portals into different spaces. Her angels began to take her to even more wonderful
places, full of light and color, on one occasion showing me a door in the cloud, a
beautiful place that must be heaven…I feel like I’ve been here before, been a long time
away but now I’m back. I know this place, this is my home, my proper real home…..I can
go anywhere I want to. I feel so special…..all the pain I’ve suffered has dissolved…She
began to talk about wanting to help others. I want to help other people with similar
circumstances, children who’ve been beaten, raped, locked in the dark….I want to be
their angel, to show them the light and beauty. I’m telling a little girl not to give up, she
looks so sad, so alone…I’ve put some light in her heart…when she’s strong one day she’ll
put some light in someone’s heart.
The continued releasing and reconciliatory work was exemplified by such
moments as:
•
•
•
•
•
•
•
•
•
•
Throwing all her past abusers to the bottom of the well where clear water
and light dissolved them (Session eleven – Expanded Awareness)
Gaining insight that the abusers were the scared ones
Feeling that it was not her fault, and being sad when people continued to be
angry with her
Appreciating that she had worked hard for her good power
Being thanked by Robert and letting him go, aware that he will be o.k.
Realizing that she is still needed on this earth, things I need to do
Restoring her childhood house to a place full of light and sunshine (Session
twelve – Peak Experience) a house to be proud of, beautiful, my house…with
the clear painted white and flowers around the well
Tearing black clothes off her mother to reveal a sad and powerless old lady
who says sorry; leading to a tender moment of forgiveness (at the end of
Session twelve)
Re-visiting the hospital room where Robert died and ritualistically saying her
farewells and tidying up his personal items (Session thirteen, close to the
second anniversary of his death, using the same music as in Session four, the
first anniversary)
One final visit to the dark cellar (Session fourteen – Inner Odyssey) and
during the drum roll in Nielsen’s 5th symphony tearing up some black plastic
trash bags she had brought to the session to symbolize the remaining dark
images of black objects from that horrible cellar. Instead of it breaking me
up, I’m breaking it up….no-one else will ever suffer in that place
Years of horrible memories, frustrations, and hurt were being torn up as trash
and Fiona felt a new, good energy and tingling sensation in her fingers at the end of
tumultuous Session fourteen. It felt as if some locked memories in the nervous system
were being given an opportunity to be released on a physical level, having worked
through the images, feelings and memories (Levine, 1997; Hall, 2009).
The Final Phase (Sessions 15-17)
Colleagues were noticing how Fiona was looking different and speaking out with
more confidence. She was sleeping better, having fewer migraines and bad dreams. She
felt better about herself and about being ready for a new relationship. The recurrent
image of a swan--a pure white swan, like an angel--occurred in Session fifteen during
Mythic Journey, a program compiled by Clark (1995). Fiona threw a list of negative
thoughts into the river but was troubled that the nearby swan would become dirty with
all that negativity so close. The swan gave her the strength to let go and not feel guilty.
The list of negative things was also burnt and all the black ash (memories of the ash in
her grandfather’s fireplace) trampled underfoot. As Ravel’s orchestration of
Mussorgsky’s The Great Gate of Kiev began, Fiona saw a funeral procession of ghostly
black figures from the past coming towards her. She gathered strength so that the
ghosts all turned back. At the climax of the music she realized that they could not touch
or hurt her anymore. They were no longer a part of her. Standing on the top of a
mountain she felt strong and guiltless.
At the start of her final GIM session (Session seventeen) Fiona talked of starting
the work like a bird with two broken wings. One wing was the grief over Robert, which
she now felt was healed; the other was the traumatic memories of her childhood abuse
which were healing, but she knew would never totally disappear. However, she knew
that she now had the inner resources to cope, to be independent and to fly from this
case/nest. She talked excitedly of the free bird meeting new friends. This final session
was a kind of summary of all of the GIM journeys and a reflection of her desire to bring
light into darkness. She asked if the music (the program Mostly Bach) could help her
move from a dark memory from a summer holiday when a young child, to being taken
by her angels to a place of light and transformation. The scene was familiar: being hit
and sent upstairs to her room to wait in terror for her father’s return. She fell on the
floor as if she had passed out. Sleep was an escape. I just want to die. Why are people so
horrible? She saw the light bulb of her room sparkling through her tears, a comforting
image. If I wasn’t crying I wouldn’t see the beauty in the light bulb. The sparkling image
was like a magic fairy, strong and good. Fiona used these comforting images as a kind of
refuge both at home and when she was being bullied at school. It was her means of
survival, living as she said in my own beautiful world, inside of a fishbowl, small, safe,
light, so high in the sky where nobody can touch me…..it’s my home. She still needed, at
times, to go that fishbowl, although everything was bigger now. Her dog was allowed in
with her and maybe one day I’ll trust someone and let them peep in.
Fiona was hoping that more people could be allowed to look into that fishbowl
and begin to share more of her life with her. She did not need to keep secrets and could
do so without feeling guilty. She dreamt of helping oncology patients to draw and paint.
At the last review session she talked about being able to speak up more, being less
overwhelmed by anxieties and past horrors. She had learnt to defend herself: she had
found her voice.
Conclusion
During the review session we listened together to the Debussy Prelude as we had
in the initial ‘taster’ session. As a focus to our joint listening, we used the image of the
poppy field on the card she had left with me. The sun shone, she was with her dog, as in
the ‘taster’, and she imagined herself as a beautiful lady wearing lovely clothes and
carrying a sun umbrella. The session and our work together ended with her favorite
tune – Greensleeves – in the arrangement by Vaughan Williams that ends the program
Quiet Music.
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Summer, Ed.). Gilsum, NH: Barcelona Publishers.
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207-224). Gilsum, NH: Barcelona Publishers.
___________________________________
1
See Grocke (2002) for details of the music in Bonny’s programs and the appendices in
the same volume for details on the programs.
APPENDIX A
Session Summaries
Session
Taster
Introduction – Focus
Light --- path
GIM Programme
Pastorale (part)
1
2
3
4
light --- path
extra blanket --- wood
crystal --- dark wood
breeze --- grave
Caring
Nurturing
Nurturing
Grieving
5
breeze --- old trunk
Creativity I
6
tense/relax…well
Mostly Bach
7
light/angel…house
Death / Rebirth
8
9
extra blanket…bus stop
light…snow
Positive Affect
Quiet Music
10
ball of light…into music
Sublime I
11
extra duvet…hill
12
light…garden
Expanded
Awareness
Peak Experience
13
light…hospital
Grieving
14
angel…energy
Inner Odyssey
15
new breath…dockside
Mythic Journey
16
17
ball of color…picture
warm wave…holidays
Inner Odyssey
Mostly Back
Some Images
walk with dog,
white swans
perfume, bedroom
big and little Fiona
big and little Fiona
bones, church, light,
four angles
old clothes well,
Robert
angel, life in well,
father, garden
cellar, coffin, new
grave
church steeple
silver lady, white
swan, flying in light
angel
flight,
Christmas
angel, own wings,
dissolving pain
lamb, new house,
sad mother
re-visit
hospital,
sort Robert’s things
cellar, black trash
bags
swan flight, burning
list, letting go
poppy, mother
mother,
punishment, tears,
light, fishbowl
Acknowledgements: To ‘Fiona’ for giving consent to use material from her GIM sessions
and to my supervisor Shelagh Layet.
Taken from: Bruscia, K. (Ed.) (1991) Case Studies in Music Therapy. Gilsum NH:
Barcelona Publishers.
CASE TWO
Music Therapy in Working through a Preschooler’s Grief:
Expressing Rage and Confusion
KERRY BURKE
Abstract
Six months of music therapy helped four-year-old Adam express his rage and
confusion at the death of his father. His aggressive behavior towards his peers and
mother found another outlet when he played loud music and expressed his destructive
rage.
Background Information
Adam’s uneventful life changed when his father unexpectedly died playing golf.
Four years old at the time, Adam was very close to his father and became aggressive
towards other children in preschool and towards his mother, yet refused to leave her
side without tantrums. After six months of increasingly disruptive behaviors, his mother
brought Adam to me for weekly sessions. He saw no other therapist.
Adam’s mother, who was also a therapist, selected music therapy because,
“Adam, like his father, could not use words to work through his feelings.” Also, the
father had played the guitar which Adam liked to mimic.
Assessment
The mother described a child needing to express his anger towards his father for
leaving him. Adam denied his anger and it became directed at other children and his
mother, and his security had been threatened to the point where he did not wish to
leave his mother’s side.
Adam was able to express his sadness to his mother over the loss of his father
with no difficulty. His mother, however, wished him to express and work through his
anger and to have ongoing contact with a male authority figure.
For assessment, I asked Adam to improvise pieces entitled fear, happiness,
sadness, frustration and anger, each in different intensities. He could not play loud
anger, keeping it soft while reporting that it was louder. He played the other emotions
both loud and soft. This assessment doubled as an activity to increase his range of
expression which we called “the emotions.”
When asked to draw while improvised various emotional states, Adam drew a
grey picture with a solitary figure half smiling under the moon and stars.
The goals became for Adam to play loud, angry music; to stop aggressive acts
towards others; to allow him to express whatever he wished through music and talk;
and finally to provide weekly contact with a male figure, getting Adam to school and
leaving his mother’s side voluntarily.
After some sessions I talked with his mother and found out how things were
going at home and school. After each session, I assessed progress towards these goals
on an informal basis.
Method
Adam came to my house each week for an hour over a six month period. My
equipment consists of piano, keyboards and guitars, xylophones, drums and percussion
instruments of various sizes. Some sessions were recorded.
I admire aspects of the work of therapists Virginia Axline (1976), Carl Rogers
(Rogers & Stevens, 1961) and Milton Erickson (Bandler & Grinder, 1978) suggesting that
reflection can cure the client. In music therapy, reflection (Priestley, 1975; Nordoff &
Robbins, 1977) leads to creative techniques for each client while affirming each
individual’s needs. In my work with Adam, reflection meant that he was able to control
the sessions to a large degree, by choosing activities and levels of intimacy. For example,
Adam wanted “breaks” after each 20 minutes of playing so that he could play a video
game, eat a peanut butter sandwich or play catch with a ball outside. Allowing him to do
this led to a sharing of therapeutic power, a way in which I like to work.
On the other hand, I provided a loose structure. After a warm-up period during
which Adam would play his choice of instruments, we would improvise “the emotions”
trying to play louder than before. Sometimes I asked him to completed phrases such as:
I feel sad about... “being silly”
I feel silly about... “school”
I feel happy about... “coming here”
I feel angry about... “having to leave”
I feel angry at...“Mom”
Often we composed a song, and every week he drew a picture and often asked
me to draw one too.
Treatment Process
Initial Stage: Four Weeks
Sessions began with a discussion about what we could do. He warmed up by
arranging percussion instruments and playing them in sequence. I encouraged him to
play many instruments.
In this period we got to know each other. Adam became proficient at a variety of
percussion instruments, copying my beats and asking me to copy his.
We tried to play songs on the guitar, using a half size guitar in open tuning, but it
posed problems for Adam and was frustrating. However, together we prepared and
played “Swing Low, Sweet Chariot.” He asked me to sing and drum while he strummed.
The electronic keyboard was easier to play and he began composing pieces which we
wrote down. The following week he asked about them when he came to the door.
Adam neither wanted to play his strong feelings nor talk about them. His
approach was mental rather than emotional. I let him take his time.
Each week I modeled loud playing, challenging him to play louder than before,
sometimes recording our playing to give him feedback. I made this fun and changed
tactics when his interest flagged. He would not play louder despite my efforts.
A breakthrough occurred when he filled his page with black scribbling when
asked to draw his feelings. Then he drew a dark crying face with big black tears. For the
first time, he expressed his sadness and rage with intensity.
Middle Stage: Four Months
In this period, we found ways to express his feelings. He wrote a song for
Halloween about monsters and we recorded it. Strumming an open chord on guitar, he
wailed his song and a tape of it proudly went home to mother. He explored the piano,
but never loudly. We worked on naming emotions as he experienced them during the
day and set them to music.
We made pictures of his family tree and assigned feelings to each person. This
led to pictures of the family tree divided between those in heaven and those on earth.
In his weekly drawing, abstract collections of lines became “mazes” with a monster in
the middle. Then came elaborate mazes with many monsters, underground rivers and
secret spaces.
Maze 1
Adam played these mazes and monsters on various instruments but never
loudly. This period ended as Adam began to play less music and asked for more breaks
to play video games and eat sandwiches. It was time for a change.
Maze 2
Final Stage: Four Weeks
I developed two activities to encourage him to express his inner feelings.
Spontaneously, I wrote a wiggly “score” for him to play on piano, as shown below. It
incorporated loud and soft, fast and slow dynamics. Adam played it while my finger
traced the wiggle. He loved it, turning it over and playing again, then turning it sideways.
He made one for me to play. Suddenly, he played very loud, it was a breakthrough. The
visual representation of loud and soft worked.
Wiggly Score 1
Wiggly Score 2
One day Adam noticed that a drumhead on a conga was starting to break. I
invited him to finish breaking it. He wanted to but then held back, and this allowed his
feelings to come into focus. He talked about how scared he was to break things. Then he
began hitting the drum harder and harder, many times until it finally broke. It felt good
and he discussed his fear that if he let his anger go, he could destroy people and objects.
The next week, I provided a cardboard box which Adam destroyed with a huge gong
mallet. His mother provided boxes at home which he destroyed.
At the next session, Adam began to escape from his mazes, talking himself
through it: “Keep to the side here and wait till the monster doesn’t look here; the
underground river has a bridge over it.”
The following week, Adam did not arrive for his session. He had not bugged his
mother to leave for music therapy and she had forgotten. She reported that he was
going to school and was not clinging to her. His aggression had also stopped. We
therefore agreed to end the sessions unless Adam brought the subject up again. The
sessions ended.
Discussion and Conclusions
Adam’s reaction to the death of his father was typical for a child of his age. What
set Adam apart was his difficulty in describing his feelings, his closeness to his father
which may have heightened his sense of loss, and his mother’s sensitivity to his distress.
He could experience sadness at the death of his father but not anger. However, with a
male figure to help, along with our music-making, artwork, and games, Adam was able
to express feelings and confusion over his father’s death which he had difficulty talking
about.
Reflection was easy with Adam. Each session, he came ready to work, usually to
finish what we worked on the previous week. Thus, I felt confident giving him choices
about how and what we would do each session. This indicated how completely Adam
threw himself into the sessions.
Significant moments were first when he drew blackness and the crying face. His
expression became intense at this point, which is an important indicator for me that
therapeutic goals were being met. When we began to play wiggly lines, the volume of
his playing increased dramatically, again indicating to me that his inner world was
becoming involved.
Lastly, when he destroyed the drumhead and boxes, he could discuss his feelings
of fear over the quantity of rage within himself. Ideally, these feelings would have been
discussed in terms of the father, however, the sessions ended at this point. This
destructive intervention developed by my noticing the way Adam’s attention was drawn
to the broken drumhead. He asked what would happen to it when it was broken and
would I throw it away. After a number of questions, I asked him if he would like to break
it. The violence in this action–and his enthusiasm for it–made me pause and consider
the wisdom of encouraging Adam in this pursuit, and whether it may encourage him to
act out. I decided that his interest in the drum indicated a symbolic representation of his
inner conflict which seemed to be true from the results, and that it was safe to continue.
When his tremendous enthusiasm for the sessions vanished and he did not show
for his session, it surprised me. No other client of mine has suddenly met the
therapeutic goals in the way that Adam did, nor forgotten the sessions in a week. It
seemed to indicate that his need for the sessions had ended for the moment and that to
continue would provide closure for me, but not him.
Update
Adam now sees me twice a year. A year after sessions ended there was a
message on my answering machine, “I need to see you, I can’t escape from the maze
again.” There was a change in the family situation. With the mother’s approval, Adam is
allowed to set up appointments when he wishes.
These later sessions are more supportive than therapeutic: the emphasis is on
peanut butter! He still draws pictures, but the maze has disappeared.
References
Axline, V., (1976). Play therapy. New York: Ballantine Books.
Bandler, R., Grinder, J., (1975). Patterns of Hypnotic Techniques of Milton Erickson.
Science and Technology Books.
Nordoff, P., & Robbins, C, (1977). Creative Music Therapy. New York: John Day.
Priestley, M., (1975). Music Therapy in Action. St. Louis: MMB.
Rogers, C. & Stevens, B., (1961). Person to Person. Boston: Houghton and Mifflin.
Taken from: Meadows, A. (Ed.) (2011). Developments in Music Therapy Practice: Case
Study Perspectives. Gilsum NH: Barcelona Publishers.
CASE THREE
Our Path to Peace: Songwriting-Based Brief
Music Therapy with Bereaved Adolescents
Robert E. Krout
Introduction
Experiencing the death of a child is one of the most difficult losses for family
members to accept, cope with, and adjust to (Children’s Hospice International, 2005;
Fletcher, 2002; Pavlicevic, 2005; Robb, 2003; Rosof, 1994). Even when a child has a lifelimiting illness, such as a terminal cancer, and is expected to die, few families know what
to do when that child does die (Armstrong-Dailey & Zarbock, 2001; De Cinque,
Monterosso, Dadd, Sidhu, & Lucas, 2004). Parents and caregivers are challenged as to
how to help themselves, as well as surviving siblings (Bright, 2002). The death of a
sibling can be an especially difficult and significant life-impacting event for adolescents
(Birenbaum, 2000; Doka, 2000). The grieving process interacts with core adolescent
concerns of gaining mastery and control over their environment, having a sense of
belonging, and seeking fairness and justice in their lives (Fleming & Adolph, 1986). This
chapter describes the use of strategic songwriting based brief music therapy with a
group of young adolescents during a single session that took place at a three-day family
bereavement retreat. This approach incorporated concepts from brief therapy, cognitive
therapy and insight therapy (Krout, 2005a; 2006).
