Case Examples of Improvisational Music Therapy [1 ed.] 9781937440381

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Case Examples of Improvisational Music Therapy Compiled by Kenneth E. Bruscia

Case Examples of Improvisational Music Therapy 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: 978-1-937440-38-1 Distributed throughout the world by: Barcelona Publishers 4 White Brook Road Gilsum NH 03448 Tel: 603-357-0236 Fax: 603-357-2073 Website: www.barcelonapublishers.com SAN 298-6299 Cover illustration and design: © 2012 Frank McShane

Dedication In loving memory of My dear “Aunt Rene” Lena Bruscia Alongi

Preface Kenneth E. Bruscia Case examples provide very unique and valuable insights into how different forms of therapy are practiced, as well as how clients respond to those therapies. This e-book describes various ways that a particular method of music therapy—improvisation—has been used to help various clientele. Its main purpose is to present music therapy students and professionals with a wide array of case examples that when carefully analyzed and compared can provide in-depth insights into how improvisation is most effectively used for therapeutic purposes. The Preface and the Introduction provide material that can the reader compare and analyze the cases from different perspectives and along different dimensions. This preface offers suggestions on the various perspectives that can be taken in reading a case study. The premise is that there are various ways to read and interpret a case study, and that when different perspectives are considered, richer insights can be gained. Reading guidelines are particularly important in this book because the cases are so diverse. As evident in the Table of Contents, these cases portray different clients with different therapeutic needs, and the myriad ways that different music therapists meet these needs. The guidelines will hopefully provide the means whereby the reader can glean principles of practice in improvisational music therapy. 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. Nearly all of the cases in this book are clinical case studies. 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. A quantitative 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. Case 4 by Carpente is an example. A qualitative research case, non-numerical data are gathered and analyzed to gain insight about a particular clinical phenomenon. Cases 21 (Turry) and 26 (Eyre) analyze musical data to better understand the client’s therapeutic process; and in Case 29 (Vanden Hurk & Smeijsters) , a

therapist and researcher use session notes and client self-reports to actually guide the therapeutic process. 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. And certainly if the reader has any experience working with the same problem or condition as the client in the case study, or if the reader practices the same method of therapy, 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 have experience with the same clientele and method are just as interested in this question as scientists. Their interest is in whether they can utilize the techniques or principles exemplified in the case with their own clients and in their own practice. Does the case give the clinician any ideas about how to enhance their own work with clients? Scientists 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 reallife, 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. But the greatest advantage of the quantitative research case is not only that it provides objective evidence of what works or does not work in therapy, but also because it can reveal the “effect size” of the therapeutic change. That is, it can show how big of 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 its 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. 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 need 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? The introduction to this book provides an overview of the unique methodological issues that arise in improvisational music therapy: interpersonal context, media, and source of reference. These issues add more specific questions to pose when reading an improvisational case: 1) Should my client(s) improvise alone, with me, with a significant other, or other clients? 2) Should my client improvise vocally and/or instrumentally? 3) How can I best elicit spontaneous sound-making from my client? Final Comments The case examples in this e-book were taken exclusively from books published by Barcelona Publishers. When taken together, these 29 cases highlight the work of music therapists who differ widely in approach and theoretical orientation; thus, one can regard this book as quite a representative sample of how improvisational music therapy has been practiced over the last 60 years. At this moment in history, electronic books are causing a revolution in the world of books, and at such a speed, that many readers are still very reluctant to adapt to this new way of buying, owning and reading books. Most of us still love to have a print book in hand. Nevertheless the advantages of this particular e-book over a print book are twofold. First, given its length, it is not as costly as a print book; second, and most importantly, this e-book provides the unprecedented opportunity for readers to actually hear the improvisations created by clients and therapists—while reading about them. And what is even more incredible is to hear how the pioneers and leaders in the field improvised with their clients, including Paul Nordoff, Carol Robbins, and the rarely heard Mary Priestley. It is hoped that, notwithstanding any inconveniences incurred by electronic reading, the audio files in this e-book will bring to life the music therapy process that so many people find elusive.

Table of Contents INTRODUCTION An Overview of Improvisational Music Therapy Kenneth E. Bruscia Part One: Improvisational Music Therapy with Children and Adolescents CASE 1 Audrey is Dancing a Song: Work, Myth, and Singing in Self-Actualization Kenneth Aigen (A case study of Paul Nordoff and Clive Robbins) CASE 2: Good-bye Indu: The Aesthetic Form of the Music Therapy Session Kenneth Aigen (A case study of Paul Nordoff and Clive Robbins) CASE 3 Improvisation and Play in the Therapeutic Engagement of a Five-Year Old Boy with Physical and Interpersonal Problems Pamela Bartram CASE 4 A Research Case Study on the Effectiveness of Nordoff-Robbins Music Therapy in Accomplishing Musical and Socio-emotional Goals for a Girl with Autism John Carpente CASE 5 Growing up Alone: Analytical Music Therapy with Children of Parents Treated within a Drug and Substance Abuse Program Julianne Kowski CASE 6 Speaking without Talking: Fifty Analytical Music Therapy Sessions with a Boy with Selective Mutism Wolfgang Mahns CASE 7 The Impact of Creative Music Therapy on a Child’s Ability to Relate Interpersonally John Mahoney CASE 8 The Knight Inside the Armor: Music Therapy with a Deprived Teenager Simona Katz Nirensztein

CASE 9 Edward Paul Nordoff and Clive Robbins CASE 10 Anna Paul Nordoff and Clive Robbins CASE 11 Preverbal Communication Through Music to Overcome a Child’s Language Disorder Amelia Oldfield CASE 12 Self-communications in Creative Music Therapy Carol Robbins and Clive Robbins CASE 13 Creative Music Therapy in Bringing Order, Change, and Communicativeness to the Life of a Brain-injured Adolescent Clive Robbins and Carol Robbins CASE 14 The Use of Piano Improvisation in Developing Interaction and Participation in a Blind Boy with Behavioral Disturbances Helen Shoemark CASE 15 Being Beverley: Music Therapy with a Troubled Eight-Year Old Girl Helen M. Tyler Part Two: Improvisational Music Therapy with Adults CASE 16 The Case of Marianne: Repetition and Musical form in Psychosis Jos De Backer Jan Van Camp CASE 17 Case Study—Michael: Music and Loss Colin Andrew Lee CASE 18

Living In Playing: A Group Case Study

Colin Andrew Lee

CASE 19 Moving into the Age of Aquarius: Aesthetic Music Therapy with a String Quartet Colin Andrew Lee CASE 20 Singing My Way Through the Cancer, the Darkness, and the Fear Maria Logis Alan Turry CASE 21 An Audio Case of Maria and Alan: A microanalysis of Our Song Improvisation “There, There.” Alan Turry CASE 22 Reclaiming a Positive Identity: Music Therapy in the Aftermath of a Stroke Nancy McMasters CASE 23 Group Improvisation Therapy: The Experience of One Man with Schizophrenia Helen Odell Miller CASE 24 The Revival of the Sea Urchin: Music Therapy with a Psychiatric Patient Inge Nygaard Pedersen CASE 25 Analytical Music Therapy and the “Detour Through Phantasy;” A Case Study of Curtis Mary Priestley CASE 26 Changes in Images, Life Events and Music in Analytical Music Therapy: A Reconstruction of Mary Priestley’s Case Study of Curtis Lillian Eyre CASE 27 Mia’s Fourteenth—The Symphony of Fate: Psychodynamic Improvisation with a Music Therapy in Training Benedikte Barth Scheiby CASE 28 Music is about Feelings: Music Therapy with a Man Suffering from Anorexia Nervosa

Gro Trondalen CASE 29 Musical Improvisation in the Treatment of a Man with Obsessive-Compulsive Personality Disorder Jose van den Hurk Henk Smeijsters

Audio Excerpts Case 1: AUDREY (Paul Nordoff and Clive Robbins) Excerpt (Session) 1 (1) 2 (2) 3 (2) 4 (5) 5 (15) 6 (15) 7 (16)

8 (27) 9 (24) 10 (24) 11 (27) 12 (Final) 13 (Final)

Case 2: INDU (Paul Nordoff and Clive Robbins) 5 (10) 6 (15) 7 (9) 8 (27) 9 (21)

Excerpt (Session) 1 (1) 2 (16) 3 (13) 4 (24) Case 7: CARLOS (John Mahoney) – DVD

8 (83) 9 (87) 10 (89) 11 (97) 12 (107) 13 (113) 14 (118)

Excerpt (Session) 1 (1) 2 (2) 3 (10) 4 (18) 5 (19) 6 (22) 7 (44) Case 9: EDWARD (Paul Nordoff and Clive Robbins) Excerpt (Session) 1 (1) 2 (1) 3 (2) 4 (2) 5 (3) 6 (4)

7 (6) 8 (7) 9 (9) 10 (9) 11 (9) 12 (9) 13 (9)

14 (9) 15 (9) 16 (9) 17 (9) 18 (10) 19 (10) 20 (10)

Case 10: ANNA (Paul Nordoff and Clive Robbins Excerpt (Session) 1 (1) 2 (1) 3 (1) 4 (3) 5 (3) 6 (3) 7 (4) 8 (4) 9 (5) 10 (5) 11 (6) 12 (16) 13 (6) 14 (7) 15 (7) Complete 16 (8) 17 (8) 18 (9) 19 (10) 20 (10) 21 (10) 22 (12) 23 (13) 24 (13) 25 (16) 26 (17) 27 (18)

Case 12: LYNDAL (Carol Robbins and Clive Robbins) Excerpts (Linked Together) 1-2 3-4-5 6-7-8-9-10 11 12-13-14 15 16 17 18 19 20 Case 17: MICHAEL (Colin A. Lee) Excerpt (Session) 1 (7) 2 (8) 3 (10) Case 18: GROUP (Colin A. Lee) Excerpt (Session) 1 (2) 2 (9) Case 19: QUARTET (Colin A. Lee) Excerpt (Session) 1 (2) 2 (2) Case 20: MARIA (Maria Logis and Alan Turry) She didn’t want to go ahead They tell me I’m sick Do I dare imagine? Woman, why are you weeping Rats in the Cellar — Disappear Rats in the Cellar — Sleep Rats in the Cellar — Bones

There, There Oh my child Piano has the giggles Case 21: MARIA (Alan Turry) There, There Case 26: CURTIS (Mary Priestley) Conversation at work After getting the sword Down under the sea The fracas Nightscene Print

Adapted from: Bruscia, K. (1998). An Introduction to Music Psychotherapy. In K. Bruscia (Ed.), The Dynamics of Music Psychotherapy. Gilsum NH: Barcelona Publishers.

INTRODUCTION An Overview of Improvisational Music Therapy Kenneth E. Bruscia When music therapy involves improvising, the client “makes up” music spontaneously while playing an instrument or singing, extemporaneously creating sound forms, melodies, rhythms, or entire pieces. The client may select any musical medium within her capabilities (such as voice, body sounds, percussion, strings, keyboard, wind instruments) and then, with the necessary instructions or demonstrations from the therapist, learns to make sounds extemporaneously. As the sounds emerge, the client follows them up with more sounds and gradually shapes them into something meaningful, such as a beat, rhythm, melody, timbre, or harmony. This process of spontaneous music-making taps into every human being’s natural propensity to create and respond to sounds expressively and aesthetically. No musical training is required. Improvising is simply playing around with sounds until they form whatever patterns, shapes, or textures one wants them to have, or until they represent or mean whatever one wants. Three variables are considered in designing the client’s improvisation experience: the interpersonal setting, the musical media used, and the point of reference. Interpersonal Contexts The first variable to consider in setting up an improvisation is whether the client should improvise alone, with the therapist, with significant others, or in a group. This determines the interpersonal context for the client’s music-making. When improvising alone, the client has to deal with only whether the sounds are what he or she wants them to be, without having to worry about anyone else’s sounds; on the other hand, the challenge is to take on all the responsibilities and risks that go with such freedom, accomplishing one’s own goals without the support and assistance of others, musically or emotionally. In contrast, when improvising with the therapist or others, the client shares all the responsibilities and risks of music-making while also enjoying their musical and emotional support and assistance; the challenge in this setting is to retain one’s own identity while still being in relationship—to be oneself with others. Aside from the forementioned differences in musical freedom, responsibility, and limitations, there are also significant clinical considerations in determining whether the client should improvise alone or with others, and with whom. The cases that follow give examples of many different interpersonal contexts and their clinical rationale. Specifically: Duets. In most of the cases that follow, the client and therapist improvise together in individual music therapy sessions. These “duets” are indicated when the client needs the musical stimulation and assistance to engage in the music-making process, while also needing

the therapist’s personal support and encouragement. They are also indicated when the client needs a more intimate therapeutic setting, or the undivided attention of the therapist, both of which are afforded by individual therapy. Examples of therapist-client duet improvisations in individual therapy can be found in cases 3, 5, 6, 8, 11, 14, 15, 16, 17, 20, 22, 24, 25, 27, 28, and 29, where many different orientations and methods have been taken. Trios. There are also several cases involving two therapists and one client working together in individual therapy sessions. These trios are indicated when the client needs musical, personal, and physical support and assistance to engage in the music-making process, or when the client’s behavior is too difficult to contain or focus by the improvising therapist. Examples of these trios can be found in cases 1, 2, 4, 7, 9, 10, 12, and 13, all of which are examples or extensions of the Nordoff-Robbins approach to improvisational music therapy (Nordoff & Robbins, 2007). Another kind of trio is when one therapist works with one client and a significant other (e.g., parent, sibling, spouse, partner). Though there are no clear examples of such trios (or couple work) in this book, examples can be found in the work of Juliette Alvin (1978, 1981), Mary Priestley (1994, 2012) and others. Solos: The client may need to improvise alone for many different reasons. Some clients have difficulty interacting and refuse to improvise with anyone else, including the therapist. Such clients cannot tolerate any form of musical or interpersonal contact. In contrast, other clients have no problem making music with others, but they need to find their own identity and express their own feelings without being influenced in any way by another improviser. Similarly, some clients need to become independent of the therapist, musically and personally, and solo improvisations provide opportunities to develop this independence. Examples of solo client improvisations can be found in case 8 where Eli needed to be listened to and heard by the therapist, and in case 22 when Vera needed to express how she felt on her own. Therapists may also improvise solo. Sometimes this occurs when the client is not willing to make music or interact with the therapist, and the therapist is trying to establish a musical and affective atmosphere that will entice the client to participate. Other times, the client needs to stop playing and singing and instead listen to or receive the music being improvised by the therapist. Brief examples of both scenarios can be found throughout the cases in this book. Group: Clients are usually placed in improvisational groups because they need to develop better ways of relating with their peers or managing their behaviors in social settings. The therapist may or may not participate in the group, depending on whether musical guidance or containment is needed. Examples of group improvisations are found in cases 6, 11, 12, 15, 18, and 19. Changes in Context: The interpersonal context needed by the client in each improvisation, and in each therapy session depends on many factors and therefore may change during the course of therapy. In some cases, the client needs group therapy before individual therapy, so that experiences in the group prepare the client for more intensive improvisational work with the therapist(s). In others, the client needs individual therapy first, so that intensive work with the therapist can prepare the client for being in a peer group or working with significant others. Examples of these kinds of changes can be found in cases 11, 15, and 16.

Musical Media The second variable in designing a clinical improvisation is whether the client uses voice, a musical instrument, or body sounds. Of course, this decision has to be based on the client’s abilities and preferences. Some clients find singing difficult or awkward, others find it easy and perfectly natural. Some clients are able and want to play melodic instruments (wind or bar), and some are better suited for percussive instruments (drum, cymbal, tambourine). From a psychodynamic point of view, each medium has its own significance, which depending on the orientation of the therapist, might be considered in helping the client select the most effective medium. “In vocal media, one’s body is the sound-producing object. The body creates the vibration, resonates, and gives sensory feedback to itself. Unlike other media, the voice requires using the invisible parts of the self. The body mobilizes the unseen physical self—to sound its inner self—according to feedback from the observing self. As the individual instrument of the body, the voice extends the physical self and projects a sound identity of the inner self” (Bruscia, 1987, p. 516). “Unlike the voice, instruments require using the external, visible parts of the body to produce the sound. Since instruments are touched, held, and manipulated through various body postures and movements, they serve as visible extensions of the body in both form and function. Since the instruments also replace the voice as the resonating object, they receive the vibrations instead of the self. Since the instruments have greater material variety than the body, they also extend its sound capabilities. Thus, instruments extend the visible self, displace the feeling self, and extend the audible self. They project the self into the outer world, displace the inner self onto non-self, and extend the inner self (voice) to project other sound identities. When manipulating an instrument, the body extends its outer self—to displace feelings onto objects—and project its inner self through various sound identities” (Bruscia, 1987, p. 517) “Similar to instrumental media, the body uses external parts of the self to produce sound; however, similar to vocal media, the body resonates and receives the vibrations instead of an external object. Thus, the body extends and replaces itself” (Bruscia, 1987, p. 517). Most cases in this book involve the client in both instrumental and vocal improvisation. The reason is that one medium naturally leads to or needs the other. Inevitably, instrumental rhythm improvisations yield a melody, which in turn invites the addition of words, or the rhythms suggest words or lyrics which then imply a melody. Conversely, vocal or song improvisations inevitably call for the addition of instrumental and ultimately harmonic accompaniments. Additionally, there seems to be a personal sequence in how each client moves through different musical media. Some clients find it easier to begin improvising with the instruments, and then gradually begin to add vocal sounds, words, dialogues, or lyrics; others find it more natural to begin by vocalizing or singing, and then adding instruments; and still others prefer to stay in one medium throughout their work. Though much depends on client preference and comfort, the therapist also has to consider the client’s musical, emotional, and/or interpersonal needs for instrumental versus vocal work. For example, clients with poor rhythmic control need to learn how to beat, maintain, and vary a pulse before they can participate meaningfully and pleasurably in a vocal or song improvisation; clients who are easily over-stimulated may

respond better to vocal rather than instrumental improvisation; nonverbal clients will invariably need to interact with others through musical instruments before using vocal sounds or words. In short, the choice of musical medium for the client is important to the success of improvisational music therapy. Points of Reference The third variable considered by the therapist is whether the client’s musical improvisation should be referential or nonreferential. A referential improvisation is one that portrays or represents something nonmusical, such as an idea, feeling, image, or story. Because the sounds are created in reference to something other than themselves, the meaning of the improvisation is derived from relationships between the sounds and whatever they portray. In most cases, referential improvisations are verbally mediated. The thing being portrayed in sound is presented and conceived verbally, in the form of words, phrases, or statements around which the improvisation is built. In contrast, a nonreferential improvisation is one that is organized and created according to how the music sounds; it represents, refers to, and derives its meaning from only relationships between sounds within the music itself. The improvisation is built purely around the sounds themselves, without any attempt to portray anything else. Thus, nonreferential improvisations have the potential for being a purely nonverbal experience: they do not have to be based on an experience that has been verbalized (even though they may be influenced by verbal discussions that precede them) and they do not have to be analyzed verbally to be therapeutic (although they may be discussed afterward). Perhaps the best way of understanding how referential and nonreferential improvisations work in tandem is to conceive of them as vehicles along the same continuum, connecting nonverbal and verbal channels of therapeutic experience. Music can provide a nonverbal means of self-expression and communication or serve as a bridge connecting nonverbal and verbal channels of communication. When used nonverbally, musical improvisation can replace the need for words and thereby provide a safe, acceptable way of expressing conflicts and feelings that are difficult to express otherwise. When both nonverbal and verbal channels are employed, the improvisation serves to intensify, elaborate, or stimulate verbal communication, whereas the verbal communication serves to define, consolidate, and clarify the musical improvisation. Aside from the verbal versus nonverbal distinction, the decision to do referential or nonreferential improvisations is also a very practical one. The therapist’s immediate concern in beginning work with a client is which type will engage the client most readily in spontaneous music-making. And which type will the client find most meaningful? A review of how the authors in this book have elicited improvisations from their clients shows how many options there are. Below are a few examples, demonstrating how interpersonal context, media, and source of reference all have to be considered simultaneously. 1) Presenting a particular instrument and its various possibilities as a way of stimulating the client to make sounds. 2) Setting up an instrumental dialogue between client and therapist, focusing on how the two instruments can talk to each other in sound.