Foundational Concepts
Moos (1995) describes how bereaved adolescents adapt to the death of a loved
one through establishing the personal meaning of the loss, maintaining an emotional
balance, sustaining interpersonal relationships, and preserving a satisfactory self-image.
Balk (1996) articulates a cognitive approach to bereavement therapy with grieving
adolescents, emphasizing the need for them to develop a variety of coping skills,
including dealing with the reality of the loss and learning how to respond to life changes
as a result of the death. Many adolescents have a strong need to belong and not seem
different from peers that may cause them to hide outward signs or expressions of
grieving (Corr & Corr, 1996). Forward and Garlie (2003) describe the adolescent
bereavement process as variable, encompassing five stages of finding out, avoiding
reality, facing reality, turning the corner, and finding new meaning versus ending the
search. In each of these stages, the adolescent focuses on the basic psychological
process of the search for new meaning.
Group activities may help adolescents organize the confusing experience of grief
and facilitate their gaining insight into what they are going through, as they may feel a
frightening loss of control (Duncan, Joselow & Hilden, 2006; Holliday, 2002; Perschy,
2004; Snyder, 2008). Among group grief services for siblings of children who have died
are complementary modalities such as creative arts interventions (Bright, 2002; Brooks
& O’Rourke, 2002; Desai, Ng, & Bryant, 2002; Hasenfus & Franceschi, 2003; Hilliard,
2001; Jimerson, 2005; Krout, 2002, 2005b; Lehmann, Jimerson, & Gaasch, 2001a, 2001b,
2001c, 2001d; Mondanaro, 2005; Rufin, Creed & Jarvis, 1997). These address a wide
range of concerns, with a particular focus on self-expression.
The use of music therapy experiences in grief interventions for bereaved children
and adolescents are designed to help them with issues relating to the validation,
identification, clarification, normalization, and expression of feelings (Bright, 2002;
Dalton & Krout, 2005, 2006; Gilmer, 2002; Hilliard, 2001, 2007, 2008; Hogan & Roberts,
2005; Krout, 1999, 2002, 2005b, 2006; Krout & Jones, 2005; McFerran-Skewes, 2000;
McFerran-Skewes & Grocke, 2000; McFerran-Skewes & Erdonmez-Grocke, 2000;
Roberts, 2006; Skewes, 2000; Skewes & Grocke, 2000; Teahan, 2000). For example,
McFerran-Skewes (2001) investigated a psychodynamic approach to music therapy
group work with younger, bereaved adolescents. The author conducted and analyzed indepth interviews with the participants following a course of ten music therapy sessions.
She reported that their desires for freedom, control, fun, and achievement of cohesion
within the group were essential in successfully addressing their grief needs (McFerranSkewes, 2001).
Music therapy bereavement interventions for adolescents have included the
specific use of song-writing-based experiences. In one two-part study, Dalton and Krout
(2005, 2006) described the development and implementation of the Grief Song-Writing
Process (GSWP) with bereaved adolescents. First, a thematic analysis was completed of
123 songs previously written by bereaved adolescents in individual music therapy
sessions that expressed core concerns regarding the death of their loved one and how
they were coping since the death. Second, existing grief models were compared with
these song theme areas, and an integrated grief model was developed that included five
identified grief process areas. Next, a systematized seven-session group GSWP protocol
was developed and implemented, during which adolescents created music and wrote
original lyrics to songs that focused on each of the five grief process areas:
understanding, feeling, remembering, integrating, and growing. These last two process
areas, integrating and growing, may be related to the model described as continuing
bonds (Webb, 2004). Webb (2004) and others have suggested that siblings should not
be encouraged to disengage from the deceased but to continue their bonds, thus aiding
in their developmental task of mastery. Packman, Horsley, Davies and Kramer (2006)
discussed the unique and continued relationships formed by bereaved children and
adolescents following the death of a sibling.
In the present example, a group of young adolescents served as a single case for
this chapter, which combined design elements of a naturalistic treatment case study
with an outcome–based evaluative case study (Bruscia, 1991; Smeijsters, 2005). I
incorporated several theoretical approaches represented through a songwriting-based
approach to music therapy, including brief therapy, cognitive therapy, insight therapy,
process-oriented songwriting and strategic songwriting (Brunk, 1998; Darrow, 2004;
Hanser, 1999; Krout, 2005a, 2006). Treatment occurred during one session. Although
unusual for case studies, a single session approach may be appropriate in grief and
bereavement work when the clinician knows, in advance, that there will only be one
session and a single opportunity to work with a specific group of clients due to the
nature of the treatment setting, client goals, and advance scheduling (Krout, 2005a,
2006).
In this session, the young adolescents re-wrote lyrics to a song I composed for
the sole purpose of working with this group on this occasion. The song represented the
overall theme for the retreat, that of each family (and family member) finding their own
“path to peace” as part of their unique grief journeys. This theme was developed during
retreat staff planning sessions in which I took part. It is important to note that the
weekend retreat was designed to be supportive in nature, and was not intended to
substitute for intensive or on-going counseling for the parents and sibling participants.
Instead, it was designed to incorporate and reflect what Teahan (2000) termed the
“V.I.N.E.” concept, which refers to the use of creative arts therapies in facilitating the
validation, identification, normalization, and expression of feelings, thoughts, and
emotions of bereaved family members as part of a natural and organic grieving process.
The Clients
This songwriting-based music therapy session took place with a group of young
bereaved adolescents at a three-day family bereavement retreat run by a not-for-profit
bereavement organization. The adolescents were all part of attending families who had
experienced the death of a sibling/child. The services of the bereavement organization
were offered to the families in a number of ways. Brochures about the organization
were available at pediatric hospitals, cancer care centers, and hospice facilities in the
area. Social workers and child life specialists at these facilities were also made aware of
the available services by the organization, and as such, families often knew about the
grief services before or shortly after the death of their child. As a result, families who
were interested in the services of the organization visited the web site for specific
programs offered or contacted the organization by phone or e-mail. The family weekend
retreat, offered twice per year, was one of the programs offered and described.
Assessment
Prior to the retreat weekend, I was provided with information regarding how
many young adolescents were scheduled to be in my group (nine), their grief and loss
backgrounds (included both sudden and anticipated sibling deaths), their ages (11-13)
and their genders (four males and five females). Intake and assessment information on
all sibling participants was provided by parents as part of the application process. This
included information about the deceased child, such as dates of child’s birth, death and
cause of death. Causes of death included neuroblastoma, leukemia, kidney and renal
failures, metabolic disorder, immune deficiency, trisomy, congenital heart defect, and
staph infection. Information on each sibling participant was also provided, including
their age at the time of the death, current home and school placement information, age
of and relationships with other surviving siblings, nature of any grief services provided
before or after the death (including participation in retreats offered by our
organization), and how the sibling had been coping since the death. Other relevant
information such as sibling medical conditions and medications currently being taken
was also provided.
Another portion of the application asked parents to describe what they wanted
to “get out of” the retreat for both themselves and their children. The information was
reviewed by retreat staff, who were all mental health professionals volunteering for the
retreat. All staff had previous experience working with bereaved families, and many
worked as clinicians at local pediatric hospitals or hospice organizations. If a family
appeared to be appropriate for the retreat after review of their application, they were
invited to take part. If the family did not appear to be appropriate for the retreat (for
example, the death being less than one month prior), or that parents described what
appeared to be symptoms of complicated mourning (Rando, 1993), the family was
contacted by staff and offered other alternatives to the retreat. These alternatives
included grief counseling for the family.
The overall goal of the retreat, as described to the parents, was to provide the
children, adolescents, and adults with a safe and supportive environment in which to
share their losses and the changes in their lives since these losses. The retreat was also
intended to provide interventions and experiences to help them identify and express
feelings and emotions, as well as to explore adaptive strategies suited to their unique
situations.
The Therapeutic Process
During the retreat, siblings were seen in separate process and recreation groups,
and were organized into groups by age (three- and four-year-olds, five-year-olds, sixand seven-year-olds, eight- to ten-year-olds, 11-13 year olds, and 14 years and older).
There were also process-oriented family sessions and experiences in which they took
part. Additional separate process groups were held for parents as couples, and for
moms and dads separately. A music therapy facilitator served as co-leader of each
sibling group. At this weekend retreat, I co-facilitated a process group with a child life
specialist who worked full-time at a pediatric cancer center and who had experience in
working with bereaved children and adolescents. The group included nine 11-13 year
olds; four males and five females. Although music therapy experiences were included in
three of the group sessions with these nine participants, the songwriting itself took
place during one 90-minute session.
The method of therapy involved engaging the group in a song-writing
experience, and creating new lyrics to the song, “Our Path to Peace” (see Table 1). At
the time I wrote the song, the retreat staff had an idea of how many young adolescents
were likely to register, their grief and loss backgrounds, and their genders. With this
information in mind, I wanted to create a song that could be used with the group and
individualized via active songwriting for each participant in the group. Again, the “path
to peace” title and focus was chosen for the song due to the fact that this was the
theme selected by the retreat staff for the entire weekend. When families registered for
the retreat, this “path to peace” title and theme was featured in the registration
information and application.
For the music therapist, using songwriting as an intervention, the issue of who
actually writes the song is crucial (Krout, 2005b). One important consideration is how
much session time and how many sessions can be devoted to this, as a song may take
several sessions to complete if working from scratch. I knew that our songwriting
session would take place during one 90-minute session. As such, I wrote the song prior
to the retreat, but planned to involve the participants in re-writing the lyrics during the
session. This approach represents a combination of strategic songwriting (song written
ahead of time for clinical use), process song-writing (song written as a process
experience by/with the participants) and lyric re-writing (Baker & Wigram, 2005; Brunk,
1998; Krout, 2006). I did this because of how I wanted to use the song in the group, and
how much time (one session) was available for this music therapy intervention.
I wanted to engage the participants in exploring the theme for the retreat and to
use the song to foster discussion regarding each participant’s relationship to the theme
via the concepts and metaphors embedded in the song. This song was designed to serve
as a departure point for sharing, and the beginning of a group process for the weekend.
I wanted to share some thoughts and concepts for the participants to react to, and to
use the song in fostering discussion regarding these concepts.
The session began with introductions and a review of confidentiality guidelines
(i.e., “What we say here stays here”). Each group member was invited to “tell their
story” and share about his/her sibling who had died. Most of the group members shared
briefly, and only three participants elaborated on their losses for more than several
sentences. This was expected, as for adolescents, sharing about their personal sibling
loss histories can be both difficult and intimidating (Birenbaum, 2000). Both I and my coleader assured the participants that they did not have to share more than they felt
comfortable with at that time.
I next told the participants “Here is a song I wrote that relates to the theme of
this retreat and to some of the issues we will explore this weekend. For now, just listen
to the song, and we can talk about it afterwards if you wish. You can also re-write the
lyrics if you want to make the song your own. I am passing out copies of the lyrics so you
can follow along.” I felt that starting with a receptive experience in which I played and
sang the song while the participants just listened would be a safe and non-threatening
experience for them. The original lyrics, as well as the lyrics re-written by the group, can
be seen in Table 1. A lead sheet for the song as re-written (verse 1 and chorus) can be
seen in Appendix 1.
I then played and sang the song with guitar accompaniment. Following the song,
I asked if anyone in the group wanted to comment on or talk about the lyrics. After a
moment of (anticipated) silence, one 12-year-old boy whose younger sister had died the
year before of renal failure, began the discussion by saying that the path to peace might
be found inside of us rather than externally like a path one walks on. Several
participants agreed with him, and a 13-year-old girl followed up, suggesting that the
path might be in heaven, where she thinks her baby sister is. Conversation continued,
and we explored a number of concepts imbedded in the original lyrics.
I next asked if the group would like to re-write some of the lyrics, to which the
participants responded positively. I wrote the original lyrics in the first person plural so
that the singer would be in the voice of, and represent, the point of view of the group. I
also wanted the song to help contribute to these individualized processes within the
environment of this particular session and the grief retreat as a whole. This appeared to
work, as participants discussed the lyrics, related them to their own losses and
situations and offered new lyrics. The songwriting process also offered participants
opportunities to reflect on and process their unique grief situations both as individuals
and as a group, which was the clinical intention. This can be seen in the new lyrics,
which include personal pronouns that are both first person singular and plural (e.g., you,
we), as well as first person and plural possessive pronouns (e.g., your, our).
Although several participants made multiple suggestions for lyric changes, all
group members offered at least one suggested lyric change. In addition, all suggested
lyrics were explored and discussed by the group, which made the decision on whether
or not to include the newly suggested lyrics in the song, or stick with the original lyrics. I
served as scribe for the group, writing down the suggested lyrics and reading them back
to the group for reflection, discussion, clarification or alteration. After new lyrics were
suggested and discussed, I sang the new song line containing the lyrics so the group
could hear how it sounded when sung. Some of the participants began to sing along
with me after I invited them to do so.
The lyric changes for the second half of verse two also seemed significant. The
sentence “Each step we take it means so much, you’re walking with us” was changed to
“Each step we take you mean so much, and you’re holding onto us.” The boy who
offered this change shared that they (the surviving siblings) were the ones walking on
their grief journeys. He said that their deceased brothers and sisters couldn’t walk
anymore (being dead), but that their spirits could hold onto them as they walked. In this
way, they would be together throughout their lives. This prompted another group
member to suggest a change for the second verse. She changed “Living every day anew,
your light among us” to “Living every day anew, you’re flying among us,” observing that
the spirits can fly even if they can’t walk.
The discussion and lyric re-writing took about 45 minutes. At the conclusion of
the process, we discussed the new song in total and how it was now uniquely theirs. I
asked the group if they would like to change the title of the song, but they chose to keep
the original title. Finally, I asked the group if they would like to sing the song with me at
the closing remembrance service and ceremony or record it so a CD of the song could be
played at the service. The group chose to record the song rather than sing it live, and we
recorded the song to a CD with me playing guitar and the group singing with me (see
Appendix A for the music and lyrics).
A remembrance service at noon on Sunday concluded the retreat. It was held in
an outdoor chapel, which consisted of a beautiful open limestone structure with a small
creek flowing through it. There were seats around the perimeter, as well as stone
benches facing a raised stone platform, with a stone wall behind it. The goal of the nonTable 1
Lyrics to "Our Path to Peace"
Original Lyrics
Re-Written Group Lyrics
Verse 1
From this journey we are on
Come the moments which have grown
To bring the rising of the dawn
And you before us
So as this new day comes to pass
Changing shape and moving fast
Forming memories that will last
Of you within us
Verse 1
We wait for you and love you
We wait for you and miss you
To bring the rising of the dawn
And you to join us
So as your life comes to pass
Shaping lives and leaving fast
Storing memories that will last
Of you within us
Chorus
We are standing here
Remembering you and holding dear
The light of love
Reflections of
The hearts that will not cease
Chorus
We will stop here
To remember you and hold you dear
The light of love
Reflections of
Our hearts that go on forever
To move forward still
As days grow bright journey will
Begin each day
And show the way
Along our path to our peace
Verse 2
Today we turn our love to you
All the dreams that we've been through
All the thoughts that we've gone through
Living every day anew
You're flying among us
So here we share our hopes and touch
Our future bright, now you're with us
Each step we take you mean so much
And you're holding onto us
To move forward still
As days grow bright our journey will
Begin each day
To show the way
Along our path to peace
Verse 2
Today we turn our thoughts to you
Living every day anew
Your light among us
So here we share our hopes and touch
A future bright you are with us
Each step we take it means so much
You're walking with us
service was to honor and remember the deceased children. After an induction by a
chaplain and remarks from the retreat leader, each deceased child was honored with a
flower placed on a wreath by his/her family. The name of each child was read by the
chaplain, along with the dates of the child’s birth and death, the child’s age at death and
how the child died. During this time, the family brought the flower forward. After all the
names had been read, I introduced the song, its relationship to the retreat theme, and
shared how the group had re-written the lyrics. At this point, several of the group
members came up to the front of the space and stood next to me. This was self-initiated
and suggested that they felt ownership for the song and how it was being shared with
their families. Copies of the song lyrics were distributed by several members of our
songwriting group. Our song was then played via a CD player hooked into the PA
system. The service concluded with remarks and a blessing from the chaplain. After the
service, I gave each group member a copy of the CD we had made.
The families then dispersed and the retreat was over. During this time, most of
the group members came over to say good-bye, and several shared how meaningful the
songwriting process was for them. Several parents also said that their children had
discussed and shared the song with them during informal times during the weekend. In
written evaluations of the retreat, all group participants rated the songwriting
experience as positive, indicating they would like to take part in a similar group in the
future.
denominational
Summary
For family members, grieving has been described as a shared, universal and
natural expression in response to loss such as the death of a sibling (Bruce, 2002). For
adolescents grieving the death of a sibling, music therapy can facilitate this natural
grieving (Teahan, 2000), and music therapy songwriting-based interventions can be a
significant part of this process (Krout, 2005b). As Bruscia (1998) wrote, “They (songs)
express who we are and how we feel, they bring us closer to others, they keep us
company when we are alone. They articulate our beliefs and values. As the years pass,
songs bear witness to our lives. They allow us to relive the past, examine the present,
and to voice our dreams of the future. Songs weave tales of our joys and sorrows, they
reveal our innermost secrets, and they express our hopes and disappointments, our
fears and our triumphs. They are our musical diaries, our life-stories. They are the
sounds of our personal development.” (p. 9)
In music therapy group work, the use of therapist-composed songs can facilitate
participant connections and goals between and for participants during a single session,
even when those participants have not interacted prior to that session (Krout, 2005a).
For adolescents, songs can function as powerful catalysts for individual and group
identity formation and the construction of feelings of self (Laiho, 2004). The music and
lyrics of group-composed songs can provide creative and safe containers in, and through
which, bereaved adolescents can experience, explore and process their grief (Dalton &
Krout, 2006). The songwriting experience in which I involved the group of bereaved
young adolescents at this grief retreat appeared to facilitate the validation,
identification, normalization and expression of their feelings relating to both their
deceased siblings and their own on-going grief journeys and processes. Although this
group process lasted for only 90-minutes, it allowed the group members to take part in
a meaningful group experience, while also examining and reflecting on their own unique
grief situations in a creative and non-threatening way.
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Appendix
Taken from: Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum NH: Barcelona
Publishers.
CASE FOUR
Where Have All Our Flowers Gone?
Music Therapy with a Bereaved Mother and Widow: A Case Analysis
Chava Sekeles
“I have a hole in my bosom. Never knew of its existence. … Here in the center of
the bosom, a private hell occurred to a woman who just wanted to hold again and again
to her love.”(Adi Lelior, 2004, Till Death Do Us Part, p. 51) Dedicated to Anetta and
Reuven Shari
Introduction
Naama, a mother in her forties, had lost her eldest son in a military action
behind the “green line.” Though this occurred at a time of war, it was not the enemy
who killed him, but, as they say in the army, “the fire of our own forces.” Throughout
the first two years after this accident, Naama continued to function to some extent,
though her motivation and efficacy had obviously deteriorated. Then, another blow
struck the family, and her husband, following a short period of illness, passed away.
Naama was left with her adolescent son David, who was on the verge of finishing
high school. The everyday activities faded away, and her depression was accompanied
by self-negligence: From a beautiful, well-dressed, and preserved wife, she turned into
an indifferent woman, could not execute her household duties, neglected her son, did
not care to eat, and slept very little. After a year in psychotherapy accompanied by
antidepressant drugs, she was referred to music therapy, where the work with her
continued for three years. Two years after concluding music therapy, she married a
widower who brought two daughters to the family nest. Throughout time, all the
children left home and Naama’s life as part of a couple continued reasonably.
Why was Naama referred to music therapy? The psychiatrist who treated her
had claimed that the medication had helped her but that the verbal therapy had not
been effective. Conversely, she had told him of her love for music, of the fact that she
was moved by music, and of her readiness to try this medium.
Intake and Observation
Naama entered the room, did not look around, collapsed into an armchair, and
stayed there. In the short conversation we had, Naama expressed enormous rage
concerning the army, her fate, the dead, her losses, herself, and what awaited her in the
future. She was very ambivalent and unsure that any therapy might help her.
Interestingly enough, she displayed all of this rage while sitting in the armchair in a bent
over position, making hardly any movement, and as though spitting the words to get
them out of her system. Moreover, she did not raise her voice above mezzo piano. Thus,
there was a disparity between the content and the vocal elements of what she said. At a
certain moment, this rage content turned into a deep feeling of helplessness, loneliness,
and emptiness. Her vocabulary changed, but the musical features remained
approximately the same.
The conversation turned to what she expected from music therapy. After a long
silence, Naama asked: “Can it energize my body and soul? Can it pour something that
will purify my being?” This was a high mountain of expectations: Was it indeed possible?
What does music enable, and where are its limitations? How much would Naama
cooperate, and how flexible was she? Specializing in the developmental- integrative
model, I asked myself what approach and technique I should choose and implement.
Therapeutic Considerations. In the mourning process that Naama had
undergone, the past, present, and future had been felt as an empty space, creating a
deficiency, deep pain, helplessness, and hopelessness. The fact that Naama could not
find a channel for consolatory activity caused me to contemplate her role in the
matrimonial relationship: Naama had always had this conflict of developing her
professional life versus being a wife and a mother. She chose the second role and
became very dependent on her husband and children. After the death of her eldest son
and her husband, as I had found with other dependent widows, she could not so easily
rebuild a new meaningful life and was not able to care for the remaining youngest son.
Generally speaking, the elaboration of personal grief either positively aids in the
adaptation of the rest of the family to the bereavement process or influences it
negatively. Death in a family causes changes in hierarchy, in resharing duties, in
communication, and more.
As long as Naama’s husband had lived, he had supported her and they had both
taken care of the younger child. Though she had not reverted to her former self after
her soldier-son was killed, she had nonetheless hung on in a way. When her husband
died, the burden became too heavy and she could not prevent her own disintegration.
Avigdor Klingman (1998) says that the death of an offspring is among the most
difficult and painful experiences of parents; always perceived and felt as too early and
unjustified. A child is an additional part of the parents’ egos, specifically in mothers’
emotional worlds. In the Israeli society, where many young soldiers are killed during
military service, there is also a kind of emotional differentiation between soldiers who
had a “heroic death” and soldiers who were killed in an accident.
There is a lot of anger (in this case, anger toward those who killed Naama’s son).
Remarks such as: “Nothing to be proud of,” “He gave his life to the country for nothing,”
can be heard from people, including the two families of the deceased.
Klingman (ibid.) says that according to the general literature on children’s
deaths, the following factors must be considered: the parents’ personality, the age of
the child, the cause of death, and the context in which it transpired.
Returning to Naama: As aforementioned, the transformation from a bereaved
mother to being a bereaved mother and widow led to her deterioration. Moreover, we
can add a bereaved brother and son who needed her to function both as a mother and
as a father to the constellation. She needed to deal with her son’s grief as well as with
her own, to organize all the official arrangements, to cope with her loneliness, and to
find new meaning in life, as she did not even have a profession or job to get back to. All
this was too much for her personality’s strength, and she sank into depression, including
all the clinical signs.
To confess to the truth, I had no idea as to what would happen in her music
therapy sessions, and the fact that verbal psychotherapy had not helped her troubled
me a lot. I did not think that music was the answer to all of her problems, and I did not
feel omnipotent. With these feelings, I met Naama for the second session.
Tied to a Coffin
Naama entered the room, fell once again into the armchair, and said, “To tell you
the truth. I don’t think I can do anything. Most of the time, I feel tied to a coffin, as if I
were lying in a grave, unable to breathe. I cannot even concentrate on my youngest son,
and I think that he may not need me.”
This image of “tied to a coffin,” and the idea that her son might not need her,
opened a narrow window for work and elaboration through music. I suggested that she
transfer this feeling of lying in the coffin, unable to breathe or think, into music. She
immediately responded: “No way! But if you can find recorded music that fits this
situation, I’ll try to listen to it.” I screened my “inner library” of art music (which was the
category she preferred), in an effort to find the image of “tied to a coffin.” After a few
minutes, I suggested Lukas Foss’s Echoi (1961–1963), an aleatoric 3 improvisation for
percussion instruments, cello, piano, and cembalo.
The composition begins with a very low cluster played in a quick tremolo style.
After few minutes, percussion and piano notes are inserted, followed by Baroque
themes, which sounds like a fantasy of distortion. I let Naama hear 10 minutes of the
beginning, which was intense enough. Naama’s reaction was mixed: “This was awesome
music. I could hardly stand it, but it perfectly portrayed the horrible stress I feel in the
suffocating coffin.” Indeed, my choice of Echoi led to a similar feeling of stress and
horror, probably due to the realistic sound of the roaring noise. Another reason was the
improvisational features of Foss’s composition, which could show Naama that this
approach exists in the work of well-known artists.
In music therapy, improvisation has a respectful position and acts as one of the
main therapeutic languages. It enables to dare even without a preliminary experience.
Thus, the expression of feelings is not necessarily accompanied by words. In addition,
improvisations act as a chain of associations, freed from the mastery of reason and logic
(Sekeles, 2002).
In the third session, we turned back to the theme of being tied to a coffin, and
Naama was ready to try to describe it through piano improvisation. Naama used to play
the piano when she was young, but she did not spontaneously improvise. I therefore
suggested that she choose one note and let me play it on the bass section of the piano.
Naama suggested the note of E, and when she felt comfortable with this note,
she carefully added her own improvisation. This one note was played in a constant
rhythm (basso ostinato), served as a container, and symbolized the narrow space of the
coffin. Naama began to play in a stiff, repetitious style and gradually developed the
melodic line, the dynamics, and the range of the music. I looked at her face and saw the
expression of a child playing with a new toy. This improvisation continued for about 10
minutes and allowed me, at a certain point, to develop the one note into a melodic
counterpoint. After finishing, I suggested listening to the recording. Naama consented.
She listened intently and afterward commented, “I have never improvised on the piano,
and I never felt free to play in such a way. I reckon that the one note held me in a
manner that allowed me to stay in the coffin without being suffocated. At the end, I
even stepped out and felt quite good. I would not suspect that I’d be able to describe a
feeling like that through music.”
Therapeutic Considerations. The ability to “play” with any material; change its
shape; remodel it; think about it in an unconventional way; be active, imaginative, and
innovative, is the basics of creativity. Musical improvisations enable us to use “divergent
thinking,” which is characterized by fluent production, multifaceted solutions,
spontaneity, and freedom from logical thinking.
From our discussions, I learned that Naama was not comfortable without a welldefined framework and that even while cooking she had to use recipes. From this point
of view, strengthening her creativity meant providing her with more self-confidence and
freedom. Symbolically, improvising on a holding pattern is to cast your own ideas on a
sound ground. This is one of the advantages of mutual playing (in this case four-hand
piano) and using techniques that do not require professional competencies.
The holding frame is typically a repetitious parameter: rhythmical pattern,
harmonic pattern, basso ostinato, an interval, a melodic line, and others. These are
phenomena that exist in musical compositions and give the listener a feeling of
consistency and confidence. I thought that we might work on broadening Naama’s
improvisational and emotional horizons by listening to compositions that develop from
a narrow space to a wider one and to correspondingly improvise in a similar fashion.
Holding and Containing
Hector Berlioz demonstrates a type of holding frame in the Pilgrims’ 4
Procession, which is the second movement of Harold in Italy, by a sounding a repetitious
note. Though this note does not resound in an intensive way, it does so very clearly.
Naama enjoyed listening to it, noticed the internal counterpoint voices and melodious
lines, and in her imagination developed an entire conversation with her late husband.
She divulged the content to me after the music was finished. I suggested that she
employ a gestalt technique of two chairs and converse again by playing both roles: her
husband and herself. In this conversation, Naama gently blamed her husband for
deserting her, leaving her alone with her suffering. Though it was said in a very soft
voice, I had the feeling that she had partially ventilated her anger. She moved from chair
to chair, even changing her voice a bit, and used painful vocabulary to ease her burden,
completely ignoring my presence.
This is merely one example of holding parameters in music, which contain the
sorrow of the patient and elicit verbal content. Another example was Ravel’s Bolero, in
which the melody is repeated from beginning to end (for 15 to 18 minutes) with
changes in texture and dynamics. In addition, there is a repetitious rhythmical pattern
typical to the Bolero dance. From a therapeutic point of view, this composition contains
elements of ecstatic music, specifically the graduate crescendo and varying of the
melodic instruments, versus the fixed rhythmical pattern.
There is, however, no accelerando, and thus the musical excitement in ecstatic
traditional rituals (Sekeles, 1994), which elicit ecstatic dancing, is far more restricted and
diminished in the Bolero. Naama reacted to the Bolero by deciding to adopt the
rhythmical pattern and drummed it on the timpani for nearly 10 minutes. In the
beginning, she could not sound the crescendo, but kept the tempo very well. After
about three minutes, she added crescendo and acceleration, which are a natural
physiological phenomenon. Naama commented on the feeling this kind of drumming
gave her: “I felt ‘high’ as if I was dancing and not playing. Amazing how a simple
repetitious melody may have so much strength and the power to energize the listener.
It was good.” Returning to the intake meeting, I thought about Naama’s response when
I asked her what she expected from music therapy: Can it energize my body and soul?
Can it pour something that will purify my being? Perhaps she had begun to open herself
to simple physio-psychological activity and felt the music not only in her head but also in
her body and soul. I remembered that I had Ravel’s arrangement of the Bolero for solo
piano. I decided to use it the next session. After a week, Naama arrived and asked to
listen to the Bolero again. I took the opportunity to suggest that she play the rhythm,
just as she had already done, while I played the solo piano. Naama agreed to try this
idea. We played it once from beginning to end, and she then suggested: “We can use
the same rhythm and improvise a new composition on it.” We did this while alternating
roles. That is to say, once she improvised and I kept the rhythm, and vice versa. I felt a
positive procession of development, and while she was busy playing I observed a mild
expression of satisfaction on her face.
Therapeutic Considerations. Both terms, holding and containing, originate in
physiology and were adapted to psychology. The fetus is held and contained in his
mother’s womb, which gives him comfort and confidence. Subsequent to birth, the
mother’s body and hands carry on this posture and function, which gradually obtains a
double meaning: physiological and psychological.
Generally speaking, a holding frame or a frame “inclines to stabilize the
therapeutic process and protect the client and the therapist from being over flooded
and carried away by situations and actions that they are not yet ready for or unable to
cope with” (Rosenheim, 1990, p. 46). In psychotherapy, the frame may be a set
therapeutic time and structure, ethical rules, and more, which enable the therapeutic
process to develop within it a proper amount of flexibility. In music therapy, we also
have specific techniques that supply a holding frame and at the same time allow
freedom for improvisations. This is a duality, typical to music as an art form, which is
present in almost all musical categories. With each patient, the holding frame may be a
different structural element: rhythm, melody, harmony, etc. We therefore need to find
the most effective element and work with it while internalizing, conversing, reflecting,
augmenting, clarifying, and more.
Naama was able to listen in a sensitive way, gradually represented actual life
events through music, and used it to suit her particular needs. An example of this is the
conversation she held with her husband in which she ventilated her anger toward him
for the very first time.
An additional sign of progress was her growing ability to improvise freely and to
feel good about it. Besides its other advantages, playing freely may sometimes impart
on the improviser an elated feeling of happiness. Indeed, this linguistic connection in
English (and in some other languages) between “playing” and “playing” a music
instrument has great meaning. A smiling expression, which was uncommon for her,
gradually began to appear on Naama’s face. A tiny light at the end of the obscure tunnel
through which we walked together seemed to appear.
It is significant to again emphasize that musical interaction in music therapy is
perceived as analogous to life itself. I felt that Naama had gradually learned through the
musical interaction that experiencing death, as difficult as it might be, was also a
universal experience of life.
One might develop personal meaning concerning life and death even when it
seems as though life has lost its value and that we are imprisoned with the dead in their
graves.
Naama also began to understand that the worn-out term “coping” contains
subterms such as adaptation, indulgence, giving, and the need to change life molds in
order to establish psychological and spiritual independence.
Mother-Son Music Therapy
At a certain therapeutic moment, Naama brought her relationship with David,
her youngest son, to therapy. She conveyed it verbally and described her guilt feelings
and the minimal care she was able to provide him, “I expect him to understand my
condition and most of the time to forget his young age and own needs.” During this
conversation, we discussed a possibility she suggested, of mother-son music therapy. At
that moment, it seemed a good suggestion and we decided to try it. This therapeutic
process lasted until the conclusion of therapy and exposed many layers of pain and
anger on both sides. By this time, David had already finished high school and had
obtained a deferment from the army for the purpose of premilitary studies. I would like
to present a few examples from this period and demonstrate the role music therapy
played in this voyage:
Togetherness. David entered the music therapy room with his mother, who
informed him that he was allowed to freely explore the musical instruments. From this
point on, I observed the two and the musical and extramusical interaction that
transpired between them.
David had no problem trying the drums, the bells, the wind, the string and selfmade instruments. At first, Naama just watched him without any interference, but at a
certain moment she gently joined him. He was playing the lyre, and she added Japanese
bells. In a moment of intermission, I requested permission to record their mutual
creation, and they agreed. Naama and her son David spent the entire hour improvising
without a directing subject, rules, or instructions. I did not see any reason to join in or to
interfere.
Relistening. Next session, I suggested listening to some parts of their
improvisations from the previous week. They agreed and did so very carefully. I noted
that David had good concentration qualities in addition to his creative freedom.
Following the listening exposition, he declared, “It is fun but we have to practice a lot if
we want to be together.” His mother responded, “Yes, you are right, but here in music
therapy we are not provided with corrective instruction. We have to find our way
together.”
Improvisations: David and Naama improvised with musical instruments for an
entire month. During this period, they showed no inclination to describe a situation, a
feeling, a figure, etc. Neither did they use their voice musically, although it is the closest
element to speech. On the other hand, the improvisations became more and more
developed and clearly structured, with dynamical changes; at times, they were even
divided into semichapters. It was amazing to see how a musical interaction could
develop without planning or words. My role at that time was to let them be and work
together in a way and through a modality foreign to them, to allow them to experience
mutuality detached from everyday life. They occasionally asked for my help, mainly on
technical matters, or requested that I replay their improvisations.
Clinical Improvisations: After about a month, Naama told David that in her
music therapy sessions she also experienced conversing, representing, describing her
feelings, and more through improvisations. Coming from Naama (and not from the
therapist), this was undoubtedly a turning point. Where would it lead them? Us? David
suggested, “I like jazz and rock, you certainly prefer your classical music. Perhaps we can
first represent ourselves through precomposed music?” Naama accepted this idea, and
for several sessions they listened to their musical choices, after which they developed
interesting conversations. They gradually began to request my involvement, and we
entered a phase in which Naama and I improvised together on the piano and David and I
played his material. I would play the piano and he the drums and other percussion
instruments. This process did not bring David any closer to his mother’s preferences, but
drew Naama closer to her son’s music and she joined in his playing, showing new
interest.
Where Has All Our Anger Gone? The final segment of music therapy with Naama
and David was the longest and dealt with bitter feelings, anger, grieving for the
deceased brother and father, and confronting mother-son emotions and each other, as
difficult and painful as this was. The musical work they had invested in so far was very
efficient in building a mutual relationship of confidence, and thus the ground was ripe
for embarking on this new level. Once again, as in previous cases I have analyzed,
patience was the key ingredient. In his chapter on dealing with anger and guilt, Parkes
(1972) emphasizes the notion that “until the reality of the loss has been fully accepted,
the greatest danger is the danger of the loss itself. The bereaved person still feels that
the dead person is recoverable, and anything that brings home the loss is reacted to as a
major threat. Relatives and friends who try to induce a widow to stop grieving before
she is ready to do so, or even those who indicate that grief will pass, are surprised at her
indignant response. It is as if they are obstructing the search for the one who is lost” (p.