3) Making the instruments symbolic of characters, feelings, situations, etc. 4) Reflective instrumental improvising: The therapist improvises music that imitates or depicts what the client is doing, feeling, saying, etc. in the here-now. 5) Reflective vocal improvising: The therapist vocalizes or sings songs describing what the client is doing, feeling, etc. in the here-now, inviting a dialogue. 6) Using a story (e.g., Cinderella) as the basis for improvising. 7) Setting up symbolic play, fantasies, or game scenarios to evoke and organize the client’s music-making 8) Using a particular sound or motif as a theme for improvising and dialoguing. 9) Giving the client images, titles, or lyrics to portray in sound. 10) Having the client draw pictures and then depict them in sound. Main Formats When the above three variables are considered, specific formats for improvisational music therapy emerge. Examples of all the formats below can be found in the case examples presented in this book. The main ones are: Instrumental Nonreferential: The client extemporizes on a musical instrument without reference to anything other than the sounds or music. In other words, the client improvises music for its own sake, without trying to make it represent or describe anything nonmusical. Three subtypes are: solo, duet and group, each of which poses different kinds of musical challenges. Instrumental Referential: The client extemporizes on a musical instrument to portray in sound something nonmusical (e.g., a feeling, idea, title, image, person, event, experience, etc.). Subtypes include solo, duet, and group, each which has implications for how the nonreferential idea is perceived and musically projected. Song Improvisation: The client extemporizes lyrics, melody, and/or accompaniment to a song. Subtypes are solo, duet and group song improvisations. Given the prominence of melody in song, and the close relationship between melody and lyrics, the addition of other improvisers can significantly complicate the process. Vocal Nonreferential Improvisation: The client extemporizes a vocal piece without words or images. Subtypes are solo, duet and group. Body Improvisations: The client improvises by making various kinds of percussive body sounds (clapping, snapping, patschen). Subtypes include solo, duet and group. Mixed Media Improvisations: The client improvises using voice, body sounds, instruments, and/or any combination of sound sources. Subtypes include solo, duet and group. Conducted Improvisations: The client creates an improvisation by giving directive cues to one or more improvisers. Clinical Applications Improvisational music therapy can be used to meet diverse therapeutic goals, for children, adolescents, and adults. The main ones are:

• • • • • • • • • • •

To promote freedom, spontaneity, and playfulness within structure To develop creativity, problem-solving, and decision-making in the here-now To stimulate and develop the senses To develop perceptual and cognitive skills To provide a nonthreatening means of self-expression and self-disclosure To establish a nonverbal channel of communication, and a bridge to verbal communication To access and work through unconscious material To promote identity formation To explore various aspects of self in relation to others To develop the capacity for interpersonal intimacy To develop group skills

Many different client populations manifest therapeutic needs in these areas: from obsessive-compulsive children to adults with borderline or narcissistic personality disorders; from autistic nonverbal children to aggressive adolescents; from impulsive, acting out children to inhibited depressed adults; and from developmentally delayed or physically disabled children to children free of handicap. The cases in this book provide examples of how improvisational music therapy can be used with various client populations: • • • • • • • • • • • • • • • •

Intellectual Disabilities: Cases 1, 2, 7, 10, 15 Multiple Disabilities: Cases 2, 7, 10, 12, 13, 14 Cerebral Palsy: 2, 10 Visual Impairment: 7, 10, 14 Emotional and/or Behavioral Disorders: Cases 1, 3, 5, 9, 14 Speech and Language Problems: Cases 2, 6, 10, 11 Autism/Childhood Psychosis: Cases 4, 9 Schizophrenia/Psychosis: Cases 16, 23, 25, 26 Depression: 8, 16 Personality Disorders: Cases 24, 28, 29 Eating Disorder: Case 28 Stroke: Case 22 Cancer: Cases 20, 21 HIV/AIDS: Case 18 Music Therapy Student in Training: Case 27 Musicians: Case 19 References

Alvin, J. (1978). Music Therapy for the Autistic Child. London: Oxford University Press. Alvin, J. (1981). Regressional Techniques in music therapy. Music Therapy: Journal of the American Association for Music Therapy, 1 (1), 3–8.

Bruscia, K. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C. Thomas. Bruscia, K. (1998). The Dynamics of Music Psychotherapy. Gilsum NH: Barcelona Publishers. Nordoff, P., & Robbins, C. (2007). Creative Music Therapy: A Guide to Fostering Clinical Musicianship (Second Editon). Gilsum NH: Barcelona Publishers. Priestley, M. (1994). Essays on Analytical Music Therapy. Gilsum NH: Barcelona Publishers. Priestley, M. (2012). Music Therapy in Action (Second edition, 1985). Gilsum NH: Barcelona Publishers.

PART ONE: IMPROVISATIONAL MUSIC THERAPY FOR CHILDREN AND ADOLESCENTS

Taken from: Aigen, K. (1998). Paths of Development in Nordoff-Robbins Music Therapy. Gilsum NH: Barcelona Publishers.

CASE ONE Audrey Is Dancing a Song: Work, Myth, and Singing in Self-Actualization Kenneth Aigen (Case Material of Paul Nordoff and Clive Robbins) It was early in January 1961 and we were going around looking for children for a demonstration group. We saw Audrey sitting at a table threading beads with another girl. Paul bent down to see her and she raised her needle and said, “I’ll poke your eye out!” I had a quartz crystal in my pocket and for some unknown reason I showed it to her and asked, “What’s this?” She looked at the crystal, looked back at me and replied, “Jesus?” Paul said, “Let’s take her!” Audrey holds a special place in the work and hearts of Paul Nordoff and Clive Robbins. Perhaps with no other child did they achieve such a depth of mutuality in a relationship forged through musical interaction. Although recognizing that Audrey would not have had the language or the concepts to form such a realization, Clive nonetheless observed that Audrey, Paul, and he “experienced each other as artists, people who live in an art together.” This ability to recognize each other’s expressive sensitivity helped Audrey to better know both Clive and Paul and helped to provide reassurance to her and alleviate her pervasive anxiety. When Audrey began music therapy on February 20, 1961 she was 7 years old. She tested in the range of 50 on an IQ scale and had speech difficulties. At first, Audrey was placed in the lowest unit in Devereux that still offered an educational program. After only a few days she was moved to another unit due to her temper tantrums and other wild behaviors. This unit was primarily custodial with little challenges offered to the children. Similar to many of the children on this unit, Audrey was medicated with tranquilizing drugs. Consequently, the sedation was an obstacle in her music therapy as it impeded her ability to concentrate. The custodial attitude held by the staff of this unit caused what Clive describes as an “institutional pathology” among the children, characterized by a “thin, rickety provocativeness that collapsed easily” and led to a scattering of focus. The children created their own subculture “that was founded of their conditions, their frustrations, and their disabilities.” For her part, Audrey saw her condition in life—specifically, her placement at this institution—as a punishment for being “bad.” Beginning

Audrey’s Therapy

Audrey met Clive and Paul and was introduced to their way of working when they ran a preliminary demonstration group seven weeks prior to beginning individual work. Upon entering her first individual session, Audrey spontaneously remembered the therapists from the demonstration group and exclaimed, “Pis, Pas, Po” which was understood as a request to play the music from “Pif-Paf-Poltrie” that she participated in during the demonstration group. It was felt to be significant that she had remembered the experience for seven weeks—it indicated that it was meaningful for her. In her first four sessions Audrey played the drum to the songs she remembered and in improvisations with Paul. In addition, she sang the lyrics to songs introduced by Clive and Paul as well as improvised her own phrases. Her considerable musicality became evident through her drum beating and singing. Rhythmically, she could change tempi, beat steadily through syncopation, make accelerandi and ritardandi, respond to changes in dynamics, and in general, evidence her innate “feeling for the structure of musical phrases.” Yet more important than her musical ability was that Audrey “experienced music directly and clearly. She felt personally connected” to it which was evidenced in the pleasure she obtained from the joint music-making. Coexisting with these skills and love of music was an “irregularity” in Audrey’s playing which was understood as “direct evidence of insecurity.” Sustaining a cooperative activity was also beyond her capacity at this time. This limitation was seen in all the children in this particular unit and was considered by Clive and Paul to be partly an influence of the environment. The improvisations in these initial sessions were characterized by an alternating form that involved a movement between musical opposites or polarities. This was seen in treble-bass dialogues on the piano, alternating between consonance and dissonance on the piano, and movement between starkly contrasting musical moods. Paul described his rationale for this clinical-musical strategy as it pertained to the second session: I began to use sudden strong contrasts in dynamics in this music. This appealed to Audrey. I was developing something she herself had done using the element of unpredictability that she had shown in her accenting in the ways she used the cymbal, in the way she started and stopped. My response was intuitive. Somewhere within the world of music I had to find a matching picture of Audrey for Audrey. All the evidences of her unpredictability could be musically expressed by these changes in dynamics and mood which where unpredictable to her. The phrase “finding a matching picture of Audrey for Audrey” demonstrates how Paul’s reflecting of Audrey’s activity matched her character. Also important is that Paul did not just create a musical portrait or reflection of Audrey. In the context of the relationship it is he himself who is being unpredictable! His way of relating to Audrey cannot be separated from the music he was playing. In expressing how he experienced Audrey, Paul simultaneously revealed himself and adopted a certain way of being that influenced the development of their relationship. The following musical excerpt is from Audrey’s first individual session. It is characterized by vitality and humor and Audrey’s rhythmic skills and overall musicality are apparent throughout:

Audio File: Audrey—Excerpt 1 (Session 1) -

Audrey beats and Paul takes up her tempo, establishing both a tonality and a meter Paul tries to accelerate her playing and disturb its unvarying character Audrey and Paul make a brief accelerando Paul makes a ritard and establishes a slower tempo which Audrey plays at and they both stop and laugh Paul plays softly in the treble and Audrey first plays the cymbal lightly and then adds the drum Audrey establishes a steady tempo and Paul joins it The music becomes stronger and more assertive and there is a brief pause, Audrey vocalizes

In the second session, two days later, Audrey begins in an ambivalent mood; she wants to play alone and becomes somewhat scattered. She tells Paul to stop playing and he firmly resists her, saying, “We’re going to work!” The alternating motif returns as the music shifts between forceful, assertive playing, and a calmer, more mysterious mood: Audio File: Audrey—Excerpt 2 (Session 2) -

Audrey and Paul are playing together over a tritone when Audrey stops Paul says, “We’re going to work!” Audrey starts playing and Paul plays forcefully in the bass of the piano in a Locrian mode Audrey maintains a strong Basic Beat against Paul’s phrases - Together they alternate playing softly and forcefully

A few minutes later, Audrey sings along with her drum beating in a free, open, and dramatic way. After Paul had sang and played in the whole-tone scale the excerpt begins as Audrey abruptly starts beating. Her singing is nonverbal at first and then incorporates deeply felt “No’s!” After the excerpt ended, this music eventually became more gentle and melodic and Audrey did not want to leave at the end of the session: Audio File: Audrey—Excerpt ( Session 2) -

Audrey starts beating and sings loudly Paul and Audrey sing responsively together in a duet style Paul sings dramatically on “la,” slowing the tempo and Audrey takes this up

This music was described by Paul: In this beautiful singing voice lives the whole being of Audrey. Her voice is strong and free. It has a beautiful quality. Through it she shows humor, musical intelligence, and pluck.

There were repeated moments of musical beauty throughout Audrey’s therapy during which she transcended her communicative and behavioral limitations. Concomitant to these types of experiences was an intense, concrete focus on artistic work and discipline that Clive and Paul felt would greatly benefit Audrey. Although Audrey had a strong will, Clive saw it as “scattered” and “antisocial” without the capacity to be used constructively. Opportunities for constructive, artistic work were offered to Audrey from a belief that the channeling of the will is an appropriate and essential part of therapy processes. In this regard, Clive noted how “it is very important in our concept of therapy to apply the will, and focus your faculties in an act sustained by an effort of will. That effort of will is an effort of the self and in bringing your faculties together it really is a very concrete step of self-actualization.” Because of her musical gifts, it was felt that it was important to lead Audrey “through free and creative musical activities, to an awareness of the forms and structures that make music meaningful. The discipline necessary to achieve this would also be healing for her.” Although she would not accept behavioral discipline, Audrey would accept artistic discipline, made possible by her “innate recognition of musical quality.” The therapeutic focus on musical changes in dynamics and mood and learning to beat various melodic rhythms can be seen in the context of helping to make Audrey’s instinctual gifts into more of a conscious experience. Paul described the quality of her playing in this regard and how it determined his clinical focus: In her [playing], she had often been more aware of her own willing and motivation than the music itself. She found pleasure in using strength and withholding strength. I was now working to make her more conscious of the music in her drum beating. An example of the way this type of work was individually implemented can be seen in the following excerpt. In it, Audrey is working on playing the melodic rhythm to the song known as “Audrey’s Song:” Audio File: Audrey—Excerpt 4 (Session 5) -

Paul begins the song slowly, helping Audrey to play the initial syncopation in the Melodic Rhythm Audrey gets the Melodic Rhythm She resists the ritard slightly, instead playing a cymbal crash

Because of her musical sensitivity, working with Audrey presented particular challenges to Paul. Speaking about the music in her sessions, he said, “I could not give Audrey the musical experiences I knew she needed with a nursery song. To bring Audrey’s entire being into focus on the musical activity, in my improvisations and in the music I composed for her I had to match her musical gifts.” Cinderella In Session 5 on March 6, Clive and Paul introduced the story of Cinderella to Audrey.

They were motivated by a desire “to bring into her desolate environment something of beauty and mystery, something that would be a great and true emotional experience for her.” They note how the version of the story that they employed was not the popular “pumpkin” rendition, but the original version as collected by the Brothers Grimm. The difference is that in this latter version “the imagery and dramatic form of the original is more developed and has more depth.” Typically, Audrey acted the part of Cinderella, Clive engaged in a dramatic telling of the story and acted the other characters, and Paul wove together improvised and composed music to accompany the narrative and intensify its drama. In choosing a story like Cinderella as a vehicle for therapy, Clive and Paul were certainly influenced by their experiences at Sunfield and in touring Steiner Institutes in Europe the previous year. Clive observed how some of these institutions “were inspiring in their practices of art, movement, music, fairy tale, and drama.” He concurred with Steiner’s view that fairy tales “had an interior meaning” akin to perennial human myths and it is this belief which is the foundation for the various Nordoff-Robbins musical plays—such as “Pif-Paf-Poltrie”— characteristic of the group work. With Audrey, we see the first use of myth in Nordoff-Robbins individual therapy. A rough outline of the events of the version of Cinderella used with Audrey is as follows: As the story begins, Cinderella’s mother dies and her father takes a new wife, a woman with two of her own daughters. She is treated cruelly by these new family members and is forced to wear rags, work from morning to evening, and is continually mocked by them. When there is a great festival to be held by the king for his son to choose a bride, the stepmother twice empties lentils into the ashes promising Cinderella that she can go to the festival if she successfully picks the peas from the ashes. Cinderella does this with help from pigeons and turtledoves, but the stepmother reneges on her promise. Cinderella is quite distressed and visits her mother’s grave where a bird provides her with a gown for the wedding festival. On each day of the three-day festival, Cinderella dances with the king’s son who falls in love with her, but on each occasion she escapes him. On the third day, Cinderella loses her shoe as she is leaving and the king’s son vows to many the maiden whom it fits. Each sister temporarily fools him in turn by mutilating her foot to fit the shoe, but the birds—continuing to serve as Cinderella’s allies as they do throughout the story—expose the daughters’ subterfuge and Cinderella is subsequently chosen by the son. The sisters attend the wedding and have their eyes pecked out by the pigeons, being punished with blindness for their errant ways. There are three distinct, although related, vantage points from which to understand the significance of the story of “Cinderella” for Audrey. They include considering the effects upon Audrey of living in the events of the story through Clive’s dramatic telling, Paul’s music, and her own ability to take on the character of Cinderella; understanding the symbolic content of the story and its intrapsychic importance for Audrey; and, understanding the actual and symbolic content of the story in relation to Audrey’s real-life situation. Clive and Paul did not merely tell the story to Audrey but rather lived it with her. It was their ability to approach the story seriously and as a myth with an important, inherent, psychological experience which allowed her to use the story as a vehicle for the resolution of an

inner crisis leading to a dawning self-awareness: This story became a moral world in which Audrey was finding coherence and stability. In living in the story, she was not just living in fantasy. “Cinderella” is an imaginative picture of moral truths; these are universal. But besides the story itself, Audrey experienced the telling of it. This was not fantasy. The concentration, the care, and the strength of intention that we put into the telling of the story were human realities that Audrey needed to experience. Paul and Clive represented a value system unfamiliar to Audrey, yet one which she immediately grasped. These values were manifest in a variety of ways: their encouragement of creative self-expression and spontaneity; their support of Audrey’s growing self-awareness; their recognition of the inner side of life and Audrey’s capacity to appreciate it; and their willingness to be playfully and artistically subversive. The emergence of a moral world to which Audrey could anchor her self and her movement to psychological awareness and wholeness clashed with her life outside of her music therapy sessions. This was readily acknowledged by Clive and Paul: In our work we could not help but place Audrey in a position of conflict. We could influence her but could not influence the environment. The process of personality growth which we had begun, and which was the fundamental process in Audrey’s therapy, was virtually taking place on a battlefield. This process, intricate and difficult enough in itself, was further complicated by the conflict within Audrey, between our values and those of the environment. What was newly developing within her as a result of our work had to find its relationship to that that was already formed within her by the environment. The clash of values is apparent in how Paul and Clive contrasted their view of Audrey (in italics) with that held by other staff members (in quotation marks): “Audrey has temper tantrums.” “Audrey is very willful.” “Audrey is emotionally disturbed.” “Audrey is emotionally immature.” “Audrey is aggressive.”

She has a strong personality. She has courage. She is creative. She feels pleasure and takes pride in learning and helping. She accepts artistic discipline.

To understand the root of this conflict is to simultaneously understand the significance of “Cinderella” for Audrey. According to Bettelheim (1975), “‘Cinderella’ sets forth the steps in personality development required to reach self-fulfillment and presents them in fairy tale fashion so that every person can understand what is required of him to become a full human being” (p. 275). It thus provided a fitting vehicle to embark on a path of individuation for Audrey, who until that time had been prevented from doing so because of the absence of a suitably engaged parental figure. On a concrete level, it is easy to see why Audrey so closely identified with this story. The fact that Cinderella exists in a state of punishment parallels precisely how Audrey saw her own

lot in life. Similarly, Cinderella loses her birth mother; her father appears to distance himself from her predicament. She is left to fend for herself with an abusive, uncaring surrogate family (the stepmother and stepsisters) who can not see her inner beauty. Audrey’s institutionalization is the corresponding act of abandonment and the developmentally inappropriate placement where Audrey is misdiagnosed, misunderstood, and her beauty and gifts are not perceived corresponds to Cinderella’s condition. Yet the story does more than reflect Audrey’s actual reality; it holds out hope for the resolution of a seemingly intolerable situation and provides an inner guide for how this can be accomplished. Bettelheim (1975) demonstrates how the crises faced by Cinderella demand that the heroine develop, in sequence: basic trust, autonomy, initiative, industry, and identity. This is the path for achieving healthy psychological development. Because “without having first been forced to become a Cinderella the heroine would never have become the bride of the prince,” Bettelheim interprets the meaning of the story as holding that “in order to achieve personal identity and gain self-realization on the highest level . . . both are needed: the original good parents and the later `step’ parents” (p. 274). Thus for Audrey, the significance of the story was that her position was not only understood and experienced by others, but that it was a necessary precursor to her achieving happiness in life. The various motifs of the story which were particularly relevant for Audrey consist of a set of polarities which can be organized into two distinct groups. On one side (the left in the table below) are those which represent the developmental path Audrey was embarking upon and on the other side are those which represent her less developed self, particularly the part that had become habituated to her environment: Polarities in the Story of Cinderella Loved Seeing Sunlight Awareness Awakening Rewards Virtue

Unloved Blindness Darkness Unconsciousness Sleeping Punishments Evil

For example, at the end of the story the stepsisters have their eyes pecked out by two birds. While they lose their sight and are forced to live in darkness, in Audrey’s view, “the princess [Cinderella] had two bright eyes and the prince had two bright eyes and they could live in sunshine.” This element of the story, wherein the heroine is rewarded with seeing and light, was one with which Audrey was extremely concerned and she needed to be reassured that both the princess and prince had their two eyes at the end. The wicked stepmother is a figure allied against Cinderella’s transformation and thus, psychologically, she is an obstacle to emotional development. She does not want Cinderella to awaken into greater consciousness. Certainly there were parallels here with the staff whose primary way of relating to Audrey and her condition was to medicate her into a kind of semistupor where she would remain asleep or unconscious. In fact, the relationship between sleep

and unconsciousness on one side and waking into consciousness on the other was soon to play a primary role in Audrey’s therapy. The Crisis: “I Cleep” On and after March 20 we went through a period of crisis. How things would turn out we could not foresee. But we continued with our work, meeting each situation as it came. Original Session Notes A period of crisis in Audrey’s therapy began in Session 9 on March 20 and continued through Session 16 on April 24. It was precipitated by the following multileveled, intrapsychic, and interpersonal conflicts: between Clive and Paul’s values and those operative in the rest of Audrey’s environment; between Audrey’s emerging healthy self and the part of her conditioned by personal history and the environment to which she had adapted; and, between Clive and Paul’s firm insistence on Audrey to opt for a growth path and her own resistance to this path. One of the difficulties with the enactment of Cinderella was that it was not possible to fit an entire telling of the story into a single session. The story had to be built in stages so that the emotional fulfillment of the story’s ending was not experienced by Audrey in each session. On the other hand, the fact that the narrative must be prolonged across a number of sessions does serve to make the effect of the story more potent. It also challenged Audrey through impressing on her that the story represented a symbolic enactment. After participating eagerly in Cinderella for several weeks, in Session 9 Audrey suddenly refuses to act the part any more, perhaps motivated by the inability to bring the story to a satisfying emotional conclusion: Audrey:

Now I’m going to be the father and you’re [Clive] going to be the mother and you’re [Paul] going to be Cinderella.

Paul:

Oh we’re going to change it around!

Clive:

No, I think that’s enough for today. Audrey, on Wednesday we’re going to do Cinderella all over again, all right? You’re going to be Cinderella . . .

Audrey:

(distressed) No! No! No!

Paul/Clive:

(sung) And a new father for Cinderella is going to come. 1

Audrey gets upset and cries without tears. She repeatedly exclaims, “No, No, No! I not Cinderella!” Clive asks her if she wants to marry the prince and she answers, “Yes.” Clive then explains that at the end of the story Cinderella is no longer Cinderella when she marries the prince and becomes the princess. “You have to wait,” he says. Clive explains that everyone has to be a Cinderella before becoming a princess.2 The leaving is very difficult and Audrey shrieks and cries intensely to the “Good-bye Song.”