80).
I felt that since her mutual therapy with her son, Naama was on the verge of a
better insight due to her revitalizing experiences and elicited more energy and
acceptance. Developing insight mostly requires interference and guidance on the part of
the therapist. With the therapist’s encouragement, Naama and David began to learn to
express those parts in each of them that were silenced and distorted for a long time.
Confrontation was necessary in order to begin an intra and inter dialogue. This
therapeutic process was technically prompted through both musical and verbal
conversations. At that point, they also began to employ musical vocality, which seemed
uncomfortable to each of them.
David was the first to realize that singing can increase the emotional possibilities
of the vocal expression, as it holds many possibilities less exploited in speech:
accentuation through many repetitions of one motive, rich emotional expression by
using a wide vocal range, and more. Despite the embarrassment, the vocal dialogues
they began to develop deepened the process of peeling away their protective layers of
armor. David expressed his anger at his mother for investing all of her emotions in his
deceased brother and later in his deceased father, though before her stood her
surviving son, who was faced with overcoming a difficult period of matriculations,
grieving, and mourning: “You barely asked me about my examinations, not to mention
my feelings. You hardly ever cooked; you neglected every motherly function and walked
around the house like a zombie.” Naama’s response was a cry that she was unable to
end. A week later, she collected herself and said to David, “You were always the
strongest in the family, stronger than your brother and father and surely stronger than
me. I had the feeling that you did not need me, but it was also very convenient for me to
think so, as I had no energy to invest or share.” At moments such as these, the
therapist’s role was to facilitate a reassuring atmosphere, relating that the world
continues to exist and that we do not come apart or dissolve when we discharge our
conflicts with our beloved ones.
The second step was to discuss the son-brother and husband-father deaths. It
appeared that David had experienced many conflicts with his elder brother, but felt that
he was not allowed to desecrate his mother’s memories or the memory of the dead. He
missed his brother in an “unfinished business” dynamic and desperately needed to
elaborate on the subject. I initially suggested working on it by representing the family
members through musical instruments and voice. He first worked alone and later with
his mother. Since his relationship with his father was very good, it was easier for David
to express the immense anger toward his brother. I must admit that these recordings
are among the most touching pieces I ever experienced in therapy. The more David and
Naama externalized their emotions, the better they began to feel. Concerning Naama,
her everyday functioning became nearly regularized, and the termination of music
therapy painted the horizon.
Music and Poetry. During this stage, singing became part of the sessions,
including Israeli songs accompanied by the therapist. This soon led to the writing of
poetry and sometimes to the composing of music to it. The latter process had many
faces: Sometimes each of them wrote a poem with regard to him/herself without or
with music; other times, Naama wrote a poem and David composed the melody or vice
versa. Their style was very different, but the mutual feature was the discovery of a
personal talent and artistic satisfaction. I would like to present the translation of
Naama’s final poem, to which David composed accompanying music. We must of course
take note of the fact that the translation from Hebrew to English changes the musical
intonation of the text itself, but I tried to stay true to the original meaning:
Death bit crudely at my heart
Left me in my grave dead-alive
Bless God for opening my eyes to beauty and to the sounds of music
Bless God for a compassionate last moment of salvation
Bless God for purifying my heart to feel the pain and to accept the joy
Bless my life-friend for leaving me the sweet memories of the dead and the alive.
Summary
Sometimes we title a therapeutic process as though it were a musical form, such
as a sonata, rondo, etc. In Naama’s case, I received the impression of a “fantasia form”
due to the fact that we walked through endless curves, turned in all directions,
experienced regression, and gradually felt new drops of life and insight. From the stage
that Naama understood the urgent need to work through her relationship with her son
David, the road turned from a stony, thorny path to a paved one. Music improvisation
and receptive music therapy from time to time were the modalities that paved this road
and the intra and inter mother-son relationship. Through this work, the relationship
with the deceased became clearer, and Naama was able to open her heart to grief and
bereavement without fearing the disintegration of her own personality.
As mentioned in the introduction, Naama remarried two years after concluding
music therapy. During this period, she dedicated time to the piano, which she had
ceased to play upon concluding elementary school. She resumed lessons and spent time
improvising. Her son, David, completed his studies and his army service (unharmed).
It is essential to mention that the process of music therapy was concluded with
the consent of both patients and therapist. It seemed like the right moment, though as
Rosenheim (1990) says, “Sharpening the coping tools does not guarantee a ‘security
certificate’ for resisting future pressures…” (p. 204). It does, however, increase the
likelihood of coping better, with reduced anxiety, when encountering a new obstacle in
life.
Notes
1) Anetta (1903–1978) and Reuven Shari (1902–1989) were born in Russia. They were
both among the compelled “numerous clauses” in their high school, which they
finished “cum laude” at a very young age. Reuven studied further and became a
young lawyer; Anetta studied dentistry and played the piano. The anti-Jewish
pogroms, which had not ceased since 1821 (1859, 1881–1884, 1903–1906, 1917),
left hundreds of thousands of Jews dead. In the 1917 Russian Revolution alone
250,000 civilian Jews died, many were wounded, and 2 million emigrated, mainly to
America and partly to Israel (Rubinstein, Chon- Sherbok, Edelhei, & Rubinstein,
2002). Anetta and Reuven were young parents of their first baby daughter when
they immigrated/escaped in 1925 to Israel. In the new country, they had to stop
their intellectual activities and work like other pioneers in agriculture, in paving
roads, in building Israel. In the forties, Reuven turned back to law and contributed
intensively to the public life of Israel. In 1948, he became a member of the Knesset,
head of civil service, and more. By decision, Anetta took responsibility for the home
and the raising of her three daughters. This chapter is dedicated to my beloved
parents, Anetta and Reuven Shari, who taught us the meaning of family, of work, of
art, and of a motherland.
2) Comparing the grieving of mothers to that of fathers: Mothers display their grief
more openly than fathers. There is less research concerning the grief of fathers, but
in Israel they take on the role of the strong family member. It is important to
remember that most of them served in the Israeli army and had experienced deathrelated situations as soldiers. They tend to be in more of a position of denial, their
mourning period is shorter than that of the mothers, and they go back to work as
soon as possible. On the other hand, there were several cases in Israel in which
fathers (including some high officers) committed suicide at the grave of their soldierson.
3) Lukas Foss is a German-born composer who immigrated to America. In 1956, he
began to work on improvisations with his students at UCLA, which led him to form
the Improvisation Chamber Ensemble. They did a lot of aleatoric work and
contributed important new concepts to art music.
4) Harold in Italy was ordered by Paganini in 1834 as a viola concerto for his
Stradivarius instrument. Berlioz remained one year in Italy and adored the
landscape. The composition, ready in 1835, was influenced by these images.
Paganini was not satisfied with the results, as the viola role in this composition did
not show enough prominence. Still, it presents a special intrinsic relationship
between the orchestra and the viola.
5) Maurice Ravel (1875–1937) composed the Bolero for ballet based on the traditional
Spanish form. It consists of a repetitive melody, a counter- melody, gradual
crescendo, a large orchestra, and changes in instrumental texture with condensation
towards the end. Therapeutically speaking, it has a stable frame, which includes the
rhythmical pattern and the melodic line. Changes of orchestration and volume occur
on this foundation. Based on my clinical experience, most patients feel good with
this composition. There are those who need repetitions and others who can
perceive the gradual changes and enjoy them. Some patients like to express this
music in movement or graphically, imitate the rhythm, and more. While working
with dance therapists, I instructed them to translate the Bolero’s musical
components into movement. The videotaped results were very interesting, as we
could observe unusual interactions between limbs, interesting choices of body parts
to express the rhythm, difficulties in keeping the tempo solid while the dynamics
changed, etc.
References
See End of Case Seven
Taken from: Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum NH: Barcelona
Publishers.
CASE FIVE
Bobby Laments his Grandfather: A Case Analysis1
Chava Sekeles
“He was gone to the blue land where eagles are red, cows are green, children are black, and
grandfathers lie deep in the purple earth.” (Bobby, nine years old)
Dedicated to S. B.2
Introduction
This case deals with Bobby, an eight-year-old child with severe behavior problems who
was brought to music therapy by his parents based on the recommendation of a child
psychiatrist. In spite of his problems, Bobby was cooperative from the first moment and
demonstrated great love, talent, and creative power through music. He soon brought up many
“burning topics” for therapy, among them the issue of his grandfather, who had passed away
when Bobby was six years old. The subject of death had remained repressed for about two
years and had placed the burden of unfinished business on young Bobby’s shoulders.
Eventually, due to a conflict with the official educational authorities, the family decided
to discontinue all therapies and schooling. Thus, many issues concerning their son were left
unsolved.
Music therapy with Bobby continued for about 18 months but never came to a closure,
in spite of the fact that the parents perceived and accepted it as a less threatening modality.
This is a case analysis, which seemed to be an unfinished symphony, a symphony with a
promising beginning and an abrupt conclusion.
Bobby was born after a full-term pregnancy. At the age of a few months, he began to
show signs of uncontrolled rage and throw temper tantrums, first at home and later at the
nursery and elementary school. The school psychologist highly recommended neurological and
psychological examinations, but the family was opposed to the idea and denied any problems.
Generally speaking, they showed a tendency to blame the system.
The intake process may involve observations on spontaneous or guided music activities.
As music engagement influences varied parts of our organism—motion, senses (and
sensations), emotion, socialization, cognition, and the integration of parts or all of the
abovementioned—it facilitates valuable observational modes. In Bobby’s case, I allowed him to
freely examine the room and the equipment and intervened when necessary. Bobby
immediately moved all over the room, examining the different musical instruments, initiating
duets, different manners of playing, etc., as though he had been in music therapy for years. His
musical expressions also included the description of different emotional situations, of which the
first one was “splitting.” During the initial intake, splitting was represented by a war between
two big-sized instruments: the drum and the cymbal. This interaction, which was solely played
by the child, began in a chaotic way with fierce blows, broken rhythmical lines, and shouts.
Gradually, from within, without any instructions or suggestions, the music became less
chaotic, more patterned and softened. Within a short time, Bobby had dramatically progressed
“from ecstasy to relaxation,” after which he said the following: “The good cymbal defeated the
bad drum, but they won’t be friends, neither will they play together.” Before leaving, Bobby
initiated an additional idea and improvised a song in which the words and music were of his
own creation, accompanied on the spot by the therapist:
THE WINNING CYMBAL
“Yes, the cymbal won.
It won over the bad and that is that!”
(Your song is beautiful) “Many thanks.”
(And your voice is pretty) “So are the flowers.”
This song of praise was indeed sung softly, with a natural flow of a tonal melody in F
major and in a beautiful clear voice.
It was very difficult to gather from his singing that this was the child whom kids in school
had nicknamed “the Devil.” On the contrary, one could sense the “Angel” within Bobby’s
psyche. The splitting between bad and good that Bobby presented in his symbolic playing
actually reflected his personality. In the music therapy clinic, he tended to show the Good
Bobby, while in school and at home he attacked children and teachers with stones and knives.
Thus the intake- observational session, which became the first therapeutic hour, concluded
with the song that described the content of the events.
Therapeutic Considerations
The reports I received from the school and the psychiatrist drew a picture of a very
troubled child: Due to conflicts with the educational system, Bobby’s parents had moved him as
a young child from one nursery school to another. This situation made it very difficult to
develop ongoing bonds, and, indeed, Bobby was a friendless child who suffered from loneliness.
In addition, he failed in coping with academic requirements. He was not able to
concentrate, and although his intelligence was found to be normal, at the age of eight he could
not read, write, or calculate. He endangered his surroundings with his aggressive behavior, was
on the edge of being removed from school, and was referred to special education. In public
elementary school, the child was diagnosed as having:
•
•
•
•
•
•
•
Organically Based Development Disorder
Impulsive-unpredictable behavior
Uncontrolled anger
Overwhelming fantasies and anxiety
Impaired reality judgment
Unstable-intense interpersonal relationship
Low self-image
•
•
•
•
Underachievement in school
No learning disabilities
Poor verbal communication
Normal motor development
Splitting. The splitting mechanism was presented in our first meeting and appeared
again several times during the 18 months of music therapy.
Splitting was defined by Freud (1938) as “The two contrary reactions to the conflict
persist as the centerpoint of a split in the ego” (p. 372).
Laplanche and Portalis (1985) defined this term as, “The coexistence at the heart of the
ego of two psychical attitudes toward external reality insofar as this stands in the way of an
instinctual demand. The first of these attitudes takes reality into consideration, while the
second disavows it and replaces it by a product of desire” (p. 427). Melanie Klein (1989)
described splitting as the most primitive kind of defense mechanism against anxiety. According
to her, it may involve the object and the ego.
In the course of normal development, the child learns to integrate the good and the bad
object. In cases where splitting and disintegration occur frequently, the child is liable to develop
emotional problems (as in Bobby’s case) and in the future have relationship problems and
exhibit obscure judgment concerning intimacy (Siegel & Spellman, 2002). As for the tantrums
mentioned, in her 83rd session of a child analysis, Klein writes, “I believe that tantrums always
contain despair as well, because while the rage and attacks go on, the child feels that he is
more and more irreparably destroying the loved person, particularly his internalized one” (p.
423).
As mentioned, different expressions of splitting emerged throughout the two years of
music therapy, but at this initial stage I asked myself whether symbolizing the splitting through
music could serve as a preliminary step for elaboration. All of this already arising as part of the
intake process gave me some hope.
Family Secrets
Mutism. Bobby’s parents brought him regularly to music therapy, probably because
they felt less threatened by this modality, but also because they understood that Bobby’s love
for music might serve as a channel for a more normalized expression. Indeed, this was true for
most of the sessions, but at times Bobby was extremely disturbed by the fact that his parents
demanded he conceal information from the schoolteacher, from the music therapist, and from
others. This dual loyalty, which deepened the existing splitting, confused Bobby to the point of
temporary mutism, as seen in the following examples.
Bobby came to therapy, sat near the door in an embryo posture, and did not utter a
word. I decided to sit on the carpet with my guitar, singing, describing and reflecting to him
what he was doing and how difficult it must be to keep silent. It took half an hour before Bobby
showed any reaction. He very slowly progressed on his bottom, came nearby and showed signs
of visual communication. At that moment, I composed a little song into which we would be able
to cast our own words. The melody served as a basic container, and I began to sing. After one
verse, Bobby joined in, and it became an improvised continuation of changing roles. From the
words that sprang forth, I could deduce that he was not allowed to tell about a certain event
that had occurred at home. When the session ended, Bobby was relaxed, said good-bye quietly,
and departed. From the moment Bobby began to react, the verbal improvisation was:
T. Your leg is moving slowly; moving to the rhythm of the music. Your mouth is strictly
closed. It is very difficult to keep mute. It is very difficult to stop singing.
B. Mmmmm, strictly closed …
(I encourage him by the same humming voices, and he begins to sing)
B. One day Bobby was numb and very sad. He could not tell why he had to keep his
mouth shut and he wanted only music for his heart.
T. I’ll sing a song for you, Bobby, I’ll sing for your sad heart and try to help it.
B. I cannot tell why I am shutting my words in the prison. It is a secret, a little secret, and
it can be dangerous to tell it.
T. It is allowed to keep secrets. You have the right not to tell.
B. But I’ll tell it to my bear, I’ll only share it with my bear, and I try to be musical.
T. And you are very successful in being musical.
B. You are right.
T. It is a good feeling to succeed.
B. It is a good feeling that you are successful. So I’ll stay here till midnight.
There was no question about several issues concerning these family secrets: Bobby was
under intense pressure. The parents, who resisted consultation, were damaging the child by
their demands. The child chose to solve the conflict by “shutting himself up,” hoarding loads of
sadness and aggressiveness. Bergman and Cohen (1994) explain that each family has unwritten
rules that supervise the inner and external stream of information. The demand on the child to
keep secrets, and the denial of the family concerning the danger in doing so, places a burden on
the child’s mind and heart. The results may surface in pathological behavior (aggressive or
passive). In Bobby’s case, though the diagnosis was based on organic development, this factor
certainly added psychological undertones to the general picture.
While playing for Bobby during his muteness, I recalled the Moroccan medicine man
that visits the patient’s house and plays on his rita (Moroccan oboe) different ariah (short
“amulet” melodies), in order to find the Jin (devil) that caused the malady, and through it to
cure the patient (Sekeles, 1996/1997). The search for the right melody and words require of the
healer intense focus on the patient and the need to remain calm and not elicit extra pressure.
In a way, all of these originate from the same therapeutic category. Added to this is the fact
that the melody was repetitive and somehow acted as a “melodic amulet.” It also occurred to
me that in the Hebrew language, mutism = elem, and violence = alimut--both are derived from
the same grammatical root.
Indeed, both situations may represent the extreme manifestations of the same origin. In
his everyday life, Bobby mainly employed violence and at times mutism. In music therapy, he
used only organized violence, namely through his improvised songs and his drumming. During
the elaboration process, it had become obvious that Bobby had aggressive fantasies toward
himself as well as toward his parents. When anger and violence were channeled into the
physical action of drumming, he was able to achieve better organization and sublimation.
Lamentations
Bobby’s grandfather, with whom he had had a warm relationship, had passed away.
Unfortunately, his death had been kept in the domain of family secrets and was neither
discussed at home nor explained to his grandchild. This was another stress factor that kept
Bobby from overcoming his problems and ventilating his overflooded head and heart.