Many clinical issues arose in this session and Audrey’s refusal to be Cinderella could mean many things: a healthy desire to no longer be a victim in life; her way of gaining control over the sessions and her life by becoming the one of the powerful figures such as the stepmother; a recognition that Cinderella’s situation so closely mirrored her own that it was too painful to be Cinderella; or, a natural resting point in that Audrey had gone as far as she could in the psychological process of individuation that being Cinderella stimulated in her. Clive and Paul soon realized that it was necessary for them to soften their stance and to follow Audrey for a time rather than lead her. This had the unanticipated benefit of enhancing their relationship with her while opening up their conception of the therapeutic process: We realized that because of the crisis, because of the critical condition, there were times where we had to let her be and go with her. It was a kind of a broadening of the relationship from our side. Then another thing that was happening concurrently with this, in the Cinderella sessions, was that she was—as the crisis became more intense—resisting what we were doing and wanted to leave the story. And so we went along with her urgent suggestion. I was to play the piano, she was telling the story, Paul was to be Cinderella. What she seemed to feel from this . . . [was] that Paul needed to experience it from her point of view, from her position. Sessions 15 and 16, on April 19 and 24, respectively, represent the climax of Audrey’s crisis and the turning point in her therapy. Paul described the first of these sessions which provides some insight into his own process as a therapist: On April 19th, she began to try to achieve a deeply personal self-expression in the free use of her singing voice. This proved to be a fundamental therapeutic act for Audrey, one which was to continue in the course of therapy. In this first singing session both Audrey and I are seeking to find the right music for her. Audrey had arrived in a messy, worthless mood. After a period of drum beating, through which she straightened out some of this disorder, I deliberately introduced the kind of music I had used successfully with another child. Harmonically, this is romantic and tender. . . . I wanted to reach Audrey’s feelings, to get beneath the layer of meaninglessness she had brought in with her. In the following excerpt Paul has already introduced this romantic and rich music which he describes as being similar in style to Puccini. Audrey beats once on the drum and Paul sings immediately after the beating which encourages Audrey to sing a beautiful, emotionally powerful aria: Audio File: Audrey—Excerpt 5 (Session 15) -

Paul sings and Audrey joins him in singing Paul sings “I am very sad today,” and “I am going to cry today,” seeming to pick up on Audrey’s mood - Audrey incorporates some of Paul’s lyrics and becomes deeply involved in her singing After a few minutes, Audrey begins to tell a story about a “big, bad wolf who goes away”

and she sings in response to this. Her singing uses some of the intervals from the melody of “Audrey Is Dancing a Song.” Paul intervenes musically by leading into this song: Audio File: Audrey—Excerpt 6 (Session 15) -

Paul builds the music to a climax, changing keys and slowing the tempo The music climaxes and releases into “Audrey is Dancing a Song” She sings some of the lyrics but does not want to do it - Audrey says “Stop ... I sing, okay?” She resumes singing and then says: “It’s not w(r)ight!”3 After playing a few notes on the piano she begins singing again and Paul improvises music for this new singing The music is right for her and she sings in a very regal manner - Audrey makes a dramatic crying sound and speaks and then sings “I cry” a number of times

The following session—number 16 on April 24—was described by Clive and Paul as “the turning point in Audrey’s development in our therapy. This was the day we feel sure she sang herself out of the crisis.” Throughout the excerpt Audrey is very responsive to Paul’s harmonic changes. The quality of her voice suggests that the words express her emotional reality in a deeply true manner. Halfway through this session there is an improvised interlude in which Audrey asks to be Cinderella. Because there was not sufficient time to get into the story, Clive improvises an episode in which Cinderella is picking some flowers. (She has brought in two—illegally picked— peonies.) She cooperates immediately. Clive asks, “Who does Cinderella give them to?” and here is where the excerpt begins: Audio File: Audrey—Excerpt 7 (Session 16) -

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In response to Clive’s query, Paul’s music suggests the lead-in to a song or aria Audrey sings, “I sleep. I sleep. I deep so tight ... I climb up high in my tower. I deep. I deep.., in a bed.” The phrase ends here and Paul continues as Audrey pauses and allows him a few bars Audrey begins a second verse of “I deep.” She develops the melody and expands its upper and lower range Audrey: “I deep, I’m crying, I’m crying, I’m crying, somebody wake me up, I’m crying, I’m crying, I deep, I cry, I sleep.” Paul changes to a dance style on the piano. This change in musical mood offers her the opportunity to, in Paul’s words, “embellish her situation.” Paul plays for two bars and Audrey then beautifully picks up on his phrasing to sing, “Listen, listen, listen, listen, I deep nice!” There is a brief pause in the music, Paul interrupts the dance tempo, and Audrey sings dramatically Paul reintroduces a dance rhythm as the excerpt ends

Paul and Clive subsequently described the significance of this session:

“Sleeping” and “crying,” what could these words mean for the real Audrey, the gifted individuality with such great potentials? She had been asleep, was still asleep, and wanted to sleep, for waking meant crying. Although these words are important from the psychiatric point of view, to us they are less important than the way in which she had sung them. The words, the thoughts, the feelings, were connected with her past experiences and the present situation. She was able not only to sing all this, but in doing so disclosed great musical abilities around which we knew we could build our work in the future; for musically, this aria is a wonder, an aria it must be called. In it the elements fundamental to musical form are freely and beautifully used. Audrey sings sequences. She develops her musical ideas. She ends the first part with her own cadence and after a musical interlude of two measures, she enters on the up beat at the perfect musical moment for an entrance. She introduces a new theme and a new idea with the words, “I cry.” When I [Paul] attempt to lighten the mood of the aria, she follows my tempo changes, adapting the rhythm of her words and phrases to them. Later she leads the music back to her original theme: “I deep.” This is a musical talent of a very high order. It fills one with humility to hear Audrey beginning to use this talent as a means for finding her way into the world around her. This is more than the release of inner tension, although that is part of the experience. It is also the stirring of an awareness of her essential being, a glimpse of fundamental self-knowledge. The significance and power of Audrey’s personal statement was not immediately apparent and Clive detailed how it slowly revealed itself over time: It wasn’t for many years that we realized that this was a clinical paradox, because in mustering up the powers, the capacities, the control to marshal her flaky language abilities into making this statement with great musical care—what was its purpose? It was telling us to leave her alone. And in doing that the therapy had achieved its goal! It had brought her out of where she was asleep. She had awakened herself in singing, “Let me sleep.” That’s the wonderful paradox of that story. Often in life I find that when you get to the stage where you finally can say something, you transcend it. Many of the polarities come together in these realizations. For Audrey, sleeping and darkness could represent a descent back into unconsciousness and a yielding to the obstacles in her path of individuation. Being awake, being aware, and being in light are all related and represent her path of acquiring self-awareness characteristic of psychological development. What is most significant in terms of illuminating the mechanisms of music therapy is contained in the paradox noted by Clive: Merely looking at the linguistic content of Audrey’s statement leads one to believe that she is resisting the growth path and prefers to be left to “sleep.” Yet it is in the constellation of Audrey’s artistic sensitivities combined with her ability to form her personal statement on such an advanced aesthetic level in combination with Paul’s music that one finds the true significance of her statement. The words say, Let me sleep; the music in

Audrey’s voice says, I am a powerful, whole human being wakening into self-awareness. Significantly, there is no verbal insight or processing attempted as the transformation takes place purely on a musical level. Keep in mind the words of Paul and Clive that Audrey “sung herself out of the crisis.” “Let’s Do Some Work!” Following these overtly dramatic sessions, much of Audrey’s clinical process continued to be work-directed. As I mentioned previously, the concept of work was a crucial component in her clinical process; it was her salvation as well as her bane. It existed on many levels and in many areas of her therapy. There is the seemingly meaningless work imposed upon Cinderella by her stepmother, seen in her commands to Cinderella to pick peas out of the ashes in the fireplace. Here, work is intended to imprison Cinderella and impede her development and to the extent that Audrey identified with Cinderella, work took on this negative connotation. Yet, as Cinderella, she also was able to invest meaning into some of the work imposed on her, doing it with care and concentration as she transforms this meaningless work into something of significance by choosing life (the peas) from death (the ashes). Developing diligence in work is clearly part of the message of Cinderella as Bettelheim observes that Cinderella must develop industry; it is also part of the healthy development of the self. Part of Audrey’s relationship to Paul and Clive was defined by their insistence that she work in therapy. Yet what they offered to her was meaningful work oriented toward achieving her creative self-expression and self-actualization. So when looked at as an aspect of resistiveness, Audrey reacted to Paul and Clive as work demanders; in its participatory aspect, Audrey saw Paul and Clive in a positive light as work providers, or even as coworkers. Some of the areas that Paul and Clive drove Audrey to work on include the following musical skills: learning to play rhythmic figures and in various meters on the drum; learning song lyrics and melodies; memorizing and correctly enacting eisythmy exercises; and, focusing on singing with emotional investment that was modulated by aesthetic sensitivity. Paul and Clive were motivated by the belief that, as Clive described it, “work is related to emotion and if you can’t do your work you get emotionally upset. If you can do your work, it’s already satisfying.” In their view, Audrey’s progress in therapy would be determined by the degree to which they could engage her in meaningful work. Clive felt that this was confirmed by Audrey’s response. She became strongly drawn to the artistic work embodied in learning processes she found satisfying and often would ask to continue work on a particular skill, often saying in her own way, “Let’s twy again, twy again!” Elsewhere I have discussed the relevance of John Dewey’s aesthetic philosophy for the Nordoff-Robbins approach (Aigen, 1994). In their concept of work, Paul Nordoff and Clive Robbins describe an activity that has parallels with the ideas of Dewey, particularly in their conception that work, properly undertaken with care and reverence, is a means for selfactualization. It is not an activity undertaken toward an external end but is instead its own reward. For Dewey, all work undertaken with this attitude has an aesthetic component whether or not it is overtly artistic. In their work with Audrey, Paul and Clive demonstrate how it is work that gives life meaning; and for a child with Audrey’s sensitivity and talents, conducting this work

through an art form is the only vehicle for activating her capacity for meaningful work. Of course, as human beings therapists can often err regarding judgments as to which avenues represent productive work for a given client. At times, the team seemed to overemphasize the idea of working and would then divert Audrey from avenues which would subsequently prove to be productive. At times, stimulating a child to extrinsic work—focusing on active, observable expression—could obscure the fact that intrinsic or internal work was going on. Clive agreed that Paul and he exhibited a certain tendency to have a judgmental attitude toward behaviors that were stemming from pathology. Not because they were inappropriate socially, but because they were standing in the way of the child’s self-realization. So quite often this “Let’s get down to work!” was to brush aside or to suppress or to say “No!” to these other behaviors—where the child could take that— so that we could then get onto that track of activity which was self-actualizing. This aspect of their clinical work was one of the elements that underwent change through time. Clive felt that, “Paul’s and my behavior and judgment of this changed a lot. I think it changed healthily—we became broader.” Their ability to be less demanding toward eliciting a focused work response acquired greater clinical relevance when their work began to include a higher proportion of autistic children whose responses could be less overt than the emotionally disturbed and developmentally delayed children that they worked with originally. Consider how Audrey’s work gets done vocally in the following excerpt from Session 22 on May 22 in spite of the team’s insistence that she play the drum: Paul and Audrey are both cross and Paul explains why, showing no patience for Audrey’s mood. He is very firm with her. Paul: Now get to the drum and do some work. Audrey improvises on the drum with Paul, follows a ritard, and engages in her longest spell of beating up until this point. Paul plays three against two in the key of C minor to which she had sung twice previously and this motivates Audrey to leave the drum and sing. The singing feels very special, as if it was coming from a deeper, more authentic, healthier place within Audrey. At Clive’s urging to do “work” Audrey returns to the drum briefly, but again spontaneously stops playing and returns to some beautiful and responsive singing. At the end, Paul sings, “Audrey, I love you.” Paul described the musical aspects of this singing in his notes from the session: Her singing [first example] was very beautiful and operatic in character. With ease, she sang up to a high C; then back to the drum, to do some work But after a little beating, she began to

sing again [second example], beginning with a long held G, over which I played dissonant intervals. She began to sing in her “language.” She sang a structured song in a perfect musical form with character and mood. The “language” is very much like the languages I have made up in playing with my children. Here was an instance where the therapy team was so eager to have Audrey work that they diverted her from singing to beating the drum, although she eventually returned to singing where her more important work actually took place. Yet Audrey’s motivation for self-expression cannot be denied: she needed to sing on this day, needed to do her work in this area, and Paul and Clive allow it to happen when this becomes evident. Additionally, their affection for Audrey is evident in this session and Paul is not bashful about singing this love and putting it into the music of the session, not in a melodramatic or trite way but as a natural element of their relationship and hence of the therapeutic process. During the course of her therapy, Audrey’s view toward working evolved and allowed her to make artistic statements with increasing degrees of aesthetic value. The role of work within the therapeutic triad changed. In Session 21, Paul adopts a self-mocking attitude toward his own expectations: Audrey does something “naughty” and is told by Paul, who laughs heartily, “You’re too little for that!” Yet, in contrast to previous interactions of a similar nature, this was responded to humorously and not punitively. Paul says to Audrey, “You know what I want! I want your un-di-vided attention, Miss P.” He continues in an exaggerated, stiff, authoritarian voice, “We must do some work!” Audrey laughs heartily in response. Clive playfully says, “Audrey’s never going to get anywhere. She’s going to find ways to waste time for the rest of her life.” Some funny, dissonant music follows in response to the tension between Clive and Audrey regarding her manners or lack thereof. Paul exhibited a warm, self-depreciating attitude regarding the need to be an authority figure. He acted the authority, while simultaneously mocking it, or more accurately, Audrey’s continued need for him to act in this role. In this way, he seems to have used humor to build the relationship into a more reciprocal one where Audrey no longer needed to see Clive and him as punitive authority figures. As her therapy progressed, Audrey began expressing positive feelings about work, often requesting to work in her sessions. This new attitude toward work was one of the most significant changes in Audrey.4 In the following clinical example from Session 27 on June 14, Audrey expresses a reluctance to follow Paul’s direction. Paul beautifully integrates her resistiveness into participation and Audrey makes a powerful statement about her feelings towards work. Paul plays “Audrey Is Dancing a Song.” Audrey says that she wants a “new song” and Paul tells her to play this one first, which she refuses. Then Paul plays and sings, “She won’t sing. She won’t dance. She won’t beat the drum with me. What will I do with Audrey?” He brings her

resistiveness beautifully into the music. Audrey returns to singing her own song and persists in saying “I want a new song!” Paul and Clive instruct her to write in a manuscript book and she says that the new song is “Audrey Can Work.” [!] What follows is an excellent example of cooperative working to create a new song, with Audrey singing in a beautifully integrated, confident, and sensitive manner. Paul contributes very rich harmonic variations to complement her simple repeated melody and words. Clive guides the lyric creation that yet comes from Audrey: Audio File: Audrey—Excerpt 8 (Session 27) -

Audrey says “a new one.” Clive asks, “What song, Audrey?” and instructs her to write and sing a song Audrey sings “Audrey can work” and plays a few notes on the piano Paul takes this up and improvises a song on these lyrics Clive helps to guide the lyric creation Audrey drives horses, Audrey drives a car, Audrey a pretty girl She misunderstands Clive’s direction to sing a “different tune” Audrey’s a pretty girl

“I Be a Flowers All the Time” In the latter part of her therapy, the symbols of birds, flowers, and the sun assumed more importance for Audrey. The song that preceded Audrey’s “I deep” singing was the “Flower Song” and Audrey took to bringing flowers to her sessions, as was noted in the following description from Clive’s notes from Session 21 on May 17: As Audrey came running to the session, she passed the peony bushes. She stopped, and after looking around to see that she was unobserved, quickly picked three blooms and brought them to the session with her. I had picked and brought two small sprigs of wildflowers. As she offered her flowers to our noses for us to savor the scent, I offered my flowers to her. Without a word she took them and put them with hers. The reciprocity here was important as Audrey felt a need to bring something of beauty to share with Paul and Clive. Her presentation of this was done silently and with a seriousness that conveyed the significance of the act for her. In Session 24 on May 29 Audrey had brought in two flowers. With Clive’s encouragement, she sings about the flowers and then dances with them: Audio File: Audrey—Excerpt 9 (Session 24) -

Clive requests that Audrey sing about her beautiful flowers Audrey sings: Flowers singing, flowers singing, [repeated] Two flowers singing, I be a flowers, I be a flowers, I be a flowers all the time, I made a flowers, I made a flowers

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She develops the melody

After the excerpt ends the music continues and Audrey rhythmically speaks the following: I made a flowers, I became, some big white flowers, somebody pick me up . . . and I’m thankful ... I pretty flowers, I made flowers Her love for flowers signified to Paul and Clive that “it was clear that Audrey was the flowers.” The power of the flower symbol for Audrey lay in its representation of the unfolding of her being and this may be why she resonated so powerfully with it. The flower symbol is also important for Paul and Clive as, in a metaphoric sense, they see their work in terms of nurturing their clients’ inner beings so that they can open to the world, much as a flower does when it blossoms in the right conditions to do so. Clive discussed Audrey’s interest in flowers as well as the connection this held to the clash of values between the therapy team and the day-care staff of Audrey’s residence: One of the things is that when Audrey sings, “Flowers, flowers, Uncle Paul can pick flowers because he’s bad and good,” it has a double meaning [See excerpt #11]. It’s “bad” to pick flowers, it’s the “wrong” behavior to run outside which she loved to do. But what she’s also referring to is the flowers in a spiritual sense, that you pick. The flowers are these beings in the children that can flower instead of being wilted and shriveled, they flower and Uncle Paul can pick flowers. [He’s] “bad” because he doesn’t fit convention, he doesn’t go with conventions and norms, he steps outside therefore he’s bad. And it’s because he’s different, “dares to be different,” to use Maslow’s phrase. Because we were then getting criticized about this time for our “crude” methods in stimulating the children. This was not by the psychiatric staff but by some of the daycare workers and the matron of the unit who criticized us saying: “These children are brain injured, you mustn’t challenge them, they can’t stand it, it’s cruel.” So let’s entertain and sedate. So our methods were “crude.” It’s incredible there can be such different perceptions. A few minutes after the “Flower Song” the music becomes a waltz to which Audrey sings ascending glissandi and ends with a descending one. Paul and Clive are thrilled by her spontaneity. Audrey sings “Good-bye” without being directly encouraged. She takes Paul’s suggestion to sing “loud but beautifully” and adjusts her voice accordingly. Paul described Audrey’s singing and is singularly moved by the relatively brief piece of music improvised by her: What followed on this same day is the most remarkable vocal improvisation I have ever heard. To the simple ascending arpeggio in the piano, Audrey sings a counterpoint suiting the tempo and character of the music. She sings with a delicacy and a perfect awareness of the final cadence. We call this “Audrey’s Bird Song.” Audio File: Audrey—Excerpt 10 (Session 24)

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Paul plays a descending phrase which sounds like an introduction to a song Paul develops a waltz and Audrey sings along Audrey sings ascending glissandi simultaneously with Paul’s piano playing Audrey ends with Paul on a descending glissando

Paul often whistled melodic accompaniments for Audrey and the singing that Paul and Clive felt to be so remarkable were certainly birdlike and described as such by them. The freedom of the bird and the unfolding of the flower both provided concrete symbols of the psychological transformation and personal freedom Audrey was acquiring through music therapy. The last of the three important symbols of this period was the sun. At the end of Session 27 Audrey sings to the sun at Clive’s direction: Audio File: Audrey—Excerpt 11 (Session 27) -

Clive draws Audrey’s attention to the sun shining She sings “Hail sun. Shine sun. Sun, sun, sun, shine.” Paul supports her melody Clive directs Audrey’s attention to the flowers She sings “Flowers, flowers. Uncle Paul can pick flowers because he’s been bad and good, because he been bad. Oh! Uncle Paul been bad.”

Her ambivalent statement about Uncle Paul being bad or good for picking flowers (and by extension, what exactly is “bad” and “good”) can be attributed to the clash of values between those manifest in her therapy sessions and those which were active in much of the rest of her daily life. Yet the reverence in her voice as she spontaneously sings about the sun also attests to the path of light and awareness that she has chosen. Moving to Wichita: The Institute of Logopedics Due to a variety of factors—with conflict in treatment philosophy being one of the more important ones—Paul and Clive began considering not returning to Devereux in the fall of 1961 when the project should have resumed after the summer break They visited the Institute of Logopedics in Wichita, Kansas on June 26, 1961 because its director, Dr. Martin Palmer, had expressed great interest in their work. Clive described Paul’s and his frame of mind at this time, alluding to the conflict they were experiencing at Devereux: By this time we were very worried about Audrey. We were in a bit of a conflict. The leading psychiatric consultant—actually the man who had been Paul’s analyst, and who was also a good friend—said, “Do you realize that if you take her away from here you’re threatening her sanity?” And we said, “But we believe just the opposite, if we leave her here she’ll go insane.” And [we stated] that she has to go somewhere better and broader, somewhere where we could continue our work with her.

In August of 1961, Paul and Clive solidified plans to leave Pennsylvania and take up their clinical work at the Institute of Logopedics. They felt so committed to Audrey that they predicated their acceptance of the positions in Wichita on a place being made for Audrey at the Institute. Because Audrey had speech delays, she could be given a diagnosis that would allow her to be treated at the Institute. They also managed to convince her parents of the inappropriateness of her placement and the benefits that would accrue to her by being placed in a setting where her new skills would be recognized and she could be offered appropriate challenges. Audrey was greatly excited by the possibilities of the move because she was so unhappy where she was. Socially, Clive recognized that Audrey needed both the challenge posed by interacting with the higher-functioning children at the Institute of Logopedics, as well as the opportunity to interact with those children who were not so ill and violence prone. Audrey was frightened of some of the children at Devereux and continued to have nightmares about them into her adult life. Clive reported that Audrey’s mother confirmed that “when she got Audrey out of Devereux she said that [the] chartered flight from Philadelphia to Chicago was one of the happiest experiences she’d ever had with Audrey. Audrey was so delighted to be leaving and looking forward to meeting us.” The Ending of Therapy: “My Heart Is Broken” In the fall of 1961, after giving Audrey three individual music therapy sessions at the new location in Wichita, Paul and Clive “decided it was no longer right to focus an exclusive relationship around the three of [them] when there were all these children to play with.” She was then put in two music therapy groups: one was with three boys who possessed skills sufficient to work on sophisticated pieces arranged for music therapy; in the other group the children were significantly more disabled and Audrey assumed the role of an assistant. This role was not merely a fanciful title offered to Audrey but instead it reflected her actual functioning in the group. March 24, 1962 was Paul and Clive’s last day at the Institute of Logopedics and on this day they were conducting a demonstration of their work for approximately 30 field workers attached to the Institute. The three boys from the group and Audrey were to assist in the demonstration. Paul described how Audrey spontaneously reacted to the situation and Paul and Clive’s leaving through beautiful and painfully poignant singing. The lyrics sung by Audrey include the phrases: “My stomach hurts, what shall we do? What shall we do with my heart? My heart is broken”: While the boys set up the instruments, Audrey stood on the piano and sang. She knew that we were leaving the next day and she was troubled and upset. She had greeted us that morning by saying, “My stomach hurts.” I began to sing these words and Audrey’s aria followed. We had been improvising for about 10 minutes when the audience began to arrive. We continued. Audrey did not stop. She continued to improvise quietly and thoughtfully. The aria that you will hear, for aria it truly is, improvised by an 8-year-old child, is an incredible piece of music.

Audio File: Audrey—Excerpt 12. “What Shall We Do? My Stomach Hurts” -

Paul and Audrey sing the lyrics Audrey has created in C minor, “What shall we do?” Paul sings “Her stomach hurts, What shall we do?” and then they sing together Audrey sings alone “My stomach hurts” Paul has modulated to a major key and Audrey sings “What shall we do?” over this Change to minor key which suits Audrey’s tragic emotion Audrey leads a series of crescendi and climaxes Audrey sings “Don’t cry, don’t cry. Please don’t cry, cry, cry” - The music reaches a temporary rest Paul sings, “Her heart is broken,” and Audrey responds, “My heart is broken” Duet singing on “What shall we do?” which leads to a climax out of a crescendo [Some noises as the audience is arriving] Paul plays lyrically in the treble and Audrey follows his playing Beautiful, controlled, melodic singing by Audrey holding the vowel sound on the word “do” which leads to another temporary resting point in the music

Paul and Clive noted that Audrey frequently desired to dominate social situations, an urge stimulated by her proclivity to assume a leadership role. However, her impaired sense of social awareness and limited communication skills had typically functioned to frustrate her desires and needs in this area. Following the impromptu aria above, Audrey turned to the audience members, addressed them directly, and tried to get them to sing. She had great difficulties in verbally communicating her desire to the audience and her initial attempt to lead the singing fails. Clive and Paul describe the significance of her second, this time successful attempt: As you listen to what happens, bear in mind that it is just one year since the crisis. Remember that incapacitated child with no social experience, lacking in self-control and purposeful intention, then you will better appreciate what Audrey is able to achieve on this day. Audio File: Audrey—Excerpt 13. “Something Is Going to Happen” -

After Audrey asks the audience to sing, Clive asks what they should sing. Audrey wants to sing “What Shall We Do?” Paul suggests the song “Something is Going to Happen,” Audrey agrees to this and sings it with Paul and Clive Audrey addresses the audience one final time and, together with Paul and Clive, is able to get them to sing the song The Significance of Audrey’s Growth Process

The Relationship Among Cognition, Skills, and Affect Investigations into contemporary Nordoff-Robbins work reveal a hierarchy of levels of relationship to music, ranging from concrete musical skills to the ability to express and transform deep-seated emotions (Aigen, 1995). Audrey’s growth can be well understood in terms of this hierarchy with the clinical focus upon concrete cognitive skills forming the foundation for enhanced self-expression, which in turn facilitated her emotional development and selfactualization. On the most basic level was Audrey’s ability to take instruction and work for increasing lengths of time, from barely a few minutes at the outset of her therapy to the ability to sustain an involved focus for entire sessions as her therapy progressed. This cognitive ability to focus on tasks was seen in a variety of ways: engaging in eurythmy exercises consisting of sophisticated sequences of movements; becoming able to drum various rhythmic figures and in different time signatures; and, staying involved in the Cinderella story for complete sessions while acting and singing the various parts. These developing capacities allowed her to develop sufficient selfdiscipline to utilize her innate talents and sensitivities in developing deeper levels of selfexpression. Again, to relate the basics of Nordoff-Robbins approach to the aesthetic thought of John Dewey, Dewey believes that it is through the mediation of aesthetic forms and artistic tools that emotional discharge becomes transformed into emotional self-expression. The focus on work and musical skill acquisition is what allowed Audrey to engage on this transformational path. Clive observed an interesting connection in this regard. Prior to Audrey’s “I deep” session, she had been placed in a music therapy group that was enacting the Nordoff-Robbins musical working game “Pif-Paf-Poltrie,” the concrete events of which require the protagonist of the story to construct a broom from twigs scattered at the story’s outset and clean up leaves that have been spread around the room. On a psychological level, the important themes involve creating order from disorder while finding the courage to undertake a challenge, through the exercising of purpose, concentration, attentiveness, goodwill, and responsibility. Immediately preceding the session in which Audrey sang herself out of the crisis (“I deep”) she had an opportunity to act the central role of “Pif,” focusing on the idea of work and seeing Pif’s tasks to their completion. Although it is not possible to establish a causal relationship by attributing Audrey’s ability to create an aria in which she “sang herself out of her crisis” to her participation in “Pif-Paf-Poltrie,” Clive nonetheless noted that to see a long process through properly is immediately related to creating an aria from beginning to end and getting your expression said. It’s seeing something through. It’s like when we have to write a statement and develop a concept and round it out. That’s a “Pif-Paf.” And all these themes are related, this integration that takes place through work, through the will. The implication here is that the concrete work engaged in by Audrey facilitated her selfexpression which in turn gave her the abilities to move through and transcend her personal crises. This is an important developmental sequence as it reveals the connection between cognitive skills, musical skills, creative self-expression, and growth in therapy. The initial skills

were worked on not for their own sake, but to stimulate the subsequent emotional and developmental processes. Relationship Their experience with Audrey had a profound effect upon what Paul Nordoff and Clive Robbins considered to be possible through their approach to music therapy; in some ways, it served as a template that stretched the boundaries of their techniques and theories. The depth and intensity of Audrey’s expression—particularly her profound grief—taught Clive and Paul about the human capacities stimulated by their work and the pain and suffering thereby released. Her expression of pain provided important information about what Audrey was truly capable of achieving: Previous to [Session 7], when we had said good-bye to Audrey, a kind of habitual demonstration tantrum had taken place. In it, teasing, regret, disobedience, and perversity were mixed up in a fragmentary, meaningless way; after the “Cinderella” the good-bye was very different. For the first time Audrey was showing deeply felt grief. This meant many things to us: it meant that we had reached Audrey, that our work was of more than superficial significance to her. It showed us too that Audrey had this capacity for warmth and love, and that there was something enduring in Audrey that we could hope to develop. Similarly, because such deep feelings were released and such primary psychological and developmental processes were activated, Clive observed that Audrey’s therapy “taught us that our work could induce crisis.” Paul and Clive learned that their therapy would not just consist of circumventing their clients’ pathology through bringing them positive experiences, but that in some cases the therapy would assume the terrain of a battlefield as various psychological and social conflicts would need to be addressed and resolved to allow their clients’ process of selfactualization to proceed. Concomitantly with stretching the boundaries of the clinical process for the clients was the deepening of the relationship between therapists and clients in their work. Because of the depth of feeling maintained by Paul and Clive toward Audrey, their support in seeing her crisis through to its resolution, their willingness to assume the role of unofficial guardians for Audrey in light of the absence of her parents, the depth of the aesthetic contact afforded by Audrey’s unique abilities, and the ever-increasing mutuality of the three-way relationship, they were led to a conception of the therapists-client relationship that comprise the upper three levels of “Scale I. Child—Therapists Relationship in Musical Activity,” published in Creative Music Therapy (Nordoff & Robbins, 1977).5 These include: Level 8 in which “the child is intently committed to the flexible expressiveness and variety of his active musical experiences . . . [and] personally expressive situations arise spontaneously” (p. 185); Level 9 in which “the child’s confidence in the total situation [of the music therapy session] is completely secure. He identifies himself with his music making and sustains well-ordered, stable, musical objectives in a spirit of mutual partnership” (p. 187); and Level 10, in which the child establishes “functional independence in group work” (p.

182).

The depth of relationship achieved by Audrey with Paul and Clive was transferred by her to the group settings where she became a bona fide helper. The achievement of being able to work in a concrete way afforded Audrey a sense of purpose and meaning in life. Their experience with Audrey’s potent involvement with work was the fertile ground for the team’s more metaphysical ideas about work, love, spirituality, and where their therapy fitted into the lives of disabled children in a fundamental way. Underlying their clinical approach is a four-level concept of love that is activated by work or meaningful activity. Clive discusses this in detail: You have got four loves: You’ve got the love of self; you’ve got the love of work; you’ve got the love of service, and you’ve got what I tend to call the ultimate love, which you could call the love of God, the love of truth, of reality, the love of life, if you like. But big life, with everybody in it. A creative person and a forceful person, what they love to do is their work. But your work can be very egotistic. So, the next step is love of service. In other words, you modify your way to work to suit the needs of others. But sometimes the needs of others are also self-indulgent, so then you come down to the ultimate sort of balance. And it’s there in one’s self. But love of self is not narcissism, it’s really appreciating that you are a self, that you have the gifts, that you have existence, that you are a person and identity, an individual. Of course, you can get involved in love of self and [stay fixed in a movement between love of self and love of work]. So in a way it was a very good thing to move Audrey into this interchange [to the level of love of service]. While Audrey’s individual therapy developed her capacity to experience first the love of self and subsequently the love of work, her roles as a careful performer in one group and as a helper with multiply-disabled children in the other brought her to the subsequent levels of love of service and the love of truth or life. Through these activities, the Nordoff-Robbins approach to music therapy endeavors to provide disabled children with the ultimate experiences which give our lives meaning and which are rarely considered to be available to such individuals because of their limitations: It’s so easy in music, it’s so easy in group work, to bring a child into a love of work. And then in mixing with the others to produce the piece, it’s a love of service. Then in creating the piece and finishing it implies a certain reverence, dedication. It’s religious and that’s why love of God is in there. It’s at the basis of a reverence for life. Postscript: In Audrey’s Words In 1974, when Audrey was 21 years old, Paul and Clive visited her in California as they were returning to the United States from Australia and New Zealand. Clive described their meeting: The first day we got there her younger brother John was in the house and Audrey introduced us as her music therapy friends. Her younger brother said, “Well, what’s music therapy?” And Audrey said, “Listen, John. There are some disadvantaged people who can’t make use of themselves, their selves, to do things. These two guys help them through music to become who

they are and do these things.” And then I showed her this book in its hardback edition (Therapy in Music for Handicapped Children) and she looked at the pictures of herself and said, “Look, John, that’s the real me.” These were the pictures of her improvising vocally. “That’s the real me,” she said. In April 1991 Clive received a letter from Audrey. The discussion of her therapy concludes with a brief excerpt from it: In my later years at the Institute I did go to a normal Christian school and I made it through the school work with much difficulties because of my nose allergies problems that interfered with my studies. And when I was staying with the couple who had two kids at the time I went to regular grammar and junior high school and finally I left to go live with my family. I’ve made headways along the way but not without much struggle and difficulties and I had real valleys in adjusting to the outside world ever since. But without you and Uncle Paul rescuing me with music therapy I, as you one time said, would have gone completely insane at Devereux and could have spent the rest of my life in mental institutions and probably had things done to me in those institutions that would have ended the possibilities of ever having a fighting chance of making it to the quality of life that I have this very moment. References Aigen, K. (1994). The aesthetic foundation of clinical theory: An underlying basis of NordoffRobbins music therapy. In C. Kenny (Ed.) Listening, Playing and Creating: Essays on the Power of Sound. Albany NY: State University of New York Press. Kestenberg, J. (1975). Children and Parents: Psychoanalytic Studies in Development. New York: Jason Aronson. Lee, C. A. (1996). Music at the Edge: The Music Therapy Experiences of a Musician with AIDS. London: Routledge. Mahler, M., Pine, F., & Bergman, A. (1975). The Psychological Birth of the Human Infant. New York: Basic Books. Nordoff, P. & Robbins. C. (1971). Therapy in Music for Handicapped Children. Gilsum NH: Barcelona Publishers. Pavlicevic, M. (1995). Music and emotion: Aspects of music therapy research. In A. Gilroy & C. Lee (Eds.), Art and Music Therapy and Research. London: Routledge. Storr, A. (1992). Music and the Mind. New York: The Free Press.

Taken from: Aigen, K. (1998). Paths of Development in Nordoff-Robbins Music Therapy. Gilsum NH: Barcelona Publishers.

CASE TWO Good-bye, Indu: The Aesthetic Form of the Music Therapy Session Kenneth Aigen (Case Material from Paul Nordoff and Clive Tobbins Two Letters to Nordoff and Robbins October 17, 1961 To: Dr. Nordoff and Mr. Robbins From: Dr. Palmer I thought that you would be interested to know that Mr. N., who cares for Indu, called at our house Sunday, and among other things he told me that over the weekend he took Indu to the Institute and that he loved to go into the classrooms now and hated to come home again. This is a very great change in his behavior. Mr. N says he particularly always wanted to get into the room where you were teaching him. I thought you would like to know this, and you are apparently reaching this boy. July 5, 1962 To: Dr. Nordoff From: Gopala M. (Indu’s Father) I hope you received my previous letter. I was so happy to hear from you. I am glad you are better. What you did for Indu during a very brief period was something unique and outstanding. I do hope it will be possible for you to go back to Wichita and take up the threads again. It is great and grand work you and Mr. Robbins are doing. May God give you strength and happiness. Yours ever sincerely, Gopala M (Indu’s father)

Introduction The music created with and for Indu is among the most passionate and powerful expressions of Paul Nordoff’s clinical vision. It conveys the sense that Paul felt that he could literally invoke Indu into being through the sheer power of the music. This belief stimulated Paul to create a complete and unique musical world, more encompassing than typically experienced when listening to music created for therapeutic ends. In March 1995, Clive Robbins commented: “Paul considered this to be his most advanced work, his doctoral level work. There is an alchemy in it; there is a transforming process in it that is also transforming Paul.” The clinical work with Indu was unique in many ways. First, except for an individually composed “Good-bye” song, all of his 41 sessions were improvised from beginning to end; there were no other songs or compositions used in his therapy.1 Not only were the sessions completely improvised, they took the form of a seamless musical creation, moving across a wide range of moods and emotions in an aesthetically and structurally integrated manner. The integrated, seamless nature of the sessions with Indu manifested a particular repeating form. Because the sessions were comprised almost exclusively of improvisations the form was more readily apprehendable than if structured songs were used. In this chapter, we will look more at the session form—and, hence, upon the therapists’ interventions—than upon Indu’s particular process of development. While this process certainly merits its own study, it will only be considered here in detail sufficient to provide a context for the discussion of the session form and the variety of clinical functions of music seen in this work. Some of these functions were seen most clearly and in their most developed form with Indu. In considering them in the light of Indu’s process, we have a unique opportunity to consider some of the most important and powerfully rendered aspects of Paul Nordoff’s clinical artistry. Synopsis of Indu’s Therapy Indu was born in India with cerebral palsy and suffered from a variety of medical conditions in his first two years—including whooping cough, mumps, chicken pox, and severe convulsions—which exacerbated the delays in his development. Sixteen years old when beginning music therapy, Indu exhibited severe expressive and receptive aphasia, his IQ was tested at a level of less than 20, and his mental development was below the level of a one-yearold. Because of the extent of his difficulties and his extraordinarily strong response to music— particularly passionate piano playing—he was seen in music therapy three times weekly between September 27, 1961 and March 21, 1962 for a total of 41 sessions. An interesting pattern emerged from the study of the first 21 of these. Every four sessions, beginning in Session 5, Indu was able to achieve a qualitative leap in his playing: this was seen in Sessions 5, 9, 13, 17, and 21. Each time, this advance was followed by three sessions where the newly acquired expressive ability was assimilated until the next development occurred. I cannot attribute any special significance to this pattern, other than to note it as Indu’s rhythm of development. Indu displayed a wide variation between his expressive and receptive capacities for

participating in music, although this gap narrowed over time. He came to music therapy already having demonstrated an affinity for music as well as a capacity to enjoy listening to it, yet his ability to participate actively in music was initially quite minimal. His growth can be seen through the way that his capacity to experience music receptively was transferred into increased musical activity, first through drumming and then through vocalizing and playing the piano. The athetosis (uncontrolled movements) caused by Indu’s cerebral palsy led Paul and Clive to abandon efforts to use sticks, cymbals, and gongs, and to encourage him to participate by beating a drum with the palm of either hand. He frequently felt impulses to beat and would either join the music or indicate his desire to have Paul play, if there was a pause, by playing the drum. Yet, he could not sustain participation and when he would begin beating the drum one of two things would typically occur: either a muscular tremor would overcome Indu’s deliberate playing or he would withdraw from the activity he had initiated and his beating would quickly stop. Through the first eight sessions, Indu’s rhythmic responses were sporadic, his beating impulsive and erratic if forceful, and yet he found ways to convey that he was in the music and listening intelligently by, for example, playing two beats to Paul’s two beats in Session 4. In Sessions 6 and 7 Indu sustained brief periods of organized beating, building up to his breakthrough in this area of functioning. Twice in Session 6 Indu was able to join in the Basic Beat of the music. The second of these exchanges was described in the session notes: One time after Mr. Robbins had helped and encouraged the hand-beating, as before, he [Indu] beat the drum for quite a long time with his right hand. I improvised in the tempo and for a very short time we were together, with Indu beating resolutely. This was closely observed by Mr. Robbins, who felt quite definitely that Indu was having the first experience of the active relationship with the music. For this short time Indu was experiencing the Basic Beat. In Session 7, Paul became more insistent, using dissonance and forceful, driving rhythms. Indu responded to this with sustained (for him) periods of drum beating. This type of playing developed slightly until Session 12 when Indu made five separate attempts at playing during a one-minute period. None of these attempts were sustained, yet it is significant that they came so closely together; Indu was trying to engage in a sustained, cooperative activity and, when unsuccessful, his impulse to play and motivation were not diminished as evidenced by the repeated attempts. Session 13 represented a breakthrough for Indu. Four weeks after his first session, Indu became able to sustain a simple beat with his hand on the drum. The physical and emotional blocks that had prevented this were momentarily overcome as, on four occasions, he was able to maintain a cooperative musical interaction and twice sustaining playing that lasted for over 30 seconds. This ability became extended in the following sessions until Indu was able to more than double his previous duration to play for a period of 1 minute and 20 seconds in Session 21. Indu was now brought into participation, both choosing to play and acquiring control over his will sufficiently to engage in sustained interaction, certainly a major achievement for him.

At this point, the work took a slightly different focus as Paul began to work with Indu’s beating in order to allow his control over his expression to develop and differentiate. This was done by helping him to develop phrasing, emphasis, and the flexible use of tempi. Having brought Indu into activity, Paul then began to work with the activity. In the notes from Session 22, Paul indicated how it was “the first time I have deliberately worked with his beating to order it and change it.” In this session, Indu entered ongoing music in its tempo and his developing restraint allowed him to engage in extended mutual ritardandi. The predominant character of the drum work from this point on was exemplified in Session 28: Indu was stimulated to begin beating by Paul’s use of dramatic romantic music. When the beating starts, Paul changes the music to one that alternates between E major and E Phrygian, playing one beat on the piano to each of Indu’s beats. Paul becomes quieter allowing Indu’s beats to stand out. He changes to playing in the treble in a florid style and introduces glissandi and then single, widely spaced chords. Indu beats intermittently throughout. The music changes to a frequently used, poignant Bb minor melody. Indu beats, it becomes a tremor which Paul reflects momentarily, he then brings back the softer music to which Indu is able to play—his music does not end with the tremor. Indu’s playing quickens and as Paul follows this he brings more phrasing into Indu’s beating which leads to a ritard at which time Indu stops. Indu had a thirteen additional sessions. In the last quarter of his course of therapy, he became increasingly less interested in drumming and chose to play the piano, often sitting at the bench in front of Paul, leaving only the treble and bass sections of the keyboard available. Indu treated the keyboard as a drum, playing repeated clusters of notes. Consequently, this work continued the rhythmic focus which originated in the drum beating. Indu began to demonstrate an incipient ability to hear phrases and respond in the breaks between them in a way that appeared musically meaningful. He also entered ongoing music in a duple or triple meter, playing two or three beats to each of Paul’s. At this time, Paul began leaving silences in the ongoing improvisations. After waiting a few seconds, Indu began to demonstrate his desire for the music by initiating it in these spaces, either through playing or vocalizing. His vocalizations became prominent in this period. They were always tonal, frequently related to the key in which Paul played, and on many occasions, matched Paul’s sung and played tones. The Session Form Thoughts on Form Aesthetic forms are sometimes seen merely as arbitrary, stylistic conventions. My belief is that these forms are not accidental but instead reflect our psychological organization, our ways of experiencing the world, and our ways of expressing ourselves within this world, as much as they reflect inherent qualities of music. To examine aesthetic forms is thus to consider external reflections of our personal and collective psychological structures as they are manifest in music. These forms are not unlike archetypes, or more accurately, perhaps they are musical

realizations of particular archetypes. As an example we can look at the rondo form (A-B-A-C-A-D, etc.) as a reflection of an archetypal developmental process. Here I am thinking about the behavioral pattern exhibited by infants at play. They first begin close to the mother (or other caretaker), then slowly move out into the world (another corner of the room), then return to the mother in what Mahler, Pine, & Bergman (1975) refer to as “refueling,” continuing exploration to a new aspect of the environment (another corner of the room, another child). The basic rhythm is one of encounters with the familiar alternating with periods of exploration. One reason we may find the rondo form so artistically pleasing, as well as a ubiquitous one in therapy, is that it reflects one of our earliest patterns of interacting with the world and developing our autonomy within a structure of safety.2 This analogy could be taken one step further. At a certain point, toddlers can refuel without actually physically returning to the caretaker but merely by establishing eye contact; the reassurance provided by contact with the familiar can now be gained at a distance. In the same way, composers can allude to themes by stating them indirectly, modulating or embellishing them, or otherwise disguising them. We take pleasure in learning to discern the familiar in an altered form; in a sense, we learn to obtain the same gratification “at a distance” as the toddler does. Moreover, these forms are not unique to music; the fact that we use common terms to describe various art forms points to a common underlying process and form. Think about how we discuss themes and their development in both music and literature, the tone color of a particular orchestra or piece of music, or the rhythm of a painting as well as that of a piece of music.