This burden was revealed in music therapy through several cases of improvised
lamentations:
1) Bobby entered the room, took a soprano recorder, sat on the carpet, opened it,
began to move forward and backward as in a Jewish prayer, put a tiny doll inside the
recorder, closed it, and sang in an incantation prayer style: “Saba (Grandpa) was sick
and died. Saba was never buried. He probably disappeared into the air. No, he went
away to the blue land where eagles are red, cows are green, children are black, and
grandfathers lie deep in the purple earth.”
2) During another session, Bobby took a Chinese box, wrapped it in a piece of cotton,
placed it beneath the huge timpani, and improvised a drumming ceremony for the
dead. His drumming was harsh but rhythmically well organized, and its grave spirit
was reminiscent of a funeral march.
3) Bobby took a black piece of paper and a white color. He filled the entire space with
tiny white figures in different directions and postures. After finishing his painting, he
folded it into a thin scroll, placed it inside the piano, and said: “Now you’ll play for
my grandpa because he loves music so much, and I’ll sing for him.” I improvised a
semi-lullaby melody and Bobby immediately joined in with the following words:
“Relax, Grandpa, I am guarding you. You disappeared, but nobody told me you had
died. I know you are dead. I know because you were my best friend. Relax. Grandpa, I
won’t tell your secret.”
Therapeutic Considerations. To the domain of family secrets was now added the
blurring of grandfather’s death and its denial by the parents in their son’s presence.They never
discussed the grandfather’s death with Bobby and were certain that he did not possess the
ability to understand the meaning of death and that it would accentuate his fear and anxiety
with regard to the topic.
Many parents, specifically those of older generations, shared the idea that the facts of
death might damage their young children, as they (the parents) did not possess the
psychological tools to cope with this issue. In a way, it was treated as taboo, similar to the
subject of sex. In his research, Kastenbaum (1974) reported that in answering a questionnaire
he distributed, more than three-fourths of the participants shared the opinion that children
“are better off not thinking of death and should be protected from death-relevant situations by
their parents” (p. 12). Smilansky (1981) suggested the following points in adult support for
grieving children:
•
Relaying the facts in a language suiting the child’s development.
•
•
•
•
•
•
Easing the grief by “being with” the children.
Emotional and cognitive elaboration on the facts and adaptation of a new reality.
Constructing a new reality.
Discussing the dead person and letting the child express his feelings toward the
dead.
Showing understanding of the child’s wishes.
Alleviating future worries (p. 94).
In Bobby’s life, none of the aforementioned was done, and he probably experienced
many black, frightening holes in his inner and outer existence. Creating symbolic rituals
concerning death and playing with it through varied artistic variations and modalities were the
first signs of grieving for his grandfather and a proper entry through the gate of elaboration
work. It is important to remember that Bobby initiated all this by himself, most likely when he
felt accepted and able to trust the therapist.
Bobby’s parents used denial and resistance as defense mechanisms and were unable to
supply their son with “holding” and safety. Superficially, the family maintained a normal façade.
However, sometimes a thick layer of frustration and anger burst through.
The role of grandparents in family life is discussed in literature, including that of
grandparents to children with physical disability. On the other hand, the loss of grandparents is
seldom mentioned or dealt with in depth. In practice, we may observe many children for whom
the grandparent held the role of a holding figure, facilitating the unconditional love of a
supporter. This occurs specifically when the parents have difficulties filling these roles,
endangering the child to the point of becoming a “child at risk.” At present, grandfathers (like
fathers) have assumed new roles that encompass nurturing, affection, being playful
companions, and acting as a listening ear rather than being an authoritarian figure as used to
be the case in the past (Anderson, Tunaley, & Walker, 2000). Bobby sensed and remembered
his grandfather as a friend, as a fun-loving person and as a play partner.3 The silence
surrounding his disappearance and the fact that he never had the chance to mourn for him
created a heavy burden on his tiny shoulders. In the music therapy room, he could for the first
time access his grief, act it out, and work through it. After creating several mourning rituals as
described above, Bobby was ready to talk straightforwardly about death. I requested of the
parents to take him to the cemetery but received a negative reaction mixed with anger, due to
the fact that the child dared to deal with such a subject in the music room. I realized that the
parents did not yet accept the role of music as a therapeutic tool and that the several meetings
I had had with them had not served to accomplish the intentioned results.
Bobby worked for more than half a year on the death of his grandfather, the anxiety he
felt, his loneliness, and his desire to be less aggressive in school. He composed songs, used the
theater dolls to tell his invented stories, and along the way began to use writing in order to put
the recorded songs on paper. Bobby was not compelled by me to do so, and this occurred
spontaneously. I sensed that he might be proud of the fact that I was keeping all of his creations
(musical recordings, written songs, paintings) in a special file and that he could look at it from
time to time. He was a clever boy not with learning disabilities but rather with emotional
obstacles, prone to attacks of rage that prevented him from developing normally. Nevertheless,
when he was contented, he discovered his natural abilities, and his musical success aided him in
his progress in general academic studies.
More Splitting
As aforementioned, Bobby portrayed the issue of splitting through different modalities.
The following examples show how he imagined himself through the pictures he painted with
the aid of music of his choice:
THE BAD ME
This was his first self-portrait, done with a black felt pen. He went over the eyes again
and again, blackening them as much as possible. He drew the nose in the shape of a penis and
the mouth possibly like a vulva and explained: “This is the Bad Me.” A week later, he again drew
a self-portrait and explained: “Me, the Wrecker. My eyes are shooting laser beams, my nose is
sending a rocket, and fire shoots out of my mouth.”
ME, THE WRECKER
Four months later, after intensive work elaborating on the subject of self- image, a new
image emerged: “The Good Me.” In this painting, we see a crowned king dressed in bright
colors. Indeed, Bobby’s self-image had begun to change. At the same time, his behavior in
school improved and became less aggressive. His parents were more cooperative, though still
very suspicious, and Bobby began to talk openly about his topsy-turvy world, his loneliness, the
unpredictability in his life, his immense longing for his grandfather figure and more. At that
time, he composed a song on his topsy-turvy world and painted the following:
THE GOOD ME
The next painting was completed when he listened to “The Golden Voyage,” mainly
composed of birds’ singing and the sound of waterfalls.
It was of mother eagle flying in the air carrying her two babies on her back. Bobby
clarified: “The picture is from the land of scribbles and dreams. The two babies and their
mother are flying through the air, never able to descend to earth. At worst, if the chicks are
tired, they can rest on their mother’s back—that is, if she agrees to slow down a bit.” With
these words, Bobby expressed several things: his wish to descend to a safe place, to live downto-earth, and his difficulty with his mother’s unpredictability. The eagle is known as a strong,
large bird. The little babies are very small, and there is a third one that looks as though he had
fallen or remained alone in the high sky. The music played throughout seemed to facilitate a
safe atmosphere and may have helped Bobby control his frightening fantasies. Bobby was now
at a stage where he was ready to speak about his problems, though he needed a lot more time
and work to become stabilized and to bring the extremities of his emotional world closer
together.
MOTHER EAGLE EPILOGUE
Due to a decision made by the educational authorities to involve the Child Psychological
Service in Bobby’s academic future, the family decided to sever all contacts, perhaps due to
their fear of the suggested special education framework. In music therapy, I was given one hour
for this sudden departure, throughout which the child was crying most of the time. It was
nearly impossible to inject a word. I was simply there with Bobby. Miri, the child from chapter
1, was lucky to have a mature father and the positive involvement of grandparents. These
aspects had helped her to use music therapy in an efficient way. Bloom (1964), Anastasiow
(1985), and Erez (1993) consider the parental maturity essential for enhancing the development
of children at risk and comment that maturity is not directly related to the adult’s age,
intelligence, or socioeconomic status. Bobby’s parents held academic professions and had their
own perspectives on life and health. The minute someone tried to guide them or to suggest a
different approach, they felt threatened. Stein and Avidan (1992), in their analysis of
Unconscious Efforts of Parents to Preserve the Psychopathology of their Offspring, found in such
families the following features:
•
•
•
•
•
Extreme rigidity
Enmeshment within the family
Inability to solve conflicts and diminish the level of emotionality
Polarity between the parents
Highly expressed emotions of hostility toward the system
These points are quite adequate for the case at hand. On the whole, in spite of the
difficulties Bobby had in the course of his development, he succeeded in expressing and
elaborating on his splitting and ambivalent feelings through art and verbal means. He was able
to drum out his anger and progressed from extreme violence to a soft, gentle creativity. In
some of his songs, he even revealed a sense of humor, being able to make jokes about himself.
But he was not granted enough time to conclude the process and was not given the chance to
overcome his behavioral problems the way he wished to, as he had expressed in the following
song:
This is what I like to do in class: To mess around, to bother everyone, to break the
teacher’s head. That’s the “bad me,” but there is also a “good me.” Sometimes the “bad me”
beats the “good me.” Sometimes the “good me” beats the “bad me.” One day, the “bad me” is
going to explode. It will explode like a volcano, and its buttocks will be blown up like a balloon,
and the “good me” will be left alone. He’ll be calm, he’ll be calm.
Notes
1) This case analysis is based on a short version that was published under a different name
and accentuation in the Niewsbrief B.M.T. (Tweede Jaargang, Editie Mei, 2000, pp. 18–
26.)
2) S. B. immigrated to Israel from Italy in the forties as an adolescent, leaving his family
abroad. He finished high school and graduated as a sculptor from the academy of art. In
addition to his studies and creative work, he used to volunteer and successfully aid
children in his neighborhood who suffered from behavior disturbances. In his midtwenties, he fell ill with brain cancer that could not be operated on or cured. Within a
few months, his condition deteriorated and he passed away. This chapter is dedicated to
him, to his artistic energy, and to his wonderful model of investment in children.
3) A few examples from my clinical work concerning the meaning of grandparents to
children: O. U. was born as a Down’s syndrome child and was in music therapy
throughout his entire childhood. At a certain point, he decided to learn to play the piano
and was very decisive about it. He recently said to me: “Do you know why I must play
the piano and be very diligent? Because my grandma who died and whom I loved very
much was a piano teacher and I want to follow her footsteps. This is why.” D. I., a 12year-old girl whose grandfather had died of cancer, told me the following: “When my
grandpa was sick in bed, I came to visit him every day. I kissed him and prayed to God to
help him die without pain because he was my best friend and we all loved him very
much. It helped because he had a kiss death.” (A “kiss death” in Hebrew means a death
without suffering: the death of a holy person.)
References
See end of Case Seven
Taken from: Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum NH: Barcelona
Publishers.
CASE SIX
Mother, the White Dove: A Case Analysis
Chava Sekeles
“I tell you, Mother. I feel sad, but cannot cry. I feel angry, but cannot scream. I am rotten, but I
cannot purify myself. I am doomed.” (Jonas, 12th session)
Dedicated to Reuven Morgan1
Introduction
The case “Mother, the White Dove” describes and analyzes Jonas, a young man in his
early twenties, whose mother died of cancer following a long period of sickness. Jonas was
diagnosed as suffering from Borderline Personality Disorder2 and resisted verbal therapy. He
agreed to participate in music therapy, assuming that he might circumvent speech and have
fun.
As art therapists, terms and idioms from the art itself frequently accompany our
observations and therapeutic considerations, such as a Sonata Form or, in the present case, an
Expressionistic Style. Jonas used “expressionistic” symbolism prompted by music and other
modalities that ultimately helped him cope with the shadows of the past.
Before proceeding with the actual case study, I will provide some background on the
concept of expressionistic symbolism, which constituted an integral part of the therapeutic
process. This concept is intended to highlight a form of expression frequently observed in music
therapy: externalization of emotionally loaded issues through broad dynamics, accelerated
tempo, and dense tones sounds, which are analogous to expressionistic visual art.
What Is Expressionism?
In general, “expressionism” is a creative style in different cultures, which accentuates,
maximizes, and distorts reality in order to highlight the symbolic or intrinsic meaning of an
object, e.g., grotesque masks used by Native North Americans for healing rituals or war. The
features of these masks were maximized, often to the point of frightening distortions that were
meant to ward away evil spirits. This was in light of the magical-tribal thinking that “like acts on
like” (Avneyon, 2005). Specifically, expressionism refers to a Western artistic movement (1863–
1944) that aimed to highlight the emotional meaning hidden in an external representation, i.e.,
to express the outer world through the subjective view of the artist (Gombrich, 1971; Laurent,
2004). Alexey von Javlensky wrote in Der Blaue Reiter that the expressionist artist expresses
only what he has within himself, not what he sees with his eyes (Javlensky, 1948).
The following characteristics typify expressionistic art: intense colors that are not
necessarily natural, dense textures, sharp transitions, and distortions. On the whole,
expressionism tended to describe the ugly, embarrassing, grotesque, and painful. Emil Nolde
expressed his feelings concerning the classical techniques in the following way, “Conscientious
and exact imitation of nature does not create a work of art.” (Chipp, 1971, p. 146) An excellent
example of this style was found in an exhibition entitled “A Psychoanalytic Portrait,” by the
Czech artist Kokoschka. The exhibition, held in Vienna in 1908, presented a character portrait
that highlighted eye expressions and hand structures. This is the antithesis of traditional art,
which typically attempts to idealize reality. The expressionist movement has often been
stigmatized as representing decadence; the Nazis went so far as to ban it and persecute
expressionist artists. Adolph Hitler said that anybody who painted and saw a green sky and blue
pastures ought to be sterilized (Chipp, 1971).
The term “expressionism” has been metaphorically adapted from the visual arts to the
context of music. Expressionistic music is written in a deeply subjective and introspective style.
The most renowned expressionistic musical compositions are Schönberg’s Verklärte Nacht and
Pierrot Lunaire, as well as Berg’s operas Lulu and Wozzeck (Austin, 1966; Griffiths, 1986). Why
use the term “expressionism” in relation to Jonas? I will attempt to clarify the answer.
Intake
Jonas provided the following information about himself during our first meeting: He was
born and raised in a village. When he was 11 years old, his mother was diagnosed with cancer.
She stayed in the small family home for four years until she died of her illness. Jonas dropped
out of high school and was discharged prematurely from the army on account of unsuitability.
He began music therapy because he found it difficult to cooperate in the process of
verbal psychotherapy. As he put it, he was willing to make a serious effort to work on his
difficulties so long as he would not be forced to talk. During the intake session, he expressed
pity for his father, pent-up anger toward his mother, and self-accusation and anger combined
with a low self-image. That was the extent of the information he verbally conveyed regarding
himself.
It should be mentioned that Jonas had never experienced music therapy, nor had he
been exposed to music or to other artistic modalities, with the exception of visual arts.
Subsequent to listening to his playing during the intake session, I noted and concluded the
following:
1) Jonas (on the right side of the piano) played a duet with me (on the left side of the
piano). Jonas had a virginal style, as he had never had formal piano lessons. He
increased the volume, tempo, and intensity of the music as he limited his playing to
the upper register of the keyboard. His piano playing was restricted, repetitive,3 and
fast. I supported him on the bass register, and the musical character he established
was undoubtedly expressionistic.
2) Jonas beat the drum as I accompanied him on the piano. I again noted the rapid,
animated tempo. The beating was not persistent, strong, or steady. It reminded me
more of a pot that is about to boil over and burst. Indeed, when Jonas listened to a
recording of the two passages, he commented: “I know I have a lot of pent-up
wrath. I can hear it in my music. But I also hear that I cannot express intense
emotion and I cannot cry.”
Therapeutic Rationale
I perceived Jonas as a sad, angry, and confused young man. During the four years of his
mother's illness, he lived with his family in crowded, intimate quarters. At the same time, he
never conversed openly with the additional members of his family, since he was brought up in
an inhibited atmosphere and his mother's illness had always been considered a deep secret.
Jonas's impressions of his mother were extremely vivid.
He described her in the following manner: [She was] domineering, harsh, oppressive. [She
would] lie there in the room and let me irritate everyone. [She let me be] a nuisance and a
troublemaker.
On the other hand, he described his father as helpless and passive. He had devoted
himself to his work and had found it difficult to express feelings toward his children. I noticed
that the musical activity gave Jonas a sense of comfort and detected a smile on his face when
he engaged in the new experience of “speaking” through music.
My assumption was that the musical expression in itself would suffice in the initial
stages of therapy and that Jonas would benefit from experiencing music as an expressive
language. Accordingly, in the first stages of therapy, my main goals were to help Jonas express
himself, to allow him to develop trust in me, and to encourage him to employ music as a
therapeutic language.
Therapeutic Process
Representations (First Three Months of Music Therapy)
Jonas used two instruments to carry on a conversation with his deceased mother. He
chose a piano to represent his mother and a dulcimer to represent himself, “because I am weak
and gentle and she is strong and domineering.” In this musical dialogue, Jonas demonstrated
his symbolic ability through his use of the instruments and particularly through his choice of the
dulcimer to represent himself: He played gently but with confidence, showing that he had
something to say. The dialogue was quite lengthy (30 minutes). After listening to the recording,
Jonas made the following observation:
I made a real effort to tell her how angry I am at her, how she stopped being a
mother and stopped caring about her children, how long I have been angry at her, and
how afraid I am to be angry at the dead.
The verbal elaboration of this material dealt with the difficulty of harboring ambivalent
feelings (e.g., love-hate) toward one’s mother, and how Jonas had suffered while his mother
was ill and after she had died and his need to express those intense feelings, a need that he had
still found difficult to satisfy.
In the following session, we replayed the musical dialogue and verbal summary. After
listening again to the musical dialogue with his mother, Jonas jotted down the following
comments:
I tell you, Mother. I feel sad, but cannot cry. I feel angry, but cannot scream. I am rotten,
but I cannot purify myself. I am doomed. I want to play to the end, to undo everything
that has been distorted, to undo all those years of decay, hallucinations, escape.
Let me be free. The piano is resolute, painful and violent. The string [of the dulcimer] is
angry, wipes its tears away, and goes on.