These terms are not fanciful metaphors but instead reflect the universal forms through which we appreciate artistic works. Because aesthetic forms reflect and activate affective, cognitive, and developmental processes, their use is not a peripheral component of clinical work but rather an essential aspect of it.3

The Session Form in Indu’s Therapy The form derived from the analysis of Indu’s sessions is as follows: • Opening • Transition • Working • Transition • Closure Each of Indu’s sessions appear as an unbroken whole, with its elements being stitched together in a highly aesthetic fashion—each section follows with musical logic from the one that precedes it. This high level of aesthetic integration can be heard particularly well in Sessions 7, 11, 12, 13, and 15. Before describing the form in detail, I will provide some sense of how its iteration grew from my consideration of data, which consisted of the audio-tapes of Indu’s sessions along with the original notes and session index sheets. The awareness of the specific structure described below was built gradually as I listened to each session.4 In an analytic memo written after listening to the first four sessions I detailed my first thoughts about the session structure and the unique qualities of the music used in each

stage of it: The sessions are completely improvised until this point; the sessions are fairly long; the mood is sustained and engaging, the music sounds very special to me, as if Indu also touched a special part of Paul and Paul was able to relate to Indu’s isolation which seems to characterize the music. More generally, the sustained mood, the moving into a musical world, the creating of a musical world that seems limitless from basic, simple, musical materials, e.g., a mode, key, idiom, scale, etc., seems very well illustrated here. Paul’s approach is very meditative in the sense that the music in Indu’s session seems to transport the listener because it creates a unique, well-developed world that draws the listener in and from which the successive session’s music is built. This is perhaps an important essence of the [Nordoff-Robbins] work which is illustrated best through Indu’s therapy. After listening to Session 7, I am struck by the elegance with which Paul segues into the “Good-bye” song and I continue thinking about the session form: The session winds down beautifully and its form is very complete. Paul must have had an intuitive grasp of the importance of the session form as an aesthetic work in and of itself. This is well exemplified in this session, showing different elements, contrasting moods and themes, and reaching a beautifully constructed closure. I next considered whether or not the idea of a ritual form was more inclusive than was that of an aesthetic form, and wondered if this perspective would shed more light upon the events, dynamics, and experiences of the session than would considering only the aesthetic character of the form. This idea continued to develop along with my original formulation, and I began hearing parallels in the dynamic content of Indu’s sessions to the archetypal Hero’s Journey and to the healing voyages or travels of shamans.5 Ultimately, I abandoned these perspectives because while they seemed true to my experience of Paul Nordoff’s use of music and, hence, to comprise a warranted construction, the

aesthetic considerations seemed to be more intimately linked to who Paul Nordoff was and how he might want his work to be described.

Session 11 also struck me as particularly well integrated and at that point in my listening I wondered whether the focus of the study should be the form of the session as opposed to the form of the course of therapy as with Terry. Nothing Paul Nordoff wrote in the notes on Indu’s therapy supported this interest, save for one brief comment regarding Session 11: “As I thought Indu should have an uninterrupted experience, I improvised for quite a long time, using a new music which I developed before leading it into the themes that he knows.” After listening to and notating my observations for Session 12, the form the sessions were taking became apparent to me. The only section that I did not differentiate immediately was the initial Transition, that I was motivated to add in an analytic memo completed after Session 20 in which I reviewed my entire data log until that point. Interestingly, the necessity

for this came from listening to two sessions with dramatically different characters. Session 13 contained a striking example of Paul working with Indu’s incipient responsiveness. Here is how I described it: At 4:00 there is an incredibly artful example of Paul drawing Indu into the working section through the use of the ascending phrase. Indu now beats with Paul in spurts, Paul pauses when Indu does, he does not just provide ongoing music, thus indicating that now we are in the working phase, although the music is still calm and accepting. [It is] very sedate, not overtly demanding, yet quietly, invitingly, insistent in its own way. Paul is like a master fisherman who must exert some effort to reel in the fish in a sense, but who knows that the slightest bit too much effort will cause the fish to jump the line and be lost. On the other hand, the same section in Session 15 was quite different. Again, here is the description from my notes: It seems like we can describe the difficulty in this session as one of not being able to help Indu accomplish the transition into work [emphasis added] after being engaged in the opening. Perhaps engagement is the function of the opening. Thus, an artful example of moving from one stage to another as well as a case where this movement did not occur each stimulated the addition of the first Transition stage. I believe that one reason that this stage was not immediately apparent is that many of these transitions were so gradual and subtle that they were particularly difficult to discern as occupying a discrete stage in the progression of the session. When a therapy session consists of a series of songs or song activities, the surface level of the session can appear broken or discontinuous, even if the underlying process or experience of the client is, in fact, more integrated. It then becomes more difficult to discern the form of the session as apart from its specific content. In addition, the linguistic content of songs can also obscure the underlying form. For example, 13 minutes into Session 31 Paul began to sing “Good-bye” to Indu. This may lead to the mistaken conclusion that we have entered the stage of Closure6 in this session. Yet, after this song was begun, Indu continued to play for 9 minutes as he and Paul reached the real Working section of the session only after the “Good-bye” was introduced. Focusing on the underlying interactions and interventions rather than on the particular song used thus provides more insight into what was actually happening in the session in this instance. The Clinical Value of Awareness of Form Elucidating the form underlying the session should have practical benefits for therapists; it is my hope that this is not just a fanciful reconstruction or extrinsic framework imposed upon the immediacy of the musical experience. First, music therapists, above all, should be aware that living in musical interaction can represent an altered state of being. This is something that can be overlooked because it is a familiar realm of experience for music therapists. What a

model for the session can do is to help therapists better understand what clients need in order to be engaged in the music therapy process, do therapeutic work in this realm, and then make a transition to their lives outside of therapy and outside of music. Moreover, in order to understand the significance of clinical interventions it is necessary to place them in the stage of the session in which they occur. This is one of the many contexts of meaning in which they become intelligible. There are different tasks associated with each stage of the session, and a given intervention must be considered in relation to these tasks in order to understand its rationale. It is important to keep in mind that this description of the functions of the various stages of the session came about from first considering the music characterizing each stage, then seeing what commonalities there were between the music from the same stage in different sessions, and last, inferring the clinical task of the stage from the nature of the music. In this way, the model of the session was built from, and remains consistent with, the music. Last, I would remind the reader that any model is an abstraction from the primary ground of musical experience. Not all of the sessions contained all of the stages of the model; at times the task associated with one of the stages could be the major theme for a given session as described above regarding the difficulty of effecting the transition to work in Session 15. Also, there is no claim here that Paul Nordoff followed any particular template or extrinsic guideline in creating the music for Indu’s sessions.7 The following excerpt from an interim clinical report is one of the only references to the form of the session that Paul made at the time of Indu’s therapy: As Indu’s responses developed I came to know them and to judge his mood, feeling, for example, whether resistance or participation prevailed at that moment. The music always expressed this. Often I would begin the session quietly and searchingly, indefinitely, withholding the big emotional experience until I felt that Indu was wanting it and was ready for it. Then I knew that he would enter into the music with more strength and alertness and that the experience would be at its most significant. My impression is that in this work Paul was primarily concerned with making music and creating a therapeutic experience consistent with the idea of aesthetic form as a healing element in the therapy. Thus, this model should be looked at as one looks at rules of style, for example: it is useful for enhancing our understanding in a post-hoc analysis, but should not necessarily be considered as a guide to action/intervention. The Five Stages of the Session Opening

The openings of the sessions were almost always musically simple. Paul would begin with a single tone, interval, or chord, and build the subsequent music from these basic materials. Many times the openings were somewhat harsh or dissonant as Paul utilized wholetone scales, tritons, and mirror image scales freely; at other times, the music was gentle, warm, and accepting, being built on octaves, fourths, fifths, or a Dorian mode. Because the Opening was often built from single tones, intervals, or scales whose tonal

center might be ambiguous, it allowed for movement into many directions. Rarely, if ever, would Paul begin with a harmonic sequence of any type; the presence of the tonally ambiguous whole-tone scale or tritone allowed for development into any number of keys and moods. Even when there was a clear tonality, such as when opening with a Dorian mode in D, there was not a strong harmonic or melodic impetus in a particular direction. It might be accurate to say that the Openings reflected a minimalist aesthetic and that there was not a strong initial impetus to move in any particular direction. Often the mood was haunting or mysterious with an air of expectancy; there was a sense that something was going to happen before the music ended for the day, and that this something would be important, momentous, perhaps even heroic. Moreover, the solemn, ancient, archetypal feeling conveyed in this music gave the impression that what would soon unfold was something that had happened before and that it was part of a timeless, repeating, universal process of self-realization. Sometimes this sense of anticipation coexisted with a calm, settled, accepting mood; Paul’s music seemed to be able to express both things simultaneously. At other times, the calm, undemanding mood predominated, particularly, for example, when the music was in D minor or D Dorian. The paradoxical nature of the music here can also be seen in Paul’s choices. In one sense, the tritone is tonally ambiguous, lending it to movement into a variety of tonal centers; yet, as a clinical statement, the tritone is jarring and powerful, demanding attention. Hence, the Opening could be both ambiguous and yet powerfully declarative. In its undemanding dimension, the music conveyed a sense of total acceptance; in the creation of a musical world with limitless musical possibilities was intimated the presence of limitless possibilities for growth for Indu. To enter into this music was to enter a world where normal limitations could be transcended. The primary task of the Opening was engagement or making contact. This was done not through reflection of Indu’s activity but instead by establishing a clear musical world or musical idea. When Indu would start beating during these sections, Paul would typically not follow his beating at this point, instead staying with the musical world he was creating. The contact seemed to be more with Indu’s underlying mood or affect than with his active responses; only later in the session would Paul begin working with, and responding overtly to, Indu’s active expressions. By not conforming his music so directly to Indu’s activity, Paul provided a gentle clashing to Indu’s self, thereby nudging his will further into actualization. In this way, from the first moments of the session Paul established his own presence and the autonomy of the music. Two examples of session Openings follow. The first is from Session 1 and thus represents Indu’s very first moments in music therapy. This Opening is based on ninths and the tritone and shows how dissonance was used at the beginning of sessions. The mood is haunting and expectant and in singing along with Indu’s vocalizations there is a lamenting quality to Paul’s voice. Audio File: Indu—Excerpt 1 (Session 1) -

Paul alternates playing a ninth and tritones on the tone of F# while singing Paul’s singing evokes singing from Indu Indu vocalizes a few short staccato bursts followed by sustained tones

-

Paul plays a few tones in the treble of the piano

The following excerpt from Session 16 illustrates an Opening that occurred within a general feeling of consonance: Audio File: Indu—Excerpt 2 (Session 16) -

Indu vocalizes on D Paul plays an open chord on D-A-D and sings “oh” and then “ee” in the Dorian mode Paul begins an ascending movement and Indu scratches a little on the drum in response Indu vocalizes close to the D Indu plays a few brief beats on the drum

Transition to Work

The Working phase of the session was often approached organically and gradually from the Opening. In many cases, the musical and emotional character of the Opening was maintained while Paul began to introduce greater challenges and to reflect more of Indu’s activity in addition to his underlying mood. Thus, when Paul would start to respond more overtly to Indu’s beating by placing his notes on Indu’s beats, this was an indication that a transition was beginning. The idea seemed to be to bring in elements of Working without sacrificing the contact established in the Opening. It is characteristic of Nordoff-Robbins therapy to use music to reflect a client’s mood and activity, as well as to create music free of these constraints. Neither of these strategies can be said to define the Nordoff-Robbins approach unless they are contextualized in a particular section of the session or in terms of the therapist’s underlying intent. This is an example where one must know what stage of the session is being listened to in order to grasp the significance of a particular musical intervention or strategy. The function of the initial Transition was to help the client move into another type of experience. The music in these sections conveyed a sense of ascending or descending, either literally through a musical motif or phrase, or at times, figuratively through the imagery suggested by the music. The presence of this type of imagery was one reason I had considered looking at the session as an instance of the “Hero’s Journey” or the “Shamanic Journey” of healing. Ascending or descending to other realms are components of each of these archetypal journeys as they facilitate the crossing of experiential thresholds. Paul utilized a variety of musical devices in effecting this transition. In addition to using ascending phrases—which were more often modal than diatonic—he would do things like bring a stronger rhythmic impetus to the music, leave spaces which encouraged Indu to beat the drum, play in a forte dynamic, begin adding more scale tones to a simple interval, or introduce a tension-resolution dynamic. All of these would serve to bring movement into the music and create a feeling that what was established in the initial moments in the music was in the process of undergoing some kind of transformation. Some examples of how these were illustrated are as follows: In Session 9, very dissonant ascending and descending cluster chords grew out of a whole-tone improvisation; in Session 12,

Paul sang longingly, even prayerfully, over a single C# note on the piano until moving into a transition indicated by the use of a triton (C#-G) played forte in octaves; and in Session 15 Paul sang over simple C octaves played on the piano supplemented with a G note—Paul then responded to a single beat on the drum by Indu with forte chords which stimulated Indu to continue beating. Typically, the existence of greater levels of coactivity between Paul and Indu indicated that the Transition to Work was being effected. In the following example of Transition music we hear the differences from the Opening in the following ways: Paul pauses when Indu does, not just providing an ongoing music as in the Opening; also, Paul’s music reflects Indu’s responses and beating more as he puts his tones to Indu’s beats and extends his own phrases slightly. Yet, the music is still contained within the D Dorian music which opened the session:

Audio File: Indu—Excerpt 3 (Session 13) -

Paul plays an ascending chord series in the Dorian mode Indu immediately beats triplets on the drum in the tempo established by Paul. His beating

ends in a brief tremor

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Indu reestablishes the triplet feeling in his beating and Paul adds a trill in the treble Indu beats in the space left by Paul Another trill and Paul begins to try to extend Indu’s playing, by raising his intensity slightly and gently reflecting the triplets in his own playing Paul plays with Indu on the triplets and makes a ritard five times and each time tries to extend his playing, the last two times by singing Indu vocalizes briefly, the music pauses, and Paul continues the ascending series of chords Paul plays dramatic, romantic-style music and vocalizes - Return to the ascending series of Dorian chords

Working The music in this stage is highly focused clinically with a clear identity; there is little of the ambiguity—tonally, rhythmically, or harmonically—typical of the music in the Opening. This music tends to be more challenging and provoking, asking Indu to stretch beyond his habitual isolation and come into coactivity. There are a few different profiles of the music in the working stage: In the first profile, the music stays in a particular mode, scale, or melodic/harmonic structure for an extended time. This was seen particularly when Paul was primarily concerned with drawing Indu into participation. This music tended to be less formed and repetition took priority over musical development as Paul treated Indu’s playing delicately, maintaining a steady dynamic when Indu would beat. It is as if Paul was saying (musically): We have arrived at the place where we were headed in the first two stages and we will stay in this place (intense contact and/or work) for a while.

A good example of this is Session 19 when Paul began his improvisation in D minor, changed to a Dorian scale 11/2 minutes later, maintained the Dorian for 2:30 before briefly playing an improvised song in D minor, again followed by period of D Dorian which led to an improvisation moving between A minor and A major. After a few minutes in A, the tonal center of D was reestablished and maintained until 17:30 into the session when it changed to a wholetone scale and then an improvisation based on tritones. For the first 17 minutes of the session the tonal center of D was firmly established, especially D with the minor third, which defines both the minor and Dorian scale. The second profile involved frequent changes between various scales, modes, or melodic structures. There is musical change between the “sub-movements” as one moves from one to the next, but it would be hard to characterize this as musical development because the changes were often abrupt and without an apparent musical logic. Usually the components of these sub movements were familiar to Indu as they were repeated at various points in his therapy. This is exemplified in Session 11. After working in a rhythmic Dorian mode centered on D Paul moves briefly to organum, then to a Spanish idiom in E Major, changes to a 3/4 rhythm and plays chromatically, and then alternates between major and minor before coming to a Mixolydian mode on E, ten minutes after playing in the initial rhythmic Dorian. This encompassed seven clearly differentiated musical structures. The third profile was characterized by extended musical development across a wide range of emotional and musical landscapes. I use the term “landscapes” because defining this music in terms of the breadth of the emotions expressed or musical elements used seems inadequate. This music seemed to be the most spontaneous, integrated, and powerful expression in Indu’s course of therapy. The music was highly individualized and it followed stylistic and emotional contours that were both highly unpredictable as well as artistically integrated. An example of this type of working can be heard in Excerpt 9 from Session 21. While Indu could participate actively by playing the drum, he also participated receptively through listening. Frequent mentions are made in the original notes of greatly enhanced eye contact and ecstatic facial expressions from Indu during this music. This will be described in the discussion of “Music for a Child.” When Indu participated actively, Paul’s clinical focus was conveyed pianistically through a variety of techniques: playing in a forte manner or with a staccato touch to encourage drum beating; the use of clearly defined phrases alternating with brief periods of silence and waiting to encourage antiphonal responses on Indu’s part; the creation of unique timbres through novel combinations of touch, repeated notes, and contrasting registers on the keyboard; and the establishment of clear tonal centers and their associated dominant to tonic movements. When Indu’s participation level was higher, Paul worked more with extended dynamic and tempi changes, with each gradual change sometimes occurring over a number of minutes and Indu following these long, gradual changes. In the following excerpt, the Working aspect of the music can be seen in the following ways: there is more use of dynamics, expressiveness, and dramatic contrasts in the music; we can see clear efforts on the therapist’s part to extend Indu’s beating and elicit his vocalizations; and there are clear attempts to establish a meter and tempo around Indu’s beating as well as to bring some flexibility and responsiveness into it. The drama in the music accompanies changes

into other musical idioms: Audiio File: Indu—Excerpt 4 (Session 24) -

Paul is playing in a Mixolydian mode in A to Indu’s sustained beating Paul introduces the major-minor alternation briefly Return to the modal music Paul sings a cappella briefly and this stimulates Indu to beating which Paul immediately joins in with A sudden bass tone again stimulates Indu to beating Paul briefly plays triplets and again plays a single bass tone which stimulates Indu to resume beating Paul vocalizes on “ee” More single bass tones Dramatic a cappella vocalization by Paul followed by a two-chord phrase that is repeated and stimulates and supports Indu’s extended beating A series of accents and slower beats are connected by a cappella vocalizations by Paul Indu starts beating and Paul supports it, bringing out its triplet character to a Spanish scale A sudden change in the music with different intervals below a repeating F# in the treble

Transition to Closure This stage of the session maintained the overall musical character of the session while bringing back musical development, because at this stage, unlike that of Working, there is a need to move somewhere else, to Closure. This stage is also a multifunctional one as it incorporates and moves between elements of work and of ending. An important function is to return the client from the musical world back to the everyday world. Not all of the sessions had a clearly defined Transition to Closure. When there did seem to be an intermediary step between the core of the work of the session and its ending, there appeared a number of ways in which the closure would be approached. The particular choice made may have been dictated by the nature of the Working section of that session. One way of effecting this transition was to follow a musical climax with sparser, gentler music that maintained some qualities of the music preceding it but in a way that lessened its intensity. This gradual lessening was one way that Paul would gradually effect a disengagement from the depths of the working stage. On the other hand, this sparser music could be equally intense in its own way, through the power of its poignancy, for example. When the working music was either modal, with a shifting tonal center, or bordering on atonality, another device was to begin to make intimations of a cadence. This could be done by playing a clear dominant chord which suggested a tonic and, hence, a feeling of resolution, or by playing a major chord without a seventh. Hinting at resolution may have been another way of maintaining Indu’s playing because, through resolution, a feeling of gratification was held out. Obtaining this gratification may have motivated Indu to maintain his active participation.

Paul would also recapitulate themes, motifs, or moods from earlier in the session as if to lay them more deeply into Indu and to indicate that while they were gone for the time being they still endured and would be returned to. For example, in Session 15 Paul began extremely delicately and sparsely with a repeated C note as Indu vocalized on C, D, and E. Nine minutes into the session Paul returned to play octave Cs in a recapitulation of the opening motif. This example, however, highlights the difficulty in making general statements about the music in the different stages. Although at times the Transition to Closure was indicated by the introduction of a stronger sense of tonality, at times it was indicated by a return to phrases which were ambiguous in tonality, rhythm, and phrase structure, as was the case in Session 16 when Paul utilized whole-tone phrases in moving to the transition, or in Session 17 when Paul engaged in what sounds like vocal toning over a simple, repeated open chord. What is more universal then, is the task of the particular stage; how it was accomplished varied dramatically from session to session. Clinically, this music tended to be less demanding or provoking and this also was one way to mark an entry to the second Transition (to Closure).