It is handsome, strong, determined and human.
This emotional material and the confrontation of his mother repeated themselves
throughout several sessions with mild variations. As aforementioned, in this process of dealing
with unfinished business between Jonas and his deceased mother, the piano represented his
mother and the dulcimer represented Jonas himself. Jonas's comments (quoted above) gave
me the impression that he had begun to see a new dawn.
Breathing and Vocality (Fifth Month of Therapy)
The feeling of filth and decay that Jonas had verbally described and portrayed through
music was so strong that I suggested he work on breathing. This suggestion was based on my
knowledge of the profound changes such work can bring about in a person’s physical state
(which might generate changes in one’s state of mind). Jonas accepted the idea, and we began
working intensively on vocality and movement, which are usually elicited by breathing. The
following poem was the product of exercises that focused on full diaphragm breathing
combined with movement:
The wind blows through the leaves and I am crying there in the rain.
All I want is to lie on the cold sidewalk to let the drops mix with my tears and cry there,
to flow with the water and scream at the top of my lungs, to let air into my body and be
there with it.
All of the excrement and rot is being washed to the sea, all of it is comes out until I turn
yellowish-green.
I stay there, squeezed out like a lemon, and I can start anew, I can start living like a
human being.
I just don't want the filth, that’s all.
I will cry to the end, I will strike a blow and don’t care if I die from it.
The Process of Transition from One Artistic
Modality to another (Seventh Month of Therapy)
At the beginning of the session, I intentionally played ecstatic music from the Atlas
Mountains, which inspired Jonas to draw a self-portrait:
SELF-PORTRAIT
When he finished, he explained: “I drew myself and showed how all of my feelings are tearing
my face apart.” In relation to this, I would like to mention that the following was written in the
manifesto of the expressionist Die Brücke movement: “Throw fire on the crust and make it
molten, liquid, until its meaning emerges from the inside [core] and breaks through its grieving
crust” (Javlensky, 1948).
This is the feeling that emerges when one looks at Jonas’s self-portrait. I suggested that
Jonas continue working on the portrait by vocalizing it. He did so while turning his back to me
and placing the painting in front of him. He began with faint humming and built up to a scream.
When the recording was replayed, Jonas commented, “I am singing about the naughty boy
inside me. [I am singing] about how I hate you for bringing me into this world, about my social
isolation, about the dirt that has stuck to me, about my desire to purify myself and be born
again or else die.” The more Jonas began to trust me as his therapist, the more he began to
express fatalistic thoughts and exhibit self-destructive tendencies. I was on guard, and when I
sensed that Jonas was in danger, I sought counsel with a professional psychiatrist (in
accordance with the code of professional ethics of the Israeli Association of Creative and
Expressive Therapies). 4
Guided Imagery in Music (GIM) (Ninth Month of Therapy)
Jonas was very agitated upon his arrival at the session following a harsh and candid
discussion with his father. His father had found it difficult to accept the things that Jonas had
said to him. Jonas, however, felt that this was the first time he had actually told his father what
he thought of him and his deceased mother and of the difficulty that he and his father had in
communicating with each other. The father had become very frightened and asked to meet
with me because he attributed the son’s outburst to the therapeutic process. I requested
Jonas’s permission to meet with his father, and he expressed his consent through the following
comment, “I will make everyone dirty so that I can finally cleanse myself.” My individual
meeting with Jonas’s father was extremely beneficial for all parties involved in the therapeutic
process. I observed that his father was at a loss: He wanted to help his son but didn’t know
how. He was willing to participate in the therapy sessions with his son.
Nonetheless, I explained to him that this would not be feasible and suggested that he
seek separate psychotherapy. The father told me of the trauma the family had endured during
the four years of his wife’s illness and mentioned that this had been the first time he had
discussed his feelings regarding it.
In the sessions with Jonas, the topic of death was constantly discussed. He confided that
he had contemplated suicide about a year before his mother had died, but that the forces of
life had prevailed. In his words, “Today I want to calm down, and I am asking you to help me do
it.” For this purpose, I chose guided imagery, which included breathing exercises to music
(involving tension and relaxation movements). I chose a composition written by the Israeli poet
Zelda just before her death, adapted by singer Adi Etzion and composer Yehoshua BenYehoshua. The passage is intense and highly expressive. In this respect, it is completely
different from the “New Age Music” or meditation passages commonly used by therapists
today. This composition actually highly corresponded with Jonas’s expressionistic creations.
During the elaboration process following the listening phase, Jonas said:
I saw a bird—a raven—flying against a background of mountains, rivers, and cliffs,
perhaps like the view one sees from this window. And I heard birds chirping. The raven
did not care about the other birds and preferred to be on his own: independent. I also
saw a white dove looking down from the sky. She looked very strange, as though she
were half-dead. Then, suddenly, the raven saw blood and understood that it was his
own. At once I was there. I observed the scene from the side. Then the raven fell to the
ground and I dug into the earth, into the blood and gore.
Jonas later arrived at the conclusion that he was the raven and that the blood was the
filth he felt inside, while the white dove was the spirit of his deceased mother looking down on
him and observing his every motion. I asked Jonas if he would like to actualize the dream in
music and he consented. He chose the drum to represent himself (preferring a powerful
instrument for himself for the first time), the dove was represented by an autoharp, and the
landscape was represented by a variety of percussion instruments. At his request, I played the
mother and the landscape, while he focused on expressing himself.
Childhood Memories
Jonas was very calm throughout the next session. He told me that he had done much
contemplating during the week and that many childhood memories had revisited him. For
example:
My mother shut me in the house and made me sit in front of a glass of milk. “Don't move
until you drink all of your milk” [she had said]. I sat there for hours and didn't drink a
drop. My mother yelled at me [and said] that I was always dirty and she wiped me
against my will. I remember when I was six years old and flew like a bird on the slopes to
the school It was a real experience in flying.
… I hate milk, with something that smells like a turpentine or gasoline. I believed I was
really dirty. In elementary school, I always felt I was abnormal, retarded, even though I
always did my schoolwork well. I liked to play a kind of roulette: I burned weeds and
even burned my room. Now I think I played the part of the bad, disturbed boy, a label I
had been given by my family.
Jonas mentioned that these childhood recollections, which had escaped his memory for
several years, had brought him relief and encouraged him to make decisions concerning his life.
Since this session did not involve any musical activities, it took place in the area of the therapy
room that was mainly reserved for verbal discussions. I would like to note that verbal
communication, which Jonas had been so adamantly opposed to during the intake session, was
an integral aspect of the therapeutic process, particularly during the phases of elaboration. The
verbal communication was prompted by the experiential musical activities.
Furthermore, if we carefully take note of his memories, it appears as though Jonas had
already experienced problems in his childhood and that his mother’s illness had simply been
the spark that had set the bramble field on fire.
To Sing and Cry: Vocal Expressionism
(One Year of Therapy)
There is nothing like the voice to reflect the emotional turmoil, pain, cracks, and
venomous snakes inside us. Two examples from Jonas’s vocal period were meaningful. Both
were revealing and embarrassing and continued for over 15 minutes.
The first example is a vocal improvisation of a repetitive harmonic sequence provided by
the music therapist:
C – Em – F – C / C – Em – F – E7 / Am – Em – F – C / Dm – D7 –G //
Jonas improvised freely without words on this “holding” frame. His improvisation began
with a soft, timid voice and developed into a “sky- piercing cry.” As a therapist, I found some of
the moments in which I persisted with the harmonic frame extremely difficult in their
expressionistic revelation. It was as though the patient were ripping open his stomach and
revealing its contents. It should be mentioned that after maintaining the repetitive harmonic
sequence for five minutes, I was able to develop the musical content and follow the dynamical
changes imparted in Jonas’s vocality. These musical changes and developments helped us
endure the 15-minute process.
The second example is a vocal improvisation of his to which he gradually added words
while the music therapist followed his voice and the words with the piano. I noted the change
of registers in Jonas’s voice, the free vocality and highly expressive text that recapitulated the
motifs elicited in previous sessions: “I am walking over an abyss of fear…I am running…I am
hitting…I am tearing …”
A Lullaby of Conciliation (Conclusion of Therapy)
From this phase, I would like to bring an example of conciliation that Jonas initiated.5 It
was a vocal a cappella improvisation in which Jonas very softly sang to his mother in a lullaby
style. At a certain moment, he asked me to be the mother and join him in his singing. It thus
became a duet in which each participant had an independent polyphonic role. Both from a
musical point of view and in a psychological aspect, this improvisation was new and very
touching and summarized a period.
Summary
The process described above was not completed. Unfortunately, due to technical
reasons, we could not really conclude the course of therapy.
This case leaves off at the point where Jonas could openly express himself. His
relationship with his father had improved considerably. At the same time, he had wrapped up
some of his “unfinished business” with his mother to the point where he was able to continue
working on some of the emotionally loaded issues more maturely than before. In terms of
practical- rehabilitative outcomes, he had changed his lifestyle and made a brave decision to
leave home, where he had been stifled in many ways. This presented him with the opportunity
to cope with the real world, which had frightened him so terribly in the past.
As I see it, the main contribution of music therapy was to enable Jonas to express
himself through “primary communication” (Noy, 1999, Ch.1), a language that touched the bare
roots of his soul long before he could employ verbal expression and gain better insight.
Nevertheless, verbal elaboration was an essential aspect of therapy that was accomplished in
different ways: through face-to-face conversation, verbal associations elicited by music, poetry
writing, and translation of his own musical creations into words and vice versa.
Notes
1) Reuven Morgan was born in Wales, became a renowned actor and theater director, and
performed in the Shakespearean theater in England. He emigrated to Israel in the early
sixties and worked for Israeli Broadcasting (Kol Israel). Morgan was the first teacher of
the drama school of the radio, directing programs, translating, writing, narrating English
literature, and more. Reuven Morgan invested many hours in my 1996 book, Music:
Motion and Emotion, of which he translated three chapters. He died of cancer a few
months later and was buried in the Christian Cemetery in the German Colony in
Jerusalem. I dedicate this chapter to Reuven Morgan, who illuminated my world with his
theatrical and linguistic knowledge.
2) Borderline Personality Disorder: “A personality disorder characterized by a pervasive
pattern of impulsivity and unstable personal relationship, self-image, and affect.
Beginning in early childhood …” (Colman, 2001, p. 99).
3) Repetitive style in music has varied meaning. It might symbolize avoidance of free
expression due to deep anxiety and low self-esteem. Repetitions may thereby function
as a calming defense mechanism and, when employed by the therapist, may serve as a
holding and containing frame (Sekeles, 1996, p. 37).
4) ICET, The Israeli Association of Creative and Expressive Therapies, is an umbrella
association to all art therapies in Israel (dance and movement, music, visual arts, drama,
psychodrama, and bibliotherapy). Established in 1971, it has three branches and holds
yearly study days, seminars, workshops, and conferences.
5) A cappella means singing without instrumental accompaniment: a pure vocal
performance. In the aforementioned case, it developed into two melodic lines sung in a
counterpoint style, symbolizing the child Jonas and his deceased mother.
References
See End of Case Seven
Taken from: Sekeles, C. (2007). Music Therapy: Death and Grief. Gilsum NH: Barcelona
Publishers.
CASE SEVEN
The Grief of the Therapist over Patients Who Passed Away
Chava Sekeles
“Do not boast thyself of tomorrow; for thou knowst not what a day may bring forth” (Proverbs
27:1)
Dedicated to the music therapy patients who passed away
Introduction
I discussed the content of this case with students and colleagues at length. As a result, I
decided to conclude my book in a personal manner, based on my own experience in the field of
music therapy.
Most music therapists have lost patients during the course of their clinical work.
Sometimes during the therapeutic process; sometimes, as in the case of a terminal patient, at
the expected termination of therapy or sometimes, years after therapy has ended.
Many of my music therapy students at The David Yellin College in Jerusalem completed
their internships in institutions where death was a common phenomenon and had to cope with
the loss. Individual and group supervision may help in such cases, and, indeed, it is important to
invest time and effort in dealing with loss during the course of studies.
Every so often, a student would return from an internship and tell us that no one had
bothered to inform him of the death of a patient. He would find himself standing in front of an
empty bed, not knowing what to do.
In other cases, the name of the patient (mostly with children) would not be erased from
the activities board for months, with the topic not even being discussed with the other children.
When a child disappears in an institute of severely sick children, it may cause more severe
anxiety than when honest information is provided in a manner suitable to the child’s cognitive
and emotional level of development.
Students would raise questions such as: Should I attend the funeral? Should I visit the
family during the Shiva (the first seven days of mourning in Judaism)? Such questions open the
gate to important discussions regarding the therapist-patient relationship; emotions that arise
with the death of a patient; the difference between therapy in an institution and therapy in a
private setting; and what is to be done with the emotions? What are these emotions? Are they
simply sadness, or are they also pain and insult relating to the therapeutic investment and the
facing of loss? As far as I have observed, these and other questions concern not only students
but also each of us music therapists when losing a patient. It took me ten years to collect the
raw material for this book, analyze it, review the recordings, and more. This lengthy period was
necessary given that it deals with the enigma of death and the loss suffered by the patients, but
also because it brought me back time and again to my personal experiences of losing patients
as well as to the cardinal question of what the differences are between the loss of a patient and
the loss of a family member or a dear friend. I am not certain I have the right answers, but since
this matter deals with varied professional and personal issues, I would like to at least explore it
within my own limitations.
Grief
The general definition of grief is the internal response to loss: what we feel, what we
think, what we imagine; the meaning we ascribe to the loss and the time we require to work
through it. The grievance period is a time that might include sleep and appetite disturbances,
concentration problems, difficulties with decision-making, loss of interest in things we once
enjoyed, social withdrawal, confusion, and disorientation. As Ruth Bright (2002) writes, it is
more than sadness, “It can include anger, humiliation, feelings of depression, disbelief, relief of
tension…” (p. vi).
Experience teaches us that when death is expected, as in terminal illnesses, and there is
enough time for emotional departure, the process takes on more of a sense of closure,
sometimes even of relief, knowing that the deceased will no longer have to endure pain and
suffering.
While this doesn’t eliminate the pain and sadness, the egocentric part of loss (I was left
alone, I suffer, why me?) is marginalized.
Nathaniel had passed away following a few months of intensive music therapy sessions.
I had never met him before, I did not know him in depth from his past, and I was not a member
of his family. I knew that he was dying and that I had to do my best to facilitate the most I could
through the sessions. I had time to think about the end of the process, which motivated me to
dedicate as much time, professionalism, and emotional attention as I possibly could to the
course of therapy. When Nathaniel passed away, I felt sad, empty, and at the same time
relieved for him that his agony was finally over. I attended the funeral with no psychological
hesitation, knowing the practical and symbolic importance of the closing of the tombstone on
the grave (“stimat golal:” according to the ancient Jewish custom of rolling a round stone on
the entrance of the burial cave), which does not leave death’s irreversibility ambiguous. The
Halacha (traditional Jewish laws) concerning burial do not attempt to beautify death. The
deceased is buried and not hidden in a coffin so that his body will come in direct contact with
the earth, as it is instructed in the Bible: “From dust thou art, and unto dust shalt thou return”
(Genesis 3:19).
While the physical aspect of death has a precise timing, the emotional departure has no
date or precise place. This is why whenever we encounter death along our paths, it connects us
to the process of mourning.
Mourning takes the internal grief and expresses it externally: visitations of the family,
the funeral, visiting the cemetery, memorial days, erecting the grave-tomb, different customs,
and more. Its objective is to assist the development of a new relationship with the departed
based on memory and the reconstruction of meaning in life. The process of grieving eventually
reaches an end, but the process of mourning may be very long. Eliyahu Rosenheim (2003)
describes grief and mourning as a “passage-ritual” that guides the bereaved person in how to
cope with death and adjust to life without the deceased (p. 174). Rosenheim claims that from a
psychological point of view, the irreversibility of death enables the shift to the next phase,
which Freud defines as “work of mourning” (p. 199). This term describes the intrapsychic
process whereby the bereaved person gradually manages to detach himself from the object
(Freud, 1917).
How does this process relate to the therapist who has lost a patient? Once again, the
process differs when we deal with a sudden death during or at the end of therapy in
comparison to a death occurring years after therapy has ended. When Jacob’s family asked me
to bring his recorded music to the 30th-day ritual, I could hardly bring myself to do it. It took me
a year to summarize his music therapy process (Sekeles, 1996, chapter 5).
Jacob had died unexpectedly from a heart attack following two years of left hemiplegia
due to a CVA (stroke). He had worked very hard on his damaged functions, had plans for the
future, and managed very well with his deficiencies. We had both felt satisfaction and efficiency
in regard to the process he had undergone. All of this had been cut short a few days following
the termination of therapy. My immediate reaction after hearing the news was one of deep
sadness mixed with anger and disappointment. I could scarcely accept the idea that the
realization of so much work and mental investment had been taken within one minute by
death. Of course, I could have assumed a different position, telling myself, for example, “Jacob
invested his last two years in a productive way, proving his mental capacity and personal
strength to his family, congregation, and himself. He died a sudden death and did not suffer,”
but at that moment, the personal “insult” had been too strong and I had to collect myself in
order to gain a better emotional and cognitive angle. How did I work through it? To begin with,
at that time I partook of psychoanalytically oriented supervision that enabled me to share my
grief, mourning, and bereavement. The conversations with the supervisor were very important
and gave me the energy to prepare the closure.
Preparing a Closure
1. Participating in the funeral and preparing musical material for the 30th-day memorial. This
was done following the clear request of the deceased’s wife and consultation with the
supervisor with whom I worked at that time.
2. Writing a letter to the patient’s wife and family. I took this initiative in light of the long
cooperation and acquaintance I had had with his wife.