Audio File: Indu—Excerpt 5 (Session 10) -

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Indu is playing on the cymbal and Paul plays a repeated chord in the bass of the piano and then alternates between E major and E minor. He is working directly with Indu’s responses Paul changes to a minor key and plays in a romantic style whose rhythmic structure is not directly related to Indu’s playing. This set idea is not taken directly from Indu’s music. The piano becomes slightly softer, a repeated C# is combined with other tones in sequence to create a variety of chords Indu plays quickly on the drum and cymbal and Paul’s music is slower and containing Paul’s music becomes even softer and moves to the bass of the piano

In the preceding excerpt, the change to the romantic music represented a concrete step in the Transition stage. The intensity of Paul’s music still meets Indu, yet the set idea is clearly not taken from Indu’s overt response as were the repeated chords that immediately preceded it. After the idea is introduced, and Indu’s intensity is matched, Paul uses his harmonic development to manage the change to a more sedate and containing music in a musically logical manner. Closure Remembering that we are considering the clinical efficacy of aesthetic form, we can look at the ending of the session much as one looks at the ending of musical works where we would expect to find the following elements: emotional resolution of conflicts set out previously; a recapitulation of musical elements; a maintenance of the musical logic of the session; and a sense of finality. As Dewey describes it, “an experience” (as opposed to the undifferentiated flow of experience in general) does not end by a mere cessation of events but instead reaches a consummation; this is a logical, coherent resting point that flows organically from what preceded it.8

The song “Good-bye, Indu” was the only one used in his therapy and it ended each session from number 12 on. At times, the song would be the final musical element and at other times Paul would add improvisational sections or extensions to the song. Some of these extensions were predicated by Indu’s active playing and expressed desire to remain in the session. Paul would also extend the session and play music for Indu’s listening if he seemed particularly taken by the musical experience. Interestingly, the “Good-bye” was not constructed as one might think: it was composed of dense chords with a shifting tonality and a dramatically sung melody which seemed to convey a fair amount of musical tension. Thus, its primary function did not seem to be one of soothing Indu. Instead, the “Goodbye” recapitulated many of the musical elements characteristic of the long improvisations comprising the session: sophisticated harmonies, tonal ambiguity, and dramatic intensity. Even the voicings of the chords appeared guided by this function, containing the dissonances and tritones characteristic of many of the improvisations. If we accept that Indu’s experiences in music therapy represented a radical change in his way of being, in his state of consciousness even, then we can see a major function of Closure as returning Indu to a state of being suited to the demands of his life outside of the sessions. One way that Paul effected the transition back to a more normal human reality for Indu was by whistling. At the end of Session 10 Paul whistles after the “Good-bye.” The whistling appears as a more human, personal expression in a session which had traversed intense expressions of a variety of moods. It puts closure on a more transpersonal experience by grounding it in the warmth of a more casual and personal contact. Because the session Closure is a crucial transition between states of being, the literature on threshold rituals can be relevant here. Carolyn Kenny has talked about how the musical “point of resolution (transformation) simultaneously represents death and rebirth” (1982; p. 62). Thus, when living in moments of significant musical transition one can achieve this type of personal transition in states of being. One way Paul would do this would be to come out of a long improvisation and reach a particular chord that would become a transitional moment to the Closure. This was done at 19:40 of Session 12 when Paul played dissonant intervals for a long period, followed by an F# major chord in root position with open voicings leading into Indu’s “Goodbye,” and again at 15:30 of Session 13 when an A minor chord, itself emerging from an alternation of a C major and an A major chord, performed the same function. These held chords were important musically and experientially in turning the direction of the session. In each case, the movement from tonal uncertainty to tonal certainty supports the movement to Closure. As important as facilitating the end of the experience for Indu was to help him to internalize a sense of continuity from session to session. This would help him to understand his contact with the therapists as a relationship rather than as a series of discontinuous encounters and also help him to consolidate the gains he made each time and build upon them in subsequent sessions. One way this was done was to treat the Closure as not just a song to get through or an ending point to the session, but as an additional opportunity for extending contact with Indu. Consider this example from Session 15. In the following illustration of Closure music, the one song in Indu’s therapy, his “Good-bye,” emerges seamlessly from the previous transition music. There was a pause in between the two but no break in mood:

AudioFile: Indu—Excerpt 6 (Session 15) -

Paul is singing and playing the “Good-bye” as Indu plays on the drum in a variety of tempi Paul vocalizes softly in a way that is reminiscent of the working part of the session but without the same intensity Paul extends the song with a thematic recapitulation of music from earlier in the session. He improvises in a rhythmic Phrygian mode which has been used for Indu’s working music and meets Indu’s drumming

This music says to Indu that We are done for today but not in general; the end of the session is not an ending but a temporary resting point. Also, Paul chooses a Work music, although it is played much more sedately and in a Closure mode, as if to remind Indu of work and to foreshadow that they will work in subsequent sessions. It is almost as if Paul wants to convey the sense that the series of sessions represents one continuous creative expression. The Session Form: Concluding Remarks In sum, if I were to provide a phrase which characterized the therapist’s stance in each phase of the session, it would be as follows: Opening: Here I am; I acknowledge you. Transition to Work: Let us do something together. Work: Look at what I am doing, can you try it? Transition to Closure: Follow me, we are going somewhere else. Closure: We are ending but we will be doing this again. In its felt quality, the entirety of the session resembles the contour of intensity of a wave crashing on the shore. One begins with the initial calm that contains a foreboding of potential (Opening); this is followed by a gathering of forces as the gentle calm gradually assumes more power and strength; the form of its power begins to be suggested (Transition to Work). Then comes the intensity and turbulence of the wave itself, crashing and releasing tremendous forces (Work); at its apex, the waters begin to recede to their origins in the wake of the wave (Transition to Closure); and finally, the initial gentle calm is returned to (Closure). Specialized Functions of Music Creating a Musical World To a large extent, the music in Indu’s sessions conveyed a sense of solemnity, seriousness of purpose, and a feeling of something very ancient and archetypal. To listen to these sessions is to be drawn into an entirely new musical world. Through the use of intense, sustained moods and extended musical ideas, and a total commitment to their realization through his playing, Paul was able to create the sense of a world of limitless possibilities in which traditional constraints could be transcended. In this new world, Indu was able to move beyond the limitations his severe difficulties had placed upon him.

This way of conceiving of the role of Nordoff-Robbins music therapy with the severely disabled was written about early in its development: There are also children who live so remotely that it is hard to gain insight into their experiencing and interpreting of life. These children . . . appear unable to find significance in any usual life context, incapable of assimilating any of the forms, modes, or expressions of normal life. Their prevailing emotional condition evokes the image of an inhospitable landscape in which they are fated to live. One may live amid tempestuous storms, another in an icy wasteland; another may walk alone in a bleak, comfortless desert. For such a child music can become something rare, evocative or consoling. It can become another landscape for him, one in which he will be able to find more than the limits of his own being [italics added]. (Nordoff & Robbins, 1971, p. 55) If it is true that what was being created for Indu through music was an alternative experiential world for him to enter, then we have to consider how entry to this world was managed musically. It also helps us to better understand the clinical-musical interventions if we see them as allowing for passage into and out of an alternative experiential realm. In some ways, Indu was trapped in a world defined by his own limitations—the human world of emotional expression and fulfillment, relationship, and cooperative activity was closed to him. Yet in creating a musical world, Paul could offer Indu a place that he could enter and into which Paul could bring the qualities of the human world—relationship, intentional action, emotional expression—previously closed to him. Through music, Paul created an intermediate plane of existence for Indu to experience these aspects of being human. A fundamental conflict for Indu, then, could be seen as an ambivalence about, or inability to, incarnate fully in the human world around him. The word “incarnate” is used in the sense of living completely in one’s physical reality, including the social and emotional aspects of doing so. The music created for Indu was often conflict embodying, sometimes expressed through the use of dissonant ascending and descending cluster chords, and at other times being manifest in the dialogue intrinsic in Paul’s use of alternating major and minor chords within the same tonality. Many times, both of these types of music seemed to portray this inner conflict. Interestingly, Colin Lee (1996) has also observed a similar use of what he calls the major/minor symmetry with his client Francis, an articulate and expressive musician with whom he worked. Francis had the following to say after one of his own improvisations: There was a dichotomy between major and minor which produced a natural ambiguity. It was as if you were getting a glimpse of something because you are not quite sure who you are. There was a light throwing a confusion of identity. A waking-up theme that was a completely different colour. I go in and out of major and minor a great deal; this is because of the instability it creates. (Lee, 1996, p. 96) Francis was struggling with feelings of being isolated and marginalized because of being a gay man with AIDS. We have also identified Indu’s profound isolation as the most salient effect of his disabling conditions. Perhaps Francis’s ability to verbally express what Indu cannot provides some insight into how the major-minor dichotomy was used by Paul and experienced by Indu. If we can generalize from Francis’s experience, perhaps we can see the opposition of

the two as reflecting Indu’s opposing tendencies: on one hand to remain alone and in his own world (minor) and on the other to struggle to stay related and be more in the world of human beings (major). Paul not only musically portrayed this conflict but took an active role in it, using his vocal and instrumental resources in a way that appeared to be calling Indu into being, as if by the force of his playing and singing Paul could invoke or incarnate Indu’s spirit. This sense of the music was particularly strong in Session 9. In this session the use of the alternating minor and major seemed to reflect an ambivalence about entering into one’s being more fully. Paul’s emotional singing seems to reinforce the calling or invoking quality of the music: Audio File: Indu—Excerpt 7 (Session 9) -

Paul alternates between E major and E minor with a G melody tone as Indu plays vigorously on the cymbal Paul alters his harmonies for greater dramatic contrast Paul starts to sing and his voice rides above the music An accelerando in the major-minor chords and then repeated low bass chords Indu plays dramatic rolls on the drum to Paul’s insistent music Another accelerando on the piano

In this example, the music is calling Indu into the human realm simultaneously with reflecting his more ethereal state. It is as if Paul is a priest facilitating a rite of passage, attempting to induce Indu to cross a threshold. In listening to this clinical excerpt, Clive Robbins felt that “Indu is almost in a kind of fluid world that is not water, but a dream-like substance, and he is reaching to come out of it.” The music itself is reflecting the state, calling the being, invoking the being into existence, and symbolizing the crossing of the threshold. In contrast to the work with Terry, whose remoteness seemed to be of a psychological character requiring intervention on a psychological plane, the work with Indu appears to occur in a transpersonal domain. Some of the imagery stimulated in me by this music is that it unfolds or turns inside out, producing a perceptual experience not unlike that created by the contemplation of a mandala. The music is helping Indu to come into consciousness, to cross the threshold by identifying with the music. The music captures the dynamic process of coming into being, and Indu’s identification with the music allows him to traverse the realms that the music does. Paul’s music instantiates the different realms just as it interpenetrates them. The original session notes discuss Indu’s reaction to this music: He was extremely responsive today. He rocked in different tempi. His facial expression changed continually, he looked joyous, and his eyes shone. He gave Mr. Robbins two very fine looks that had dignity and expressed pleasure and satisfaction. . . . Several times he beat the drum, often in the tempo of my improvisation. At one time I stopped playing. Indu gave the fact his attention and beat the drum. I played with him. After he had stopped beating I stopped again. He beat again, obviously calling

again for the music. I played with him and stopped when he did. This made him beat yet again. In this session, Indu’s beating had a rhythmic relationship to my tempo. This happened many times. [These are all detailed in the notes.] Paul used his voice in unique ways with Indu, primarily in support of the process of inviting Indu to come into being. He often vocalized in a way that could best be described as prayerful. At times this singing was sedate with a solemn, spiritual feeling, at other times it was more dynamic with almost a pleading quality. Yet it was always intense in its focus and highly emotional. The quality of this singing is an aspect of the work with Indu that leads to my estimation of it as some of the most personal work that Paul Nordoff has done. It certainly shows how he was capable of taking an intensely personal stance toward a client, working with all of his being to ally himself with his client’s potential for growth. Clinical Attunement and Non-Attunement It is characteristic of Nordoff-Robbins music therapy to use music to hold or support a client, as well as to stimulate, challenge, confront, or even provoke a client, when clinically warranted. This is just as true with someone like Indu as it is for clients such as Audrey or Terry. With Indu, however, this was done purely through the instrumental improvisations rather than through song lyrics (Where is Terry?) or through verbal interventions (We’re going to work!) and the implementation of demanding structured musical activities (both of these as with Audrey). It is frequently observed in the records of Indu’s sessions how intensely he responded to dramatically played romantic-style music, not through active musical responses but through listening. Indu eagerly anticipated these parts of the sessions, living completely in the music and reacting ecstatically to it. Often he would stand when this music was played and establish eye contact with Paul. This type of music was used throughout Indu’s course of therapy, to both engage his receptive musical intelligence and to bring this capacity into the expressive realm. Providing this music was one way that Paul conformed and attuned to Indu’s expectations, needs, and desires. Yet, as was noted previously, Paul deliberately withheld this music, gradually building to it so that it grew out of his musical openings and became an expression of Indu’s ability to experience it fully. Paul and Clive describe how they looked at this ability and what role it played in their clinical strategy with Indu: Indu’s response to the music was often intense and ecstatic, particularly when the music became dramatically romantic. At such times he would put his feet up on his chair in the lotus position and live in the musical experience. He showed a desire for these experiences in marked anticipation of the sessions. I wanted to see if I could bring him beyond this desire to receive only and to see if he could be led into expressing a unity with the music and myself through drum beating. I tried to stimulate this beating emotionally by playing the big emotional music that always excited him. I tried playing bass notes to stimulate his will. A contrasting clinical strategy with Indu was to not always conform to his preferences or

expressions, which then resulted in a deliberate clash between Indu’s present need and the therapists’ willingness to go along with this. Although the clashing was a by-product of the primary goal, which was to expand Indu’s rhythmic capacities, in and of itself this clashing—or rather the repeating pattern of clashing and reattunement—holds developmental significance.9 Judith Kestenberg (1975) observes that a primary mechanism of normal developmental and interactional processes is comprised of a rhythm of attunement and clashing in relation to the mother’s and infant’s mutual perception of, and reaction to, tension levels in each other. Perceiving and adjusting to these changing tension levels forms the basis for the establishment of trust and empathy. She uses the analogy of a musical instrument consisting of a resonator and vibrator to describe the mother-infant dyad and describes a situation where vibrator and resonator do not work in harmony: At times, the resonator and the vibrator are out of phase, working against each other. A resonator may refuse to be the slave of the vibrator and may produce interference. In the language of mother-child interaction, we speak of clashes between them. However, clashing is part and parcel of the interaction in which a mother calms the baby or vice versa. A clash occurs, for instance, when the mother lowers her tension while the infant’s remains high. If the mother lowers her tension gradually, there comes a point at which the baby follows suit, and a harmony between their tension qualities can be reestablished. A feeling of sameness is re-created that is an intrinsic aspect of empathy. Clashing that is not followed by a reattunement creates battles between mother and infant. (p. 141) Paul created a therapeutic clashing in two ways with Indu, through his use of dissonance and through his non-attunement of rhythms. An example of the former occurred in Session 7: -

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Indu pulls Clive’s tie and Paul says: “If you can see that, you can see the drum!” Paul insists that he beat and uses dissonance. A very good stretch of beating occurs. Paul becomes much more insistent and forceful, telling Indu, “Take it! Hit it! You can see it, hit it!” The music becomes even more dissonant and forceful. This produces a brief flurry of rapid beating. The forceful, dissonant, pushing music continues with very dissonant clusters. More dissonant and driving music with a stop followed by four very strong, well-defined beats in the rest. The music then changes to a big “rolling” improvisation. It is a very different kind of music, not as pushing, more accepting, showing the development of the music and a different clinical strategy.

From the session notes it is observed that: he beat well in short periods. Then he grabbed at Mr. Robbins’s tie and pulled it. Finally I said, “If you can see that, you can see the drum,” took his hand away from the tie, put it on the drum, and he beat for some time. I used plenty of dissonance in this session; although I do not think he likes it very much, he responded to it [emphasis added].

We can look at this one of two ways in relation to the issue of attunement. On one hand, we can see the pragmatic aspect of the Nordoff-Robbins approach well exemplified here. The issue is not to soothe Indu or make him happy, but to engage him in meaningful, willful activity—any musical intervention that facilitated this would not only be sanctioned but actively pursued. The dissonance is not just a musical one but an interpersonal one in that it shows Indu that Paul will not always supply what Indu overtly desires. Of course, it is in this nonmeeting of his immediate needs that Indu becomes more aware of his self and his own desires; he thus experiences an enhanced motivation and ability to engage in actions which express his needs, stimulating the development of willful activity. It is not unimportant that the period of dissonant music is followed by a reattunement between Paul and Indu through the use of more consonant music, more to Indu’s liking. Alternatively, we can think of attunement as neither a singular nor a global phenomenon but something that can variously apply to different aspects of a person. Perhaps Paul’s use of dissonance represented an attuning to an underlying affect or pervasive attitude in Indu, although the tension of the dissonance clashed with another part of Indu. Thus, it is not as simple as saying that the therapist and client are or are not attuned to one another, but that there are varying levels of attunement, or different parts of a person which are themselves in conflict. In this way, it would be impossible to attune to the whole being, especially with someone like Indu whose existence seemed to be defined by a very basic conflict. Moreover, because music can convey multiple levels of meaning, it is possible that one aspect of the therapist’s music can be considered to be attuning while another aspect might be clashing. It is certainly possible that through his harmonies, Paul could be establishing a tension level that was an example of attunement, while the rhythm of the music could be seen as clashing with Indu’s overt expressions. Thus we can see attunement and clashing existing simultaneously. The process of attunement-clashing-reattunement can also be seen in the rhythmic work. This became particularly prominent in the second half of Indu’s course of therapy and offers a supplementary rationale for why rhythmic and tempo flexibility is often considered an important manifestation of a client’s development. From Session 23, Paul wrote the following: his beating to accent it with my measuring of it, putting it in measures of 3 or 4, as seemed best in the immediate moment, using definite techniques to slow it down. This is the first time I have deliberately worked with his beating to order it and change it. Several times in this session Indu responded to musical techniques by making ritards to slower tempi than he has ever beat before. In two wonderfully dramatic places, one can feel Indu experience the music in such a way that his beating is controlled and he can make the ritard to my slower tempo. Many times in this session he began his beating in the tempo of the improvisation. At that point, Indu was playing more frequently and for sustained periods of time. Paul had succeeded in drawing Indu into activity, musical activity. He then began work to engage

Indu in tempo changes, helping him to participate in ritardandi and accelerandi. Indu also began to play with an awareness of the Basic Beat, to develop a sensitivity to the Melodic Rhythm and to accents in the musical phrases. All of these goals functioned to make the experience more of a conscious one for Indu. We could consider that they had reached a working stage of the therapy because, in general, Indu was drawn into activity. Paul could then become much more concerned with moving and changing Indu’s beating rather than only reflecting it. Kestenberg (1975) wrote about how the mother’s gradual lowering of tension could induce the infant to follow, but that this period of mismatched tension levels (clashing) was preceded and followed by periods of attunement. Working with Indu’s rhythms in a similar way seems more than analogous to the infant-mother interaction but as another manifestation of a shared, archetypal, social process contributing to the development of self. Before the clashing of rhythms can be used productively, the client or child must have an experience of complete matching or attunement. Kestenberg uses the example of the breast-feeding infant, where the mother’s supply and cessation of milk production must conform to the infant’s rhythm of sucking and swallowing. Here, the mother supplies exactly what the infant needs in the rhythm demanded by the infant. In Paul’s work with Indu the issue is not so clear. In conforming to Indu’s rhythms in the first half of his therapy, Paul was supplying the “milk” in a way not to engender clashing, although, as described above, clashing was introduced through the dissonant harmonies. With Indu, Paul was working with someone who functioned on different levels—although his verbal and social capacities were those of an infant, his physical age and receptive musical capacity were more developed. That the work with Indu cannot be characterized by the schema of attunement-clashing-reattunement without qualification does not mean that the schema is not applicable to this work; rather, it shows how all theories from child development have to be adapted when applied to the realm of music therapy. Music for a Child (Client) I have previously alluded to the idea of Music for a Child. By this, I mean music created by the therapist that is neither a reflection of the child’s/client’s activity nor intended to stimulate any active response, musical or otherwise. Instead, this is music intended to be heard, to be listened to by the child. Paul Nordoff played music to engage Indu’s intellect, his emotions, and his spirit. There was no expectation conveyed in the music other than just to experience it and live in it. This was an important clinical intervention, focused on giving to the client and creating an experience for him. It appeared to reach deeply buried and difficult to access capacities and sensitivities. Although intended for listening, the function of this music was not to render Indu passive but to activate his receptive capacities. Thus, we are talking about individually composed music for listening that contains the same level of clinical focus and intent as does music intended to stimulate activity. Because Indu’s receptive capacities seemed to far exceed his expressive ones—and by this I mean that he felt and reacted to music that was far more complex than that which he could actively play—this use of music was especially important for him. These musical moments typically, although not exclusively, occurred at the end of sessions (for example,

numbers 8, 12, and 18). They had the quality of a musical offering to Indu from Paul and appeared quite moving and personal; there is an inherent sense that Indu had worked very hard, that Paul recognized his demanding stance, and that there was a need for a pure musical giving that asked nothing of Indu. A particularly clear example of this type of music occurred at the end of Session 27. This music is peaceful, calm, meditative, definitive—everything the working music is not. Yet it is also differentiated from the opening music by its sense of finality, closure, and settledness: Audio File: Indu—Excerpt 8 (Session 27) -

Paul sings and plays the “Good-bye” while Indu plays on the drum in a way that alternates between his tremor beating and more regular beating

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Paul extends the music and vocalizes Indu’s name on a descending fifth

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This is followed by an arpeggiated descending chord progression and then an unpredictable sequence of chords Indu is quiet for the most part, listening to the music consisting of arpeggiated chords

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Indu vocalizes and claps in response

This music is a clear example of the concept of providing an experience for a child through a musical offering. It shows how providing a child with an experiencing of quality, individually-tailored music can be its own clinical goal in the Nordoff-Robbins approach. The purpose is not to have the client do something but to experience something. Conclusion Of all the clients in this study, the clinical functions of music illustrated in the work with Indu seem most difficult to capture and communicate through isolated excerpts. Their functions are best revealed when one has listened to an entire session and is living more in a musical state of consciousness. Space limitations have prevented me from including an entire session on the audio recording for this study. The final excerpt from Indu’s therapy is slightly more extended than most of the others. My purpose is to offer the listener/reader an opportunity to experience this music in a less analytical way and enter a musical state of consciousness that might approximate Indu’s experience. Perhaps some of the interpretations regarding the clinical functions of music with Indu will become more readily apprehendable through listening to this extended excerpt from Session 21. Some of the ideas that it illustrates include the following: music for a child; creating a music world; the process of moving from working music to transition to closure; and the invoking quality of the voice. The excerpt begins in the middle of the Working section of the session, before its climax. The music that begins this excerpt represented a change from what immediately preceded it. The chromatic chordal improvisation seems to create a sense of a descent—there is a deepening of one’s experience which parallels the movement to the bass of the piano. Paul’s singing seems to have a prayerful quality as well as a pathos in it. The music continues to

deepen into more dissonant intensity. Paul seems to musically paint himself into a corner, but this is illusory as he introduces a glissando to the bass which heralds a new section. He slowly dissolves the tonality of the session until he reaches almost an atonal realm. He pushes the idea of tonality to its ultimate end where it becomes its opposite. Paul is working incredibly hard on the piano, playing with utmost physical exertion. His musical “right turns” or movements into other realms initiate movement by Indu and keep him engaged. The dramatically timed glissando led into a very clearly defined Transition to Closure. After this glissando the music changes character, becoming calm, sedate, and prayerful with solemn singing by Paul. This music is beautiful, intensely delicate and focused, and appears as a musical gift. Although Indu plays a few beats to it, Paul does not go with this, instead staying with his musical idea and the Transition to Closure that he is creating. Audio File: Indu—Excerpt 9 (Session 21) -

Paul vocalizes over a chromatic improvisation using whole-tone chords and is also playing with Indu’s beating There is a return to octaves and tritones which had been used earlier in the session As Paul alternates bass octaves with a B-F tritone Indu beats continuously Indu makes several slow beats with the music and this is followed by an accelerando Paul plays chromatically in the treble of the piano and Indu becomes ecstatic in his expression The music increases in intensity and there is a dialogic quality between chords in the treble A glissando to the bass marks a change in the music. Paul plays and sings more calmly as Indu continues beating Tremoli in the treble in a pentatonic scale lead Indu to make ecstatic high sounds and to beat in spurts; Paul sings Indu’s name The music is calming and extremely delicate It changes to an improvisation in Eb major Indu beats and Paul does not respond directly to it Paul brings out the chords that were underlying the previous music to end the improvisation. References

Aigen, K. (1994). The aesthetic foundation of clinical theory: An underlying basis of NordoffRobbins music therapy. In C. Kenny (Ed.) Listening, Playing and Creating: Essays on the Power of Sound. Albany NY: State University of New York Press. Aigen, K. (1995). Cognitive and affective processes in music therapy: A preliminary model fo contemporary Nordoff-Robbins practice. Music Therapy: Journal of the American Association for Music Therapy, 13(1), 13–46. Bettelheim, B. (1975). The Usess of Enchantment: The Meaning and Importance of Fairy Tales. New York: Vintage Books.

Robbins, C., & Forinash, M. (1991). Time as a multilevel phenomenon in music therapy. Music Therapy: Journal of the American Association for Music Therapy, 10(1), 46–57.

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

CASE THREE Improvisation and Play in the Therapeutic Engagement of a Five-Year-Old Boy with Physical and Interpersonal Problems Pamela Bartram Abstract Tom is a five-year-old boy with a history of seizures, physical complaints, and interpersonal problems, both at home and at school. In the 37 music therapy sessions which have been summarized, he engaged with the music therapist through musical improvisation and play. Tom’s plight is considered in the light of the material arising out of these interactions. Prologue Tom: (Talking to a puppet of Humpty Dumpty lying down). Oh Humpty, you’re a very naughty boy....a very naughty boy. Pamela: Because he keeps lying down all the time when it’s in-time? Tom: (Silence) Pamela: He flops down dead. Tom: He keeps going...flimp. Oh, now he won’t...he’s doing tricks. (Tom is holding Humpty by his two long legs and spinning him round and round). Pamela: Oh no, poor Humpty, he’s feeling sick with his upside-down tricks. Tom: Oh whee, whee (spinning Humpty round). Pamela: He’s spinning around, spinning faster and faster. That’s going to make him feel very sick, all that spinning. Tom: Look....(laughing to Humpty). Look, you’re tangled. Pamela: Mmm...That’s what spinning does. It makes you all tangled. Tom: (Anxiously) How can this get back? In this dialogue, Tom and I (with the aid of Humpty) are exploring themes central to this study. There is the naughty boy, the boy who flops and flimps, or who spins around doing tricks. But the spinning tricks make him sick and tangled. How can he rediscover a better state of being? Here we will have the opportunity to consider more fully Tom’s state and the conditions which may have been instrumental in bringing it about. We will also consider issues raised by Tom’s own question about how it may be possible for him to be something other than in a ball and sick or spinning, tricky or tangled.

For two reasons I will neither attempt to focus on changes through time in his behavior, nor to make a case for improvement in his condition having arisen due to music therapy. These are firstly, the way in which I structured my own contribution to the sessions changed as my understanding of his difficulties deepened under the influence of supervision and personal therapy (thus, I myself was a variable in our “equation”); secondly, it was clear that Tom associated his concurrent experiences in psychotherapy with those in music therapy. It was likely that processes prompted by his psychotherapy would bear fruit in the area of his creativity, both in general and in his musical material. It would be impossible, therefore, to judge music therapy events, and even less so, strictly musical events, as sole agents in any change process that might be identified. My aim is, therefore, restricted to using session material to illustrate how it is possible to know through music or through the mixing of music (i.e., the therapist’s with the patient’s), to explore how such knowledge may be understood in relation to Tom’s presenting difficulties, and to explore the meaning for him of moving in and out of musical material. Background Tom, aged 5 1/2, was referred to me for music therapy by a clinical psychologist, both because he himself showed an interest in rhythm and musical instruments, and because she felt he needed to succeed in a noncompetitive environment. At home he would sometimes sing rather than talk about his school day. Having met Tom for the first time, I had the impression that music therapy might indeed be a medium in which he could channel and creatively use his imagination and his physical energy. However, I also wondered to what extent a child as verbal and as scattered as he appeared to be, would actually take up and use the medium of improvised music-making. Tom is the first child of financially comfortable upper middle-class parents. He has a younger sister who was born when Tom was three years old. Tom’s development had been described by his pediatrician as “unusual” but not grossly delayed. When he was three years old, his parents took him to a Child Development Unit where they were told that he was retarded, hyperactive, and that he would “never earn his own living.” On taking him for a second opinion, no doubt in a state of shock, they were told that Tom was well within the normal range of development. In the parents’ minds, therefore, there has been confusion as to Tom’s potential. He was referred to speech therapy at three years three months, where he was described as having poor concentration, immature articulation and poor expressive language. A few months later, Tom was sent to a school run along formal academic lines, perhaps as a preparation for going to boarding school at seven years. Around this time, he began to suffer from recurrent attacks of headache and vomiting. There is a history of migraine in the family. School described him as unable to concentrate, disobedient, and failing to achieve, and he was often punished by, for example, being kept in to do school work at break time. He had no friends. At four years eleven months he suffered a generalised convulsion in bed, and another almost a year later, also in bed. On the second occasion, he went into status epilepticus, requiring intravenous valium. When he regained consciousness in hospital some hours later, he

did not ask where he was or what had happened. Some weeks later however, he referred to the hospital as the place where he’d had his headache. CAT scans have shown no gross organic damage, although there is a hypothesis of fetal distress during his delivery by Caesarean section, and a possible lack of oxygen having led to “minimal damage.” After the second convulsion, an EEG showed abnormal activity which might indicate that, apart from the generalized convulsions he may experience brief absences or petit mal seizures, which go undetected. He has a history of eczema, allergies, and a “droopy left eye” which becomes more pronounced when the nausea, headaches, and vomiting prevail. He sometimes has a tic, a movement involving a head jerk back and slight roll of the eyes. When Tom’s mother first brought him to meet me, she referred to his difficulties primarily in terms of his vomiting, headaches, and his short concentration span, which was making him unsuccessful and unpopular at school. She said he ate well, although he always tended to regurgitate feeds as a baby. There was no disruption of sleep, in fact, she described how Tom loved to go to bed, fell asleep straight away, and slept soundly all night. He would often ask to be allowed to go to bed long before bedtime. I subsequently learned that he suffered from nightmares and bedwetting, which upset him considerably. I also learned that he had a difficult relationship with his father, he bullied his younger sister, he was “disobedient” and without friends at school, and that there were difficulties in his relationship with his mother. Tom also had a tendency to be inappropriately friendly with adult strangers. At the initial meeting with mother and son, I was struck by the contrast between them. She is a tall, elegant woman, softly spoken, and with a gentle, dreamy, sometimes absent manner. (It has sometimes been difficult for her to remember Tom’s appointments for music therapy). She described Tom (while he played outside) in bemused, slightly irritated, and mildly ironic tones, as if he were a naughty boy and as if the situation were tiresome. Any anguish she might have felt was not expressed. At that interview, Tom came into my office, a rather overweight little boy, with angry red blotches on his face. He looked disheveled, and his tic was noticeable. He spoke to me immediately, asking questions, and then moving around the room without waiting for an answer, but helping himself to objects in the office and asking more questions. He spoke very loudly in what seemed to be a falsely sociable, apparently self-assured tone. Beside mother, who seemed so quiet and stylish, Tom looked a mess--and after a few minutes the office began to look a mess too. When I took him to meet a colleague who had agreed to occupy him, he did so willingly, running ahead of me without a goodbye between him and his mother, and then talking incessantly with my colleague. Tom gave a superficial first impression of being a “bit of a character.” When I returned to the office, mother raised her eyebrows, smiled gently, and gave a shrug. Tom’s father is a successful businessman, who on a later occasion described how he arrives home tired in the evening with little patience for a naughty son. After Tom’s second seizure, he was remorseful at the idea that he had sometimes disciplined Tom for bad behaviour, which might have been related to his condition. At that time, both parents still tended to view Tom as a boy with medical problems, hitherto undetected, which had resulted

in management problems. Thus, they assumed that once the medical problems were solved, the others would disappear. In the case review a year after the initial referral, the pediatrician expressed the view that while Tom does have medical problems, possibly related to minimal damage at birth, his disposition and life events have interplayed with them to produce phenomena which cannot now be treated as medical problems, pure and simple. A few months after beginning music therapy, Tom began anti-epileptic medication. Shortly after that, he moved to a less academic local school where he was, at first, excessively aggressive to other children--especially in the playground. This aggression subsequently diminished, however, his difficulties in concentrating and in making relationships remained. At the same time, Tom began weekly psychotherapy. Before offering him sessions, the psychotherapist contacted me, and after some discussion, we agreed that it would, at least, not be harmful for Tom to attend both psychotherapy and music therapy, and indeed together they might be useful. Treatment Process From the first sessions, Tom brought a mixture of musical and nonmusical materials. The latter often taking the form of nonmusical use of instruments and competitive games. The overall trend was away from music-making, although each session contained at least some musical material. Although the organic development of session material cannot be sharply delineated as the following schema might suggest, the sessions can be conceived as falling into three sets. In the paragraphs that follow, an overview is given of what transpired in each set, and a more detailed transcript is given of the second session. Sessions One through Eight The first eight sessions were characterized by a pervading atmosphere of anxiety, disorder, and brief, inconclusive engagements. Tom found it difficult to stay in the therapy room for the duration of the session. I had to discourage him from dismantling instruments and from bringing items such as food or toys into the room. Beginning and endings of sessions were abrupt and disordered. Tom commanded and attempted to direct my musical and nonmusical activity. Musical material in which I had to imitate him was particularly significant. I tended to resist Tom’s commands and to insist that I make my own choices. He often spoke in false voices, including a witch voice. There was little sense of satisfaction, either individual or mutual. I felt resentful of his apparent communication that whatever I offered was not the right thing, and I also resented his attempts to help himself to something better. Notes on Session Two

This session began with Tom racing me from the waiting room to the therapy room, and running into the therapy room, alone. A variety of instruments are arranged as for the beginning of the first session with the addition of a reed horn which he had requested. He goes straight to the horn, picks it up and plays it briefly, then moves to the drum, playing with a bouncy body movement, and soon brings in the cymbal. I have closed the door and made my way to the piano where I sit, listening. Without stopping playing, Tom gesticulates for me to join in, but as this gesture is ambiguous, I have to talk over his playing to ask, does he mean for me to play. I begin to play, but after sharing only one full phrase length, he breaks off, saying that when he plays the drum, I must play the bells (which are small and tinkling). He tries to give them to me, but I am reluctant to change instruments at this point and especially from the piano to the bells, given the force of his drum and cymbal playing. I say that we can each decide what we are going to play and I choose the piano. He returns the drum, though still appearing to instruct me in a lisping babyish voice. When he announces with stage-authority, “Off you go...the big drum,” a duet begins with him on drum and cymbal and me on piano. This turns out to be an unusually sustained (six minutes or so) period of shared musical engagement. During this “episode of engagement” (Stern, 1977), Tom changes his instrument several times (drum and cymbal, horn, drum, glockenspiel, piano, cymbal, drum and cymbal). Yet there is an overall sense of continuity, largely due to the rhythmicity of his playing, the recurrence of a tempo of 120 beats per minute, and the continuity of my own playing. Tom himself gesticulates and instructs me verbally to carry on playing during his changeovers, and I have an image of him trying to keep me going (like a machine) by conducting with one hand, while playing with the other. He has a natural tendency to organise his percussive playing into a strong pulse which is regularly inflected and which contains rests that allow for the formation of repeated phrases. These features give a robust quality to his playing, and provide firm material for engagement. The volume and timbre give his playing a sturdy quality. At the same time, his prevailing choice of percussive instruments limits his exploration of melodic qualities which might suggest to him contrasting dynamics, timbres or rhythmic forms. I try to play music which reflects and contains the strength of his playing, and which accommodates the changes in his tempo, rhythm, pitch, and timbre. At one or two moments there is renegotiation of the elements after one player has introduced new material. We play an intense “trembling” duet on the piano, but Tom abruptly breaks off and begins to spell out the piano brand name. Then giving one cymbal crash, he asks “How many minutes are we going to go?” I remind him of the length of the session and ask, “Does it feel like a long time to be away from Mummy?” He replies with an unexpectedly powerful and very loud cymbal crash. This leads into a few slow and deadly drum/cymbal beats, and then speeds up into strong pulse playing (126 beats per minute) which breaks off mid-phrase. Here, my own playing becomes dissonant in response to the wilder character of his. Nevertheless, I am almost inaudible at times as I struggle to judge the register and volume required to withstand the ferocity of his playing. The final break, which ends this episode of musical engagement, occurs as did the previous two, mid-phrase, cutting across the musical phrase rather than arriving at a natural ending. Tom anxiously suggests, “Shall we go now...or something?”

Even this short section of material reveals the extent and limits of Tom’s creativity in musical and interpersonal relationships. His music is powerful and often has a recognisable form and organization. It feels like a force to be reckoned with rather than, for example, a tentatively formed and executed music whose manifestations need to be awaited and delicately nurtured. Music such as Tom’s might have a lot to contribute to a relationship. On the other hand, he also seems to be struggling to create the illusion that he alone is starting, maintaining, and ending our musical engagement, as well as largely determining its character. When I had refused his offer of the little bells, he acted as if he was the one determining the course of events, presuming to instruct me to do what, in fact, I was already doing. Rushing into the room and beginning to play without me, then conducting my playing while he changes instruments are perhaps other examples of this illusion-creating. I sense that he feels responsible for my part, for my liveliness, as well as his own, and the energy he expends playing so strongly seems to serve the function of also keeping my part alive. It was unusual, but in retrospect understandable, that when Tom ended the episode, I suggested that he sit down and have a rest from playing. It was as if this illusion requires such energy to maintain, that Tom is left exhausted after only a short time and there is a feeling of the impossibility of going on. In fact, there is no more sustained music until the last eight minutes of the session, when I remind Tom that it is near the end and ask whether he would like to play again. We improvise a horn/voice duet. It has a jittery quality reminiscent of the “trembling” duet on the piano. There is a tense sharing of phrase lengths in antiphonal exchanges. Antiphonal playing seems more tolerable to Tom than simultaneous playing, perhaps because it promotes a clearer demarcation of the separate parts. Tom further controlled even the antiphonal play by often insisting that I imitate him in this way, even more closely “keeping an eye” on my part. Later, in a drum duet, Tom divided the drums between us so that he had the bigger ones, and then proceeded to divide the musical material by insisting that I imitate him antiphonally, thus making my part dependent on his. As a leitmotif, he used the following rhythm in duple meter that he introduced in the first session:

This sort of controlled duet could easily feel more like a mechanical test for me than a shared musical expression, nevertheless, we manage to enjoy a playful moment when I imitate his accidental stick-click, and he adopts it as part of our shared repertoire. Although Tom is laughing, the sound of his laughter has a tense, choking quality. For some time, I have resisted Tom’s attempts to control my instrumentation and musical material, as this sort of domination feels entirely inappropriate within an art medium. The feelings evoked by being ordered, “Sing now!” or “Play like this!” painfully arrests the free inward ranging and suspension of disbelief so necessary to shared musical expression. Here, I was faced with a choice either to satisfy the requirements of creative improvisation or satisfy the requirements of the anxious boy in the room with me. It now seems to me that to be

helpful to Tom, I needed to be able to tolerate the feelings of being interrupted and cut-off, of being un-free, of being like a puppet, of being at best, a musician in his orchestra, playing his score...the feelings which he put into me. It was these considerations which led me to abandon some of my earlier structuring tactics, such as insisting that I choose my own instrumentation. Tom’s use of the chimes in this session and in later ones, illustrated his tendency to make primarily nonmusical use of instruments. A small table would be laboriously covered with a selection of musical instruments, usually fetched from the cupboard with my help. Tom and I would sit opposite each other, and he would repeatedly engage me in unnerving “tests” less related to the sound of the chimes than to their appearance. For example, he would play a phrase for me to copy which consisted of two small black bars and one large white one with a green dot. I was supposed to respond by playing two small black ones and one large white one with a yellow dot because I did not have a green dot. I would, of course often get this wrong, as I would be listening to the pitches rather than thinking about the color and size of the bars. Subsequently, Tom would change his criteria for correctness so that I seemed ever doomed to get it wrong and earn an irate reprobation. Thus, Tom effectively gave me a clear experience of what it is like to be on the wrong end of a learning difficulty. Another chime game that developed was “Hey Pamela, Hey Tom.” We would begin playing antiphonally or together, and then Tom would venture onto one of my chimes, at which time I would give a cry “Hey Tom!” Often I would be instructed as to when to play on one of his chimes so that he could then be indignant and cry “Hey Pamela!” At other times our music games would require my imitation of his leitmotif. Sometimes these games began to move towards being truly musical, and short improvisations would “break out.” Occasionally, waves of ringingly dissonant simultaneous chime playing would emerge briefly, which had more an abandoned quality than the robust and square playing of much of Tom’s material. In these episodes it seemed that the small sounds of the chimes made our shared engagement feel more manageable than did the larger instruments, although, most often, we soon had to return to more formally demarcated structures in order to be co-active. In one instance, Tom even halted the musical interaction with “Oh, I’ve got one point,” as if we had been only scoring against each other rather than exposing ourselves in self-expression. Session 9 through 18 Much of our work in sessions nine through 18 was still characterised by disordered and interrupted exchanges, however, Tom did begin to initiate and sustain some episodes of more prolonged and satisfying musical co-activity. I began to allow him limited access to the cupboards. Particularly important in this period was that Tom began to find good objects (including the therapist) within the sessions, and began to communicate this. For example, he sings of one session, improvising “And it was good....and it worked...” I continued to feel anxious, resentful, and resistant to the unsatisfactory aspects of our relationship. Sessions 19 through 37

From the 19th to the 37th session, some ordered, slower and calmer episodes occurred, along with some welcome silences. Our musical activity decreased, while nonmusical play and conversation increased. When musical activity did occur, brief moments of freer improvisation emerged within extended periods of playing together. Tom developed an increasingly important relationship with the gong. He was becoming more able to think about endings (e.g., of sessions and holiday breaks). I allowed him free access to the instrument cupboards, and allowed him to bring toys and other things into the room. Tom spoke more in his own voice, and I became, at times, the wicked witch to whom he had earlier given voice. He was also better able to take in what I said to him and to express his confusion verbally, thus allowing me to address it. Eventually, Tom began to acknowledge me as a possible container, commenting for example at the end of Session 30, “I’ll leave the mess in here.” I began to feel more able to accept his plundering and to tolerate my feelings of inadequacy. Discussion Earlier, it was mentioned that Tom would attempt to break away from an engagement by wanting to leave the room. While this continued to be a feature in almost all sessions, it later developed in the form of his wish not to enter the therapy room at all but to dash into nearby rooms which might contain instruments, a television, or people who Tom would try to engage in conversation. Sometimes he expressed a wish to stay in the waiting room playing with toys rather than come to music. Often, during our half-hour sessions, he would run to the window banging and shouting to passers-by in witchy, authoritarian voice. Tom’s avoidance of the therapy situation turned out to be an important clue to understanding the feelings underneath all of his naughty, controlling, and tricky maneuvers. It is therefore a fitting place to begin a more in-depth discussion of what Tom may have been revealing to me throughout these sessions. Session 19 was of particular significance. When our appointment time arrived, I found Tom sitting on the steps outside the building, sobbing, and refusing to come in the main door. The sense of his fear and misery seemed more evident than they had previously been. The manner in which Tom had characteristically moved around in the therapy room, or expressed his wishes and dissatisfactions had always been similar to that described at our first meeting, by his teachers, etc. He appeared confident, fussy, and bossy, and his attempts to control me were irritating rather than expressive of fear and deep distress. On this occasion, when I asked Tom what he was afraid of, he was able to tell me through his tears: It was the gong in the therapy room—he was afraid of going into the room if it was there. Tom’s reluctance to enter the room, his frequent requests to leave it, his wish to control my instrumentation, his preference for antiphonal over simultaneous playing, and his tendency to break away from musical improvisation seemed to be interrelated. As in his fear of the gong, they may be viewed as aspects of a phenomenon in which Tom is terrified and distressed by something which is very big, whose resonances multiply set off by a single stroke, and which grow with an overwhelming effect of vibration and sonority, impacting on mind and body. Perhaps the freedom of improvisation itself sets up these kinds of feelings within him. In fact, Tom developed an activity in which, standing together with him at the gong, I must be ready to