3. The following components are routinely completed subsequent to the conclusion of a music
therapy process, but in the case of death they also assist with emotional closure:
a. Summarizing all the reports written after every session into one document.
b. Summarizing the recordings, highlighting the most important moments in the patient’s
development.
4. Transcribing parts of the patient’s improvised music and safeguarding them in his file.
5. Many years later: writing a case analysis as a chapter in my 1996 book.
All this served to create an emblem of the man or, in a way, a “working memorial
monument.”
Paying Respect by Playing
John had been suffering from early dementia due to severe alcoholism. In the past, he
had been a well-known pianist-performer, but had lost his technical ability, memory, and
dynamic performance skills. I worked with him through improvisations, a field he had not been
fond of in his professional days, and through employing different techniques had gradually
enabled him to return to playing short compositions. Yet again, this had been a mutual effort
that bore mild fruits. Years later, I was informed of his death. In this case, I had to find an
alternative way of paying my respect to John’s memory. I did so by working on Chopin’s
Revolutionary Étude, ever so beloved by John, who had attempted to reconstruct it in his
memory and fingers in spite of the agony he endured while doing so.
As with the abovementioned points (3, 4, 5), this was an action taken by me alone, thus
not interfering with possible ethical restrictions.
Suicide
Eric (a schizophrenic patient with whom I worked for four years, accompanying him through the
thorny road from mutism to creativity) committed suicide many years after his release from the
hospital, as had Edwin. Again, I had heard of the tragedy after I had left the hospital and
returned to my homeland. Eric used to write to me from time to time, and consequently his
death by suicide did not come as a real surprise to me. I had always harbored concern regarding
his loneliness and desperation.
Eric had persevered 20 years after leaving the hospital, but then had regressed and been
hospitalized. In his final letter to me, he wrote: “I have the feeling that my music has been
finished and that my life is back to zero” (Sekeles, 2005b).
Edwin had also endured the world beyond the hospital for over ten years. With both, I
had experienced a sense of deep desperation, of sitting far away, helpless, powerless to help. I
knew that this did not reflect the actual reality and that these schizophrenic patients survived
outside the hospital, but had many regressions and periods of hospitalization. I knew that they
obtained very good treatment; however, emotionally, I still felt a responsibility. This is probably
due to the long therapeutic alliance, the emotional investment, the idea of helping a very ill
individual grow and develop within the boundaries of his condition, the closure of a long
therapeutic process, and the disadvantage of geographic distance.
In his book, Suicide—The Tragedy of Hopelessness, David Aldridge (1998) states:
By concentrating on repeated sequences of interaction, the episode of suicidal
behaviour can be constructed not as impulsive but as belonging within an extended
time frame. Rather than punctuate reality into a short arc of critical disturbance, it is
possible to see the episode as belonging to a cyclic pattern of escalating interaction (p.
276).
For the person who is suicidal, then, distress has escalated beyond the threshold of their
toleration. They have no more resources to sustain themselves. This is a process of
desertification (p. 278).
Eric and Edwin had both been very lonely men: Edwin’s wife had been killed by him,
while Eric’s had divorced him. Eric filled the emptiness with a musical group he organized with
colleagues-patients; Edwin created some music but was not involved in any meaningful activity
that might advance his contact with other human beings. It seemed as though they had indeed
reached the threshold of their toleration.
Transforming the Energy of Grief
One of the ways that people cope with their grief and turn it into a positive, creative
action is through a memorial gesture. For example:
•
•
•
•
•
•
•
•
Choosing a special tombstone.
Composing music.
Organizing a musical evening.
Arranging an album with photos.
Publishing a book with the letters, poetry, etc., of the deceased.
Making a film.
Erecting a sculpture as a memorial monument.
Cultivating a garden.
Some of these undertakings may help us as therapists, specifically when they
incorporate music and do not interfere with the bereavement of the deceased’s close family
and friends. It is essential to remember that a therapist is not a member of the family and that
interference beyond the empathic space might generate ethical problems. What the
boundaries of this “empathic space” are depend in a way on individual therapeutic ideology. I
know of therapists who would never attend the funeral of a patient and remain distanced even
in the case of a child. Others are more flexible or even devoid of any boundaries. I prefer to
maintain individual consideration and base my decisions according to each particular case that
arises, i.e., to remain flexible within the ethical boundaries.
Some ethical regulations are very clear concerning the appropriate behavior for a
therapist in the incidence of a patient’s death. For example, the Israeli association of clinical
psychologists treats the ethical regulations for a deceased patient in the same way as it handles
the regulations for a living patient. Conversely, the Israeli Association of Creative and Expressive
Therapies does not broach the issue at all. Jehudit Achmon (2004, Ch. 8), deals with the dual
relationship in a very thorough book, Ethical Issues for Professionals in Counseling and
Psychotherapy. In regard to writing about the patient, Achmon warns the therapist to be aware
of and clear about his or her own interests, which may conflict with the patient’s well-being (p.
174). Nonetheless, any contemplated action must first be discussed with the family members
involved in order to obtain their consent.
It should be noted that Achmon’s chapter discusses the relationship between two living
people, the patient and the therapist, whereas what I’m concerned with here is the reaction of
the therapist following the death of his client. Obviously, when a patient’s home is a hospital or
other institution, as is most often the case with chronic patients, it might be healthier for the
patients and the therapists to find a way to commemorate the deceased within the patient’s
community. When the setting is different, considerations should be made with regard to the
specific situation, within the professional and personal ethical boundaries.
As rendered in this book, each chapter was dedicated to a deceased individual who
influenced my personal and professional life. The last two chapters were dedicated to patients
who passed away.
Death may be irreversible, but what we carry in our hearts and memories, the
experiences we had with the deceased person, whether a family member, a friend, or a patient,
accompany us for the rest of our lives and give meaning to our existence.
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CASE EIGHT
Feelings of Doubt, Hope, and Faith
Henk Smeijsters
Introduction
I am a qualitative researcher reporting on Ingrid’s experience of music therapy. In her
sessions, Ingrid’s music therapist, José van den Hurk, suggested music improvisations on the
piano, split drums, fiddle, and congas and with voice to help Ingrid express feelings and
strengthen her personal identity and self-esteem. Ingrid had felt depressed since her husband
died three years earlier. Sometimes she said to herself: “Who am I? I’m in the habit of acting as
though on a stage. I have lost myself.” Ingrid was referred to music therapy after 21 sessions of
verbal psychotherapy; while in music therapy, she continued psychotherapy on a less frequent
basis.
After each session, Ingrid and José independently wrote self-reports for this research
project, and I made a detailed report from the videotape of the sessions, transcribing Ingrid’s
words verbatim. Ingrid’s self-reports were also typed out in transcripts on which I commented
in memos. The transcripts and memos were checked by Ingrid and José. I analyzed the
transcripts, using qualitative research techniques: I developed diagnostic themes, gave
feedback on the treatment process, and made suggestions for goals and techniques. During this
process, there was repeated feedback between José and me. On several occasions, there were
talks between Ingrid, José, and Ingrid’s psychotherapist.
I present Ingrid’s statements during the music therapy sessions (three through 22), her
talks with José and the psychotherapist, and her written self-reports, all of which describe the
therapy experience from her perspective. I follow Ingrid’s words with my own analysis from a
phenomenological point of view (Smeijsters, 1997); this is called a protocol analysis (Colaizzi,
1978; Giorgi, 1985). Phenomenology tries to “understand what meaning ... the music therapy
intervention has for those who experience it” (Forinash, 1995, p. 372).
Ingrid’s Statements
Session 3
Self-Report. My first thought was, “How will it be?” How is it possible to use music
instruments without being able to read a single note? I was very surprised that I felt pleasure in
just making sounds. I liked searching for some sort of a melody. José made me even more
enthusiastic. How will it be the second time? Now everything is new and surprising. I will wait
and see what the next session will bring. I have faith.
Session 4
During the Session. How can music therapy help me? It feels as if I’m acting as though I
am a handicapped person.... When José intensified the music, I said to myself, “Don’t go any
further.” I won’t let myself hurry up. But sometimes it feels as if I have more energy.
Self-Report. Contrary to the previous session, there was a need to make music of my
own. When José started playing loud, I thought, “You can do it.” But I kept to my own tempo
and loudness. I did not want to attune to José’s playing. My experience was very different from
the previous session. I wanted to explore sounds myself.
Session 5
During the Session. I feel fine. I like to do gardening at home. Why should I come to
music therapy? Why am I digging in the past? What I am doing completely lacks melody. In the
beginning, I thought that this was stupid. If I could not succeed immediately, I stopped it. But
when you [Jose] asked me to give it another try, it worked out. I don’t want to be soft. It is
impossible to say how I feel. Something is missing. Is there a need to come next time?
Self-Report. Searching for notes that make a whole--make a harmony--with notes
played by José on the piano gives me a pretty feeling. Whenever I cannot find the right tones,
there is disharmony. When we are playing against each other, I don’t like it. When José told me
afterward that she had felt contact, I could not understand what she was saying. I cannot feel it
that way. The statement made me nervous, and I felt as if I was going to hyperventilate. I
guarded against it by not giving way to it. I think I become frightened when people come too
close. Sometimes I get angry because I want to decide myself when there should be closeness.
Why am I afraid of closeness?
Talk with José and Psychotherapist. I did not feel any contact with you [Jose] and
thought, “What are you talking about?” Do I want this with a stranger? Do I have to become
even more sensitive? I am afraid when you talk like this.... Does music therapy have any effect
on my daily life?
Session 6
Self-Report. I hesitated to write this self-report. Why? Because I found it so difficult.
Everything is so close again, but I shall try to write down what I felt when I was looking at the
videotape from the improvisation. I was watching with a lot of concentration and with a critical
attitude. I don’t know what I felt while watching. But I know what I felt afterward. I was moved
and sad at the same time: sad because I am a sad person but also because I cannot accept
myself. I look very rational, but this attitude gives me a bad feeling. Often I think that I am doing
and saying things all wrong. Deep inside, I feel very insecure. I would like to change, but how?
Session 7
During the Session. What I am doing is stumbling. The moments when we played
together were nice. If you [Jose] play loudly, I do not understand it at all. I wonder whether
making contact is the same as playing together. When I say I felt contact, I become anxious.
Crossing hands with you on the piano is weird.
Self-Report. When you [Jose] were rubbing the congas, this was irritating, as if
somebody were petting over my body. But when I kept on playing on the piano and
surrendered to the sounds of the piano, it became less frightening. Later on, for the first time I
felt sorrow about the death of my mother [a long time ago]. When I remembered my
childhood, I felt the lack of cuddling by her. She gave me a lot of care, but at a distance. There
was a lack of warmth. My parents never gave me compliments and this took away my
enthusiasm. I believe, therefore, that my self-image did not develop. I hope that in music
therapy and psychotherapy, it will be possible to develop my self-image. I want to become
cheerful and relaxed.
Session 8
During the Session. I ask myself why I write the way I do. Why is it so restless? Why
can’t it be quiet? Always, I am hewing things down. It resembles my behavior in music. Playing
the piano is like my life. In music now, I try to let it merge, but saying to myself that I am playing
on the piano is so strange. Is it really playing the piano?
Self-Report. I have no self-report because it is always the same. Why am I so negative?
Is this the process?
Session 9
Self-Report. During piano-playing, a lot of memories came up. But they are just
memories. I don’t feel any pain. Negative experiences belong to life, and one should try to
guard against these experiences in the future. I want to work on the future; I want to
strengthen my ego, accept myself.
Session 10
During The Session. Using my voice costs me a lot of effort. It is oppressive; my voice is
so locked. It only comes out stumbling. I am afraid. There is a lot of energy that is not coming
out. Humming is spasmodic; it is not spontaneous. But I have to try because I want to break
down my façade. If I put away my frustrations, I will never find rest.
Self-Report. When I am playing with José on the piano, I am searching for balance and
for a melody. I want to make a consonance, a fluent whole. When I succeed, it gives me a nice
feeling, although it still is melancholic. I feel sorrow. In the beginning of music therapy, this
feeling had to do with me; now it is linked to others. Today, I know that I need to release myself
from something, but I don’t know what it is. I also feel anxious and insecure when I manifest
myself in sounds. I need to have less pride. Reluctantly, I started walking on thin ice. In past
years, I built an immense façade, looking tough and communicating “Don’t come close; I can do
it all by myself.” As a result, I cannot handle important feelings. In the last few weeks, I have
learned to have more insight into these things. Some time ago, I didn’t know what others were
talking about. I had only one thought: “I don’t want to be soft.” Now, this is totally different.
Cognition and feeling are in contact; they are balanced now. Because of too much pride and
fear of making errors, I was very tense. Now I want to listen to my feelings. It is a very slow
process. There still are many blocks--for instance, in my voice. Nevertheless, I want to do my
best. I must show and accept myself.
Session 11
During the Session. Putting feelings into words, saying things without defense, is
difficult. I become angry. I have to stop suppressing my feelings. Whenever there is some
melody, I enjoy it. I am growing up. I liked the improvisation, but it is very difficult. I need to
accept myself. There is nothing that gives me the feeling that this is what I am good at. I really
want to be able to do something very well, not just play like in kindergarten. Immediately, there
is the feeling that what I am doing is of no value. I am searching for the reasons.
Self-Report. There is no self-report because I am always writing the same things. This is
boring. Things are moving too slowly.
Session 12
During the Session. I am still in a melancholic mood. I feel sorrow and resignation that I
can hear in my voice. I am unable to write things down on paper. I can make a sound, but this is
not feeling.
Self-Report. While singing, I felt a block, which made me feel peevish and angry. The
feeling of anger disturbs me and increases tension. I think it is because of the death of my
husband. Maybe it will last for years. I cannot accept this, but I cannot change it either. Pain
and anger are present very often, especially during music therapy. I feel pressure; I feel a heavy
burden and a sorrow about a lot of things. I don’t want it that way. It makes me angry, as if I
need to account for everything.
Session 13
During the Session. I can’t think of an instrument [I want] and I don’t want to bang on
an instrument to express my anger. Nobody can force me to do it. Banging, being
temperamental, does not help at all. My helplessness can be expressed on the violin. I have the
feeling that music therapy cannot bring me any further.
Self-Report. Since the last music therapy session, I have felt very depressed, tired, and
lonely. José asked me to make an evaluation report, but I am inclined to postpone it. Writing
down feelings on paper feels like stepping over a high threshold. I have the same feeling during
music therapy. Inside me, something blocks my feelings. But I will try to continue writing
because it is necessary to make progress in music therapy. I am on a good track. In
psychotherapy and music therapy, processes have begun. Especially in music therapy, my
feelings are evoked, and then I can feel a block. Because I have been very aware of this block
during the last days, I am depressed. At the start of music therapy, I said to José that I want to
work on the future. My childhood and education were very normal. There were no traumatic
experiences; however, now I know that there is a period in my life that I think about frequently.
When I remember this period, I become very angry and feel helpless again. One of my sisters
was favored above others. She was a troublesome girl, disobedient. One time she attacked my
throat. Previously, I could not shake off these memories. Sometimes an immense fury came
over me. I always had to be the wise girl who did not hit back. Thus I learned to keep silent, to
suppress my feelings. I felt misunderstood but was too helpless to fight for my own rights. I
think because of this period in my life, I have been blocked and have lost my spontaneity and
self-confidence.
Talk with José and Psychotherapist. I feel anger. What am I doing? What is the reason I
am doing this? There are positive aspects, too. I am putting my life upside down, quarreling
with my family. What is the profit of this? I was depressed last week. I feel there is a block. I
also feel a lot of anger against my sister, who was hysterical [and] stupid but smart enough to
get what she wanted. I think about those moments, but I don’t know if it makes any sense to
bring up these memories. What should I do? My brother is the same story. If he hurts me, I will
hit him. He is a son of a bitch, always telling me that I am worthless. What is the value in all
this? I am not the one I used to be. I feel depressed and chaotic and am unable to sleep at
night. When I sleep, I dream a lot of new things. I am no expert. I don’t know where the limits
are. I don’t want to quarrel. At the same time, I tell my brother, “If you talk like this to me, you
no longer can count on me.” I want music therapy to help me to be less depressed. But please,
don’t come too close. I don’t want to evoke problems that are not real.
Session 14
During the Session. Not everything is negative. During music therapy, negative things
surface. I am frustrated that I am doing nothing with the negative things. I get sad about my
anxiousness, my hesitation to speak of things. [While looking at the videotape of the previous
session, she says to herself], Come on, sing with more certainty; let’s hear yourself. [After she
starts singing while watching, she says,] Do it like this. What are you doing? It can be much
better, more energetic.
Self-Report. Looking at the videotape is fascinating and makes me feel good. I am not
humiliating myself but telling myself to go on. Although on the videotape there was much
hesitation and I was thinking how laborious it was, I had no negative feeling. I said to myself,
“Carry on.” I felt very lonely, but I want to continue, to become less tense. Will I ever succeed?
Session 15
During the Session. Things are going fine, but writing them down is very difficult
because then everything looks so negative.
Self-Report. It was my task to write down how I feel when I have to make decisions.
From this I learned that when someone asks me to do something I don’t want, I am unable to
say no. Afterward, I have a bad feeling because I didn’t react at the right moment. This week
has been very quiet. I stayed at home the whole week and tried to become conscious of my
feelings, not knowing yet how to handle them. I have decided to go on with it.
Session 16
During the Session. I reacted very impulsively last week when somebody told me
rubbish about other people. I became very emotional and felt it deep inside me. I don’t want it
that way. I realized when I looked at the video that for the first time, I have been not
humiliating myself. Now as I remember, I feel that I am not completely free because there is
pressure in my chest. When I use my voice, I come very close [to expressing something]. I have
to jump over a rock, but I don’t want to run away. There is almost no variation when I am
singing. You [Jose] have much more variation. If you are not playing the piano, my voice
completely breaks down. When you were playing the conga, I said to myself, “Now throw it
out.” There is not yet joy, but there is no more depression. It is not easy.
Self-Report. During the improvisation, I was not satisfied; I could not get started and
again felt the block. While driving home in my car, I said to myself that I should try to sing now.
Then it came out much more spontaneously. During the session, I felt the same loneliness I felt
when looking at the videotape. How lonely I am. When I left church on Sunday and when I saw
families around me, I had the same feeling. How sad it is. I need over and over again an
affirmation to help me to build self-confidence. I need to tolerate being lonely. I try to get over
my blocks or to accept them. I also want to discover new ways of living outside music therapy,
by taking courses; however, I think my goals are too high. I always want to reach goals quickly. I
need to be more quiet; then I will succeed.
Session 17
During the Session. It doesn’t work. In my car, I can sing along much better. In the car, I
am much more relaxed. During the music therapy session, there are too many thoughts. Being
lonely feels so bad; I get angry about it. It is possible to learn, isn’t it? I am so lonely; everybody
else has companionship. Inside me, there is a lot of pain.
I had to blow my nose, but I didn’t want to stop playing. I wanted to sing through my
grief. Being together is beautiful. If you sing along with me, my grief fades away. When it
sounds beautiful, the grief disappears. I feel less lonely, but grief has not disappeared
completely. Things are going much better.
Self-Report. During the improvisation, I felt a lot of grief about my deceased husband.
After some time, the grief faded away. Then there was rest. I consciously tried to use my voice.
I felt that I wanted to go through this. Sometimes I tried to sing loudly. I didn’t like the pain I
felt. In the beginning of the improvisation, it was so deep. It was a very fine experience when,
later on during improvising, the peaceful feeling came. I hope this will stay and grow in the
future. I show my vulnerability, which still is not easy. With little steps forward, I will succeed.
Session 18
During the Session. I want to sing through something. What is this? Is it aggression,
pain? It happens every time when I am in music therapy. I just want to sing a simple melody
without feeling anything, and then strong feelings come up. I will try to use my voice as I do in
the car. Why is this so difficult in music therapy? In music therapy, there is no singing--just
screaming for my husband. It hurts. Why does this grief not come to an end? The grief blocks
my spontaneity. Music therapy evokes very strong feelings.
Self-Report. I feel there is stagnation; I want to sing, but my voice is blocked. Is there
something else we can do? The transcripts of the sessions were fascinating and astonishing. I
would like to talk over some of the points with the psychotherapist to reach more insight.
Session 19
During the Session. In the transcript, it seems as though the aspects of my life have
been well organized. I am unable to write it down this way myself. It looks nice, but in real life
things are mixed. Several things I do not understand yet. Is it possible to live without a pressure
to achieve? What I wrote about myself is difficult to read. Feelings come up. Today I don’t want
to sing. Using my voice is linked to being free, but there still is no freedom.
Self-Report. There is a conflict in me. I feel lonely; I want to meet people and at the
same time I don’t. I know that I can be a complete human being only together with others, but
it is so difficult to be open. I want intimacy, but at the same time, I revolt against it. Often, I
think that I don’t have any creativity, that I hold on too much to the well-known. But I also long
for something new. I have a mass of feelings. Again and again, I search for self-acceptance and
identity. In the last weeks, I have been close to hyperventilation; my chest became tight. There
also are a lot of good things.
Session 20
During the Session. In church, I have been singing with a trembling voice, fighting my
grief. I felt as if I had to surrender [to the grief]. I was anxious. It [the improvisation] went right
through my soul. My chest became tight; I don’t know what it is. Am I straining myself too
much? . There is a wish to make contact but with a clear limit. When you [Jose] played on my
instrument, I felt this to be intrusive. Being very close is not pleasant; I don’t want to surrender.
When the music gets loud, I don’t like it, but I also say to myself, “Let it happen; stand up for
yourself.” I don’t know exactly how I feel. Is there an unconscious anxiety? Is it because of my
fear of being rejected?
Self-Report. During the session, there were a lot of mixed feelings. But most of the
feelings were fine. I liked it when contact came up spontaneously, when it did not intrude on
me, and when we were carefully touching each other in music and creating something
beautiful. When someone else comes too close, I feel resistance. Loud music is not pleasant
either. It makes me insecure; then I lock myself up. I have decided to cancel my holiday trip; this
decision felt good. But I am still insecure and hope that I will feel better. I feel lonely and I don’t
like it. I don’t know how to continue.
Session 21
During the Session. Playing loudly is aggressive. I don’t like it. I don’t experience the
intimacy you [Jose] feel while we are playing. But I like it. I have a long way to go.
Self-Report. Writing down my feelings in the self-report takes a lot of effort. Is it
because I don’t want to show my weak sides? . Our contact in music was very nice, but for me,
this is not intimacy. Body contact--when José touched my hand during playing--I don’t like.
Playing together is wonderful. I felt very fine when I drove home. There was rest, balance,
complete harmony, no tension, no nervousness, no questions, and no negative feelings. Last
week, I tried to stay connected with this feeling. It is so important to make contact with my own
feelings. Each time when I become insecure, I say to myself, “Stay close to your feelings. Don’t
try to be someone else and don’t press yourself. Attune to your feelings.” When I attune to my
feelings, I learn to accept myself. My negative self-image is changing. Now I can meet
difficulties without losing self-confidence. It still is difficult to be assertive at the right moment.
Processes have begun that take time. Not everything can change at once. Last week, this came
to my mind: “Life is like an expansive garden in which you are walking, sowing, planting, and
trimming, where plants are flowering and dying. But all the time, one takes a walk, during rain
and sunshine. Again and again. Life is good to live! It is good to learn how to live!”
Session 22
During the Session. I want to love somebody, but there is no feeling of love for anybody.
I am very clumsy, challenging someone else and then withdrawing. What do I want? Today I
can’t sing, I am blocked. [Nevertheless, after some time, she spontaneously starts singing.] I said
to myself, “Come on.” Today it came out very well.
Self-Report. I look back at the session with much pleasure. The music-playing was
beautiful; I was involved in it and there was no anxiety about coming too close. The alternation
between loud and soft was beautiful. It was fragile, and I felt completely there as a personal
self. I experienced life going up and down with highlights and setbacks. In the music-playing, I
experienced being moved as in life but without the big discrepancies between hills and valleys.
In the subtle passages, I found a part of my inner self that is deep feeling, tenderness, and love.
I also felt vulnerability and a lack of self-confidence. In my contacts, I try to transform the
indifferent woman into a feeling human being. I try to listen; I try to be patient. I feel engaged
and feel love for someone else--not like love between man and woman; however, not
everybody notices that I am changing. Last week, someone said to me that I am dictatorial, that
there is no love inside me. When I heard his words, I cried. It hurt me deeply; there was real
pain. Then I realized that my self-confidence is still weak. I doubt myself. I am getting tired of
this, but I want to continue and I will try it over and over again.
Self-Report: Prepared for Talk with José and Psychotherapist. My self-confidence, selfworth, and assertiveness still are weak. I have to work hard on it. I say to myself, “Continue;
make transformations from negative to positive feelings.” Is it because I cannot yet find an
activity that I can master, like when I am playing subtly on the piano? I will try gardening and
drawing. There is progress, too. At the time, I feel much more relaxed and less depressed. I stay
close to my feelings, as if I have to pull down first before I can build up again. In summary, I can
say that several changes have been initiated and that I need to continue. Perhaps the time has
come to stop therapy now and continue on my own.
Final Talk with José and Psychotherapist. I am still weak; I get frustrated when
somebody says I am dictatorial. Yes, I am firm, but I am helpful, too. I think when I am firm, I say
things in a way that people don’t like. I have changed. I feel relaxed, less nervous, and less
depressed. I stay close to my feelings, but I am not yet satisfied. I am in the stage of pulling
down and building up, like in gardening.
Now I don’t say anymore, “You are playing like a child”; I say, “Continue.” In music,
things have changed already. In daily life, change is not yet spontaneous; each time, I need to
think about how to behave. There should be fewer hills and valleys in my life and more selfconfidence, self-acceptance, and positive assertiveness. When I am stable, then I will be
creative. I will continue with gardening, without the pressure of high standards. I will put my
feelings in colored drawings. When I draw, I say to myself, “I am who I am; I will use the blue
color because I want it.” On the one hand, I want to continue music therapy; on the other hand,
I want to stand on my own feet. I will search for something I can do on my own, into which I can
put my feelings and find self-confidence and pleasure.
Henk’s Thematic Analysis of Ingrid’s Statements
Theme 1: “Why Am I Doing This?”
Ingrid was suspicious in the beginning about music therapy and about her playing on
musical instruments. She asked herself how this could help her because she had no formal
music training. Throughout the course of therapy, she doubted the value of expressing negative
feelings. She kept asking why negative feelings had to be expressed. When the music therapist
asked her to express her feelings on instruments, she said she could not find the right
instruments and she was resistant to banging on an instrument to express her anger. In her
opinion, banging on instruments did not help at all. She had doubts about digging into the past.
She had the impression that she was turning her life upside down. Remembering past
experiences made her upset and depressed. She felt chaotic and was unable to sleep at night.
At those kinds of moments, she would say that music therapy could not help her any further.
Ingrid wanted to become less depressed and decided she did not want to evoke
problems that she thought were not real. She had the impression that especially in music
therapy, negative experiences became manifest.
When improvising with her voice, Ingrid felt blocked, whereas she said that in her car,
she could sing spontaneously. Each time she wanted to sing a simple melody, strong feelings
were evoked. Many times, she asked herself why singing in music therapy was so difficult.
Singing was like screaming for her husband. At times when she recognized that this grief had
not come to an end, she felt stagnated and resigned. It was burdensome to her that her
personal process was a very slow one.
When, at the end of therapy, Ingrid started to make decisions and change her relational
behavior outside music therapy, not all her relatives noticed the changes in her. Because of this,
she again felt her insecurity, vulnerability, and lack of self-confidence. This made her cry and
filled her with doubts about herself. It made her tired.
Theme 2: “Will I Ever Be Creative?”
When playing with the music therapist in the beginning, Ingrid forced herself to find the
right notes. Not finding the right melody upset her. At those times, she felt stupid and
handicapped and stopped the improvisation. She felt she wanted to do something well. In
music therapy, she felt as if she were playing in kindergarten.
She complained that there was no variation in her singing and that her singing
completely broke down when the music therapist stopped playing the piano. When Ingrid
started to experiment with free melodic lines, she doubted whether she could ever be creative.
In her opinion, she stayed too much with the expected. She expressed a strong wish to change
this situation. She longed for something new, and whenever she found a new melody, she
enjoyed it.
At the end of music therapy, Ingrid no longer felt as if she were playing in kindergarten.
She now communicated a personal wish to be more self-confident, self-accepting, and assertive
in activities without feeling she had to fulfill high standards. She decided to put feeling into
activities, to give way to her wishes, and to be who she is.
Theme 3: “I Want to Make Contact My Way”
When Ingrid was playing with the music therapist, she was searching for balance and
consonance. When she succeeded in doing this, it gave her a nice feeling. Although Ingrid liked
playing ensemble, she was unwilling to imitate or synchronize with the music therapist’s
increase of tempo and dynamics. For Ingrid, this felt like an act of aggression that made her
insecure and made her close up; however, there were moments when she reacted to this by
saying to herself, “Let it happen; stand up for yourself.”
Several times, Ingrid said she could not understand the music therapist’s playing. She
did not feel any contact in the music and was afraid of the music therapist’s talk about contact.
When the music therapist rubbed the congas, she said that it was as if somebody were petting
her body. When the music therapist played on Ingrid’s [part of the] instrument and accidentally
touched her hand, it felt intrusive.
Ingrid told how in the past she had built a facade that communicated to everybody not
to come too close. There was a wish to make contact but with clear limits. When someone else
passed her limits, it felt as if she would surrender. Because she didn’t want to surrender, she
expressed resistance.
In the final sessions, Ingrid liked it when contact came up spontaneously, when it did not
intrude on her. When she and the music therapist were carefully touching each other in the
music, they were creating something beautiful. Although she didn’t experience intimacy as the
music therapist did, she said it had been wonderful. When driving home (after Session 21), she
experienced rest, balance, complete harmony, no tension, no nervousness, a lack of questions,
and no negative feelings.
Theme 4: “I Need to Cry It Out from My Soul”
Ingrid was frightened to express feelings. When feelings came up, it was difficult for her
to say how she felt. She told the music therapist that she looked very rational on the outside,
but that deep in her heart she was very insecure. Her anxiety and her hesitation to tell things
made her feel sad. On the other hand, she wished to release a lot of energy. At some moments,
this wish manifested itself in impulsive reactions, which upset her. She expressed a wish to
change but did not know how.
She experienced her voice as being blocked and was afraid to express herself in sound.
For her, this felt as if she were walking on thin ice. When she became aware of the vocal block,
she became depressed. She realized that she never had been able to understand and to handle
feelings.
Although at the start of music therapy Ingrid had told the music therapist that she had
had no traumatic experiences as a child, during music therapy she admitted that she had. Pain
and anger about her life were present very often during music therapy. When remembering her
childhood, she felt a lack of warmth and caring by her mother. Because one of her sisters had
been very difficult, Ingrid had been forced to control herself and to suppress her own feelings
all the time. Now she felt furious about this. She expressed anger because of what her sister
and brother had done to her. She concluded that because of these past experiences, there had
been no development of her self-image and self-confidence and that she had lost her
spontaneity. This, in her opinion, now became obvious in music therapy. She said she did not
feel completely free in music therapy. She used her singing to counteract her grief but at the
same time felt anxious. She told the music therapist that the vocal improvisations went right
through her soul and made her chest feel tight. Ingrid’s negative feelings forced her again and
again to search for self-acceptance and identity. She also was aware that there were many fine
feelings.
Theme 5: “The Music--That Is Me”
Ingrid talked about her restless writing and way of relating. She compared these
behaviors to her music-playing. These she thought were identical. Playing the piano, she said,
was like her life. Using her voice was like an expression of freedom. On the other hand, she had
doubts whether playing together on musical instruments is the same as making contact. Inside
and outside music therapy, Ingrid experienced an inner conflict about social contacts and the
wish to meet people.
In the final session, she experienced the music improvisation as fragile. In it, she said,
she found a part of her feeling self. She described how during improvisation she experienced
life going up and down, with highlights and setbacks. In the improvisation, she experienced
being moved as in life but without the great discrepancies between hills and valleys. She said
that while in music therapy she had changed already, in daily life her changes had not yet
occurred spontaneously.
Theme 6: “Just Look at Me”
Looking at the videotapes of several sessions was fascinating to Ingrid and gave her a
good feeling. She was aware, when she saw herself on video, that she was not humiliating
herself by telling herself to go on.
Although writing her feelings down in the self-report cost her a lot of effort, Ingrid told
the music therapist that the transcripts of her self-reports, the music therapist’s self-reports,
and the researcher’s observations were fascinating and astonishing. She expressed a wish to
talk them over to reach more insight.
Theme 7: “I Hope I Can Change; I Want to Change”
Ingrid expressed the hope that by means of music therapy and psychotherapy, it would
be possible to develop her self-image, to become less insecure, more cheerful and relaxed.
When grief for her deceased husband had turned into a peaceful feeling, it was a very fine
experience for her. She expressed hope that this feeling would stay and grow in the future.
In the first music therapy sessions, Ingrid was surprised that it was possible to make
music, and this experience stimulated her to explore her musical possibilities further. The
experience gave her faith. In the final session, she was pleased that when playing she did not
have anxiety about coming too close.
Ingrid felt as if she was growing up and learning. Her negative self-image was changing
and her self-confidence was increasing. Although she knew that her self-confidence, self-worth,
and assertiveness still were weak and that she had to work hard on them, she knew there had
been progress already. She said that she had become more relaxed, less nervous, less
depressed, and was closer to her feelings. She felt that she was on a good track and that she
had begun to make progress. She became confident that she would succeed little by little.
During the course of music therapy, Ingrid became convinced that she needed to release
herself from something and she expressed a firm wish to express her energy because she
thought this would be the right way to break down her resistance. She expressed a wish to
listen to her feelings, to lower her pride, to show herself vulnerable, to take the risk of making
errors, to strengthen her ego, and to accept herself.
By singing, she tried to get over her blocks and to express what was inside her, to sing
through her grief. Several times, she overcame her resistance to singing. She showed her strong
will when she continued improvising. Although sometimes as a result of her experiences in
music therapy she felt depressed, tired, lonely, blocked, and unable to write her self-report, she
continued writing because she wanted to make progress. After looking at the videotapes, she
expressed a strong wish to continue.
Outside music therapy, she tried to stay connected with feelings of harmony and rest.
Sometimes she stayed at home the whole week to become conscious of her feelings. When she
became insecure outside music therapy, she trained herself to stay close to her feelings, not to
try to be someone else.
Ingrid used several metaphors that expressed her will to change: a rock she had to jump
over, a garden that time and time again needed care, and a building that had to be pulled down
first before it could be built up again. She knew that the process takes time, and that not
everything can change at once, but she was willing to keep trying. At the end of music therapy,
she expressed a wish to stand on her own feet.
Epilogue
José and I were deeply moved by Ingrid’s will to change. We observed a very brave
woman who, knowing that the road to health was a rough one, nevertheless decided to take
the path. It was moving to observe how she gradually let go of her perfectionistic goals, how
she became more open to her feelings, and how she allowed herself to experience her inner
self in the music.
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
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The Music Within You (Katsh & Fishman)
Resource-Oriented Music Therapy in Mental Health Care (Rolvsjord)
The Rhythmic Language of Health and Disease (Rider)
Sounding the Self: Analogy in Improvisational Music Therapy (Smeijsters)
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Authentic Voices, Authentic Singing (Uhlig)
Psychiatric Music Therapy in the Community: The Legacy of Florence Tyson (McGuire)