dampen it on his instruction, so that he could hit it very hard without its full resonance returning. Perhaps it is when that fearfulness, here elicited by the gong, is not fully conscious, that Tom has to adopt a range of maneuvers in relation to other people in order to keep it at bay. Maneuvers such as engaging in, but prematurely breaking off, interaction manifest as irritating, naughty, and “tricky” behaviour and appear to be the result of poor concentration or sequencing problems, but in actuality may be defenses. It is easy to see that his relationships with family and peers would suffer as the result of such defensive maneuvers, as would his ability to take in and keep down learning. Interaction with Tom often does feel tangled. It is difficult to sustain one activity with him without constantly expecting it to be broken off. In any setting where an adult had predetermined activity goals, I imagine that Tom would certainly be described as disobedient. It is as if Tom himself “gongs” around, as he did that first day in my office, a constant flow of physical and verbal activity, overturning and upsetting things, making sure that his “vibrations” disturb whatever is around him. Then, when he strikes the actual gong, it all comes back at him. Suddenly, all the unmanageability assaults him as if from outside--but magnified, amplified. What elements of his disposition and early experiences might have contributed to his inner world being characterized by a fearfulness which seems to vibrate like the sound of the gong through his whole body? This image itself conjures up the frightening image of finding oneself taken over by a convulsion, which shakes one from the inside. We do know of at least two occasions on which Tom suffered from extreme forms of generalised convulsion. Conceivably, there may have been others, possibly nocturnal, which went undetected but were, nevertheless, experienced by Tom alone. His bed-wetting could have been seizure-related at times, and headache and nausea may have accompanied the seizures themselves, and be more easily alluded to by Tom than the seizure itself. A family history of migraine might dispose him to experience these particular manifestations of illness. While this vision should be borne in mind, I am also reminded of the contrast between Tom and his mother which suggested itself at our first meeting. Perhaps he has had a repeated experience of himself as somehow too big for her, too much to be “borne” by her. It may be that his frequent request to leave the sessions comes from a fear of being too much for me, of damaging me as he fears he has damaged his mother. For the child who experiences his mother as absent in some way, or not there for him, must attribute the cause of her absence to himself. Tom may also leave the therapy room in order to check that his actual mother is still accessible (although she, in fact, chose to leave the building during his therapy sessions). He may need to be physically close to her because psychically the safe inner mother seems absent, or not big enough to hold him safely. These speculations seem to be confirmed by two themes in Tom’s music therapy sessions: Firstly, his preoccupation with broken objects, and an anxiety that he had broken or would break instruments; secondly, his preoccupation with big and little things, where he frequently tried to ensure that I have smaller instruments or beaters than his. The tragedy of this situation, or rather the tragedy of its internal meaning, is that while he feels frightened that he is too big for the therapist, he is equally frightened that she is bigger than him: for what could be more frightening than to feel completely vulnerable with a big person who may not respond to your needs? In the moments when he breaks off our contact, he may be frightened

that he is going to damage me with his bigness, or equally frightened that in being out of his control, I am going to damage him with mine. In his rummaging in the cupboards, he seems to show that he needs to help himself to what he needs, rather than hope that together he and I can negotiate to fulfill his needs. If the caregiver is experienced as unable to contain the child’s feelings, then the world feels intolerably unsafe, and the child feels unheld. The spinning trickiness seems to result. Tom moves quickly from one thing to another, not managing to settle into a satisfying engagement. As in feeding, food that is offered and taken in cannot be held down (vomiting), or feels as if it must come back up again (nausea). Tom feels ill; he rolls into a ball and asks to go to bed where at least the external spinning world recedes. But by lying down in a ball, he deprives himself opportunities to take in, to learn, and to make real relationships rather than attach himself, inappropriately, to strangers. Why might Tom experience himself as unheld and uncontained? Several factors may have contributed. Firstly, the dispositions of Tom and of his actual mother may have been in some way mismatched, so that if a slow and gently-moving mother has a fast-moving and extroverted baby, adjustments have to be made until they find possible ways of relating. Stern (1977) refers to such difficulties as the result of “missteps in the dance” of the mother-infant relationship. The fact that Tom tended to regurgitate feeds as a baby might indicate that it was difficult for him to ingest the good things that were offered. The pace of feeding may have been a source of difficulty between them, and an optimal “balance of power” was perhaps not successfully achieved. Furthermore, if Tom did suffer minimal damage at birth, which is now related to his having both generalised and petit mal seizures, he may have had recurrent experiences of, as it were, the world dropping away from him. That is, constitutionally he may have been disposed to experience absences. In petit mal seizures, this would happen quite privately within Tom’s world, unmitigated, therefore by observation and concerned explanation. When he awoke in hospital after his generalised convulsion, he may have had an experience not only of having dropped out of reality, but of reality itself having dropped away. This would easily integrate into an experience of a caregiver who seemed less than fully there, not quite “as large as life” as the child himself. What has been described so far may well have been compounded by his experience of losing his mother to a sibling in his third year, and shortly afterwards being sent to a formal, academic school, thus losing his own time to be a playful child at home. While a hearing loss and an articulation problem may, of course, have an organic component, they may also externalise the child’s experience of himself as not being able to take in and not able to make himself understood. If Tom feels that he has to stop the world from disappearing from his frenetic activity, he must be in a state of pain and fear. Unfortunately, his “naughtiness” and “disobedience” make it harder to get and stay close enough to him to understand more about his real state. The “tricky” Tom is a draining child, and a drained caregiver has even less energy with which to try to understand him. A father, himself stretched by professional responsibilities, may avoid spending more time at home when his son is so frequently naughty and troublesome. This study has in some ways focused on the tricky, tangled Tom, rather than on the sick and “in a ball” Tom who did not generally find a place in our sessions. One exception to this was

the session following his hospitalisation, in which he made himself a bed on the floor and lay sadly hugging a small drum which he said was “the thunder in his bed.” Until now, I have perhaps not said enough about the well Tom, the hopeful Tom who engages with the therapist, bringing her not only his difficulties but also his resources. His playing, as we have seen, could be remarkably strong, sturdy, outwardly directed, selforganised, forward-moving, trembling, and even randomly free. His break-off points were not due to a lack of sensitivity to my playing. On the contrary, it was his sensitive awareness of our being together in phrase, volume, etc., which seemed to drive him to break off. In his rummaging in the cupboards he often remarked as if to himself “Something might work...” His pun on the piano’s brand name, substituting his own name for its second half, seemed both proprietal and celebratory, and became a repeated and much enjoyed point of shared understanding. His present of a flower to me, with the remark that queens have flowers, and brides do too...all these aspects of Tom seem to show that he has had good experiences, albeit incomplete or unfinished, and that he is hopeful of finding more or of “getting back.” In one of our last sessions, Tom acknowledged that “Humpty needs a doctor...a lady doctor...the one he’s pointing at” (Me). The material in his sessions became less musical as time went on. In the last sessions before summer holiday, he very much wanted to play a game in which he repeatedly called me towards him, and then sent me away again just as I drew near. When I related this to the holiday and the breaks between sessions, he was able to say solemnly and without “gonging” how much he would miss music. It should be understood that when faced with the choice of committing myself to the medium of “pure” music versus trying to help Tom, I chose the latter. This did entail working beyond the medium in which I was originally trained, and was a responsibility which was not taken lightly. Though this did cause some anxiety, I came to accept less truly musical meaning in the sessions. Tom did surprise me in Session 35 by playing a free solo improvisation on the piano strings, an instrument he had previously anxiously avoided, fearing that it was broken. When he asked me if I liked what he played, I replied that I did and then asked him rather prosaically, “What did it say?” To this Tom replied, looking at me as if I should know better, “It didn’t say anything, it was music.” Perhaps my acceptance of all his material actually freed him to make musical explorations, which previously felt impossible because of his experience of my own resistance. In the nursery rhyme, no one was able to put Humpty together again. This may have been at the back of Tom’s mind when he asked anxiously, “How can this get back?” The answer is that he couldn’t really get back, in the sense of putting back the clock and growing differently. However, my hope was that through the holding he experienced in therapy, he might find the ability to feel the pain and fear of his early losses fully, rather than being driven through current experiences under their power. he role of improvised music-making in this process remains unclear. It may offer holding experiences; it may also reflect changes which have originated in nonmusical play. It may facilitate the surfacing of fear, although it cannot refer directly to its causes. It seems certain however, that therapeutic theory and technique must always adapt to the needs of the patient, rather than vice versa.

Glossary CAT Scan: Computerized Axial Tomography. A technique using computer technology to produce cross-sectional X-ray pictures of the body. EEG: Electroencephalography. A recording of the electrical activity of the brain as measured with the aid of electrodes attached to the scalp (Scott, 1969). Episode of Engagement: A sequence of social behaviours of variable length bounded by clear pausing time on either side (Stern, 1977). Generalized Convulsion: A violent series of involuntary contractions of muscles usually associated with complete loss of consciousness (Scott, 1969). Petit Mal Seizures: A brief epileptic fit...not associated with convulsive movements but with a brief loss of consciousness (Scott, 1969). Status Epilepticus: A serious condition in which one major fit follows another without consciousness being regained (Scott, 1969). References Scott, D. (1969). About Epilepsy. London: Duckworth. Stern, D. (1977). The First Relationships: Infant and Mother. London: Open Books.

CASE FOUR A Research Case Study on the Effectiveness of Nordoff-Robbins Music Therapy in Accomplishing Musical and Socio-emotional Goals for a Child with Autism John Carpente This case study examined the effectiveness of Nordoff-Robbins Music Therapy (NRMT) carried out within a Developmental, Individual-Difference, Relationship-based (DIR®) Floortime™ framework in addressing the individual needs of a child with autism. The primary aim was to determine the effectiveness of NRMT in meeting musical goals specifically established for the individual child, and to determine if progress in musical goals paralleled progress in socio-emotional goals (DIR®) goals. Nordoff-Robbins Music Therapy Nordoff-Robbins Music Therapy (NRMT), originally coined Creative Music Therapy is an improvisational and compositional approach to music therapy developed by Paul Nordoff, an American composer/pianist, and Clive Robbins, a special educator from Great Britain (Bruscia, 1987; Kim, 2004). They worked closely together from 1959 to 1976 as therapist and cotherapist with children with special needs in various settings (Nordoff & Robbins, 1971). After the death of Nordoff in 1976, Robbins continued to develop the work worldwide. Today NRMT is practiced and studied throughout the globe. Traditionally, NRMT involves two therapists participating in sessions: the primary therapist is responsible for spontaneously creating music on a harmonic instrument, usually on guitar or piano; the co-therapist interacts directly with the child, facilitating musical participation and engagement. A central concept in NRMT is the “music child,” which is based on the belief that all children have an inborn musicality and the capacity, regardless of pathology, to respond to musical experiences (Nordoff & Robbins, 1977, p.1). However, in order for the “music child” to flourish the “child must be open to experiencing himself, others, and the world around him; for it is through these experiences that receptive, cognitive, and expressive capabilities are developed” (Robbins & Robbins, 1991, p. 57). What prevents the “music child” from functioning is what they called the “condition child” (Nordoff & Robbins, 1964; 1977). The condition child, encasing the “music child,” represents what the child has come to be—his learned responses to the world and his personality development based on how he has internalized life’s experiences. Nordoff and Robbins (1964; 1968; 1971; 1977) found that, through the use of music improvisation, the “condition child” can be bypassed, reaching the inborn musicality of the individual’s “music child.” In nurturing, challenging, and supporting the “music child” through musical experiences, the child develops beyond the conditioned self and into new ways of experiencing the self and the world. A “new self” is born, and the “condition child” becomes the “old self” (Robbins & Robbins, 1991, p.59).

The primary focus of interaction in NRMT, then, is the musical relationship between the child and therapists. Verbal interaction is not essential in NRMT, rather, it is the musical experience and level of musical relatedness of the child that is important. Because the primary focus is on music, “the musical process is the clinical process” (Aigen, 2005, p. 94), meaning that the therapist’s primary concern is to develop and incorporate musical interventions to deepen the child’s musical engagement and interaction. In NRMT, musical goals are clinical goals (Aigen, 2005). What a child accomplishes musically is regarded as a clinical or therapeutic accomplishment. For example: NR therapists may work on a child’s ability to increase the dynamic range (loud and soft) of his drum playing, or expand the range of tempi (fast and slow) while playing the xylophone. Although the focus is on musical goals and the widening of the child’s musical experiences, it is clear that these goal areas can also address cognitive, expressive, sensory, and social deficits. In considering all that is involved to achieve the above musical goals: motor planning, auditory cuing, fine and gross motor skills, visual spatial processing, and sensory modulation, it becomes clear that developmental goals are realized through musical goals and experiences. In NRMT, the child is an active creator of music, playing a vital role in the direction of the musical process. The child plays various instruments that require no formal training or experience, while the therapist improvises music built around the child’s music-making, emotional state, and/or movements. Meanwhile, the therapist improvises music to musically engage, match, support, and enhance whatever the child is offering, musically or non-musically, therein promoting relatedness, communication, socialization, and awareness within the music itself. In working within the Nordoff-Robbins approach, the therapist directly responds or calls out to the child, creating musical questions and answers to elicit a back and forth musical dialogue. The therapist may create a musical scenario that seeks a musical response; create music that reflects a child’s “being” or emotionality; or improvise music to address the child’s sensory needs for musical engagement. Furthermore, the therapist may create music that seeks to provoke a child into a certain musical response, or improvise music to a child’s idiosyncratic, perseverative behaviors to make the behaviors communicative and interactive. In all forms of NRMT, the therapist uses his or her musicianship, creativity, intuition, and clinical knowledge of the child to improvise music that will activate the child’s will, motivation, and passions, thereby bringing the child into musical mutuality and intentionality. Through the experience of coactively improvising music, children can experience themselves in a new way, beyond their pathology, and perhaps free from their habitual behaviors (Sorel, 2005). Over time, the therapists and child together develop various musical materials (e.g., themes, songs, and instrumental pieces), based on spontaneous events and experiences that arise in each session. Within these co-created musical materials, clinical goals and treatment plans are identified and pursued by the therapists. All sessions are videotaped and documented so that significant responses may be noted, and musical ideas and new songs can be transcribed for future use. In reviewing each session, therapists may observe that a particular musical theme (e.g., an interval, motif, or rhythm pattern) or song evokes an instrumental or vocal response from the child; the therapist can then incorporate that music into the clinical repertoire to explore further in subsequent sessions. Developmental, Individual-Differences,

Relationship-based Model (DIR®)/Floortime™ DIR® is a developmentally-based approach that is used as the foundation for a comprehensive intervention approach (Greenspan & Weider, 1998; 2006b). The focus of the model is to help children with special needs build healthy foundations for social, emotional, and intellectual capacities, rather than simply focusing on isolated behaviors (1998). The term, “Developmental,” includes six levels of development that help the child build these capacities. The six levels of development are described below as affected by ASD in children of any age (Greenspan & Weider, 1998; 2006b): • • • •

• •

Level one: Shared attention and regulation occurs from age 0–3 months. An infant at risk for ASD may show difficulty in sustaining his attention to sights or sounds, and may prefer to engage in self-stimulatory behaviors. Level two: Engagement and relating occurs from 2–5 months. An infant at risk for ASD may show difficulty sustaining engagement and will usually withdraw from interaction and become self-absorbed. Level three: Purposeful emotional interactions occur from 4–10 months. An infant at risk for ASD may display no interest in interacting, or engage in brief back-and-forthexchanges with very little initiative and may engage in random or impulsive behaviors. Level four: Chains of back-and-forth (joint attention) emotional signaling and shared problem-solving occur from 10–18 months. A child at risk for ASD will show an inability to initiate and sustain several back-and-forth interactions of emotional signals (e.g., showing mom or dad a toy) and may engage in perseverative behavior patterns. Level five: Creating ideas occurs from 18–30 months. A child at risk for ASD will have difficulty using words or phrases meaningfully and engaging in pretend play; he/she will repeat words of what has been heard or seen (echolalia). Level six: Building bridges between ideas: Logical thinking occurs at 30–42 months (e.g., I want to eat because I’m hungry). A child at risk for ASD will display either no words, use memorized scripts with random ideas or use words and ideas illogically.

“Individual-Differences” refer to how the child processes: information and language; underlying motor and sensory capacities, such as touch, sound, and other sensations; auditory processing; visual-spatial processing; and motor-planning and sequencing abilities. For each of the six stages described above, the therapist needs to look at these particular “individual-differences” of the child and determine how they interfere with the child’s moving up the developmental ladder. This gives the clinician an integrated picture of the child’s development. The term “Relationships” in the DIR® model refers to how the child interacts with others (e.g., family members, teachers, therapists, and caregivers) and what patterns of interaction should be included in the therapeutic program to support enhanced development of the child. As can be seen, each component of the DIR® model complements the other. First, it is important to understand at what level the child is functioning developmentally. Secondly, one must ascertain what stands in the way of a child’s development and how the child is processing the world around himself or herself. To understand this, one must know how the child

processes information and navigates in the world. Lastly, it is critical to know how the child relates to others in the world. Once there is a developmental picture and a sensory profile of the child, the therapist can guide him/her into ways of interacting and relating that will provide the proper sensory input necessary to move up the developmental ladder. One of the main components of the DIR® Model, which parallels NRMT, is Floortime™ (Greenspan & Weider, 2006a). Floortime™ is a systematic way of working with the child to help move him/her up the developmental ladder. Similarities between Floortime™ and NRMT are that they both involve improvisation, creativity, spontaneity, emotionality, and a playful spirit. The main difference is in the medium. NR therapy primarily involves the use of music, and Floortime™ primarily involves the use of objects, toys or sensory items. Described below are the five primary steps involved in Floortime™ (Greenspan & Weider, 1998; 2006b): 1) Observation: Both listening to and watching a child is essential (facial expressions, tone of voice, gestures, body posture, and use of or lack of words). 2) Approach—Open circles of communication: Once assessing the child’s mode of interacting or responding, the therapist can approach the child with the appropriate words, gestures, and affect. He or she can open the circle of communication with a child by acknowledging the child's emotionality, then elaborating and building on whatever interests the child at the moment. Follow the child's lead: After the initial approach, following a child's lead simply means being a supportive play partner who is an "assistant" to the child and who allows the child to set the stage by directing the action, and creating dramas. 3) Extend and expand play: As one follows the child's lead, extending and expanding play themes involves making supportive comments about the child's play without being intrusive, helping him/her to express ideas and move to ideas into different directions. (Asking questions to stimulate creative thinking may keep playful exchanges moving along, while also helping the child understand emotional themes involved). 4) Child closes the circle of communication: As the therapist opens the circle of communication when the child is approached, the child closes the circle when he/she builds on the therapist’s comments with comments of his own. One circle flows into another, and many circles may be opened and closed in quick succession as one interacts with the child. By building on each other's ideas and gestures, the child begins to appreciate and understand the value of two way communication. In the present study, NRMT and DIR® were used in tandem. NRMT was used as the primary treatment approach, and focused primarily on musical goals and the establishment of musical relationships between therapists and child. DIR® was used as the primary means of conceptualizing and assessing the child’s strengths and needs in nonmusical modes of interaction and relationship, and evaluating the child’s progress in these areas. Research Questions

Four efficacy questions were posed: 1) Did the child make significant progress in achieving the individualized musical goals formulated specially for the child within an NRMT framework. Progress toward these specific goals was measured using Goal Attainment Scaling (GAS) (Kiresuk & Lund, 1974; 1978), an interdisciplinary approach to formulating individualized treatment goals and evaluating their accomplishment. (More details will be given later in the study). 2) Did the child make significant progress in achieving the individualized nonmusical goals formulated for the child in the DIR® model? Progress in meeting these goals was measured using the Functional Emotional Assessment Scale (FEAS) (Greenspan, DeGangi & Weider, 2003). (More details will be given later). 3) What is the process by which goals for this child were addressed by the therapists and accomplished by the child? The process was assessed evaluated through a comprehensive music therapy and DIR assessment followed by comparing outcomes using the FEAS and GAS. 4) Did progress in musical goals (NRMT) parallel progress in nonmusical (DIR®) goals? Efficacy Measures Musical Rating Scales Musical characteristics and needs were initially assessed and later evaluated through Goal Attainment Scaling (GAS) (Kiresuk, Smith, & Cardillo, 1994). (See Procedures for a description of these sessions).The GAS consists of a set of musical goals established for each child by the researcher and an independent observer (e.g., an experienced, board-certified, Nordoff-Robbins therapist), following the music therapy assessment, along with five possible outcome levels for each goal. The outcome levels consisted of a 5-point continuum, ranging from the most unfavorable possible outcome to the most favorable possible outcome. Thus, the child had a set of individualized musical goals, which had been operationally defined in terms of five levels of outcomes, and had been weighted for relative significance for the child’s therapeutic program. Socio-emotional Rating Scales The Functional Emotional Assessment Scale (FEAS) was used as a pre-and post-test measure of the child’s progress in achieving goals pertinent to DIR®. The FEAS is a standardized, age-normed assessment tool developed by Greenspan and DeGangi (Greenspan, DeGangi, & Weider, 2001) that can be applied to videotaped interactions between children with autism and their caregivers (Solomon, Necheles, Ferch, & Bruckman, 2007). The FEAS provides a framework for observing and assessing a child’s emotional-social functioning in the context of the relationship with his/her caregiver, assessing the child in six areas of social-emotional development: (1) regulation and interest in the world, (2) forming relationships (attachment),

(3) intentional two-way communications, (4) development of a complex sense of self, (5) representational capacity and elaboration of symbolic thinking, and (6) emotional thinking or development and expression of thematic play(Greenspan, DeGangi, & Weider, 2001). (See Appendix A.) For information on validity and reliability, see Carpente (cite dissertation). The FEAS is divided into two sections (caregiver and child) with six subtests in each section corresponding to six levels of social and emotional development: (1) regulation and interest in the world, (2) forming relationships, (3) intentional two-way communications, (4) development of sense of self, (5) capacity of symbolic thinking, and (6) emotional development and expression of thematic play (Greenspan, DeGangi & Weider, 2001). According to Greenspan and DeGangi (2007), typically developing children achieve early two-way communication by seven to nine months, correlating to Functional Developmental Levels (FDL) one to two. FDL three is achieved between ten and twelve months, FDL four between thirteen to eighteen months, FDL five from twenty-five to thirty-five months and FDL six between three to four years of life (Greenspan, DeGangi, & Weider, 2001). Scoring is based on a 2-point scale for most items, except where indicated. The scorer identifies three possible outcome levels (0, 1, and 2) for all areas within each of the six levels of core capacities (Greenspan, DeGangi, & Weider, 2001). The FEAS scored the child on their mastery of the skill as follows: 0 = behavior is not seen or is briefly observed (skill not mastered). 1 = behavior is present some of the time or observed several times (skill partially mastered). 2 = behavior is consistently observed or observed many times (skill mastered). The ratings can be summed to obtain subtest scores for the caregiver and for the child, as well as total test scores (Greenspan, DeGangi & Weider, 2001). In order to determine if a child or a caregiver is at risk (below cut-off scores), the total scores are compared to cutoff scores of a given category (cutoff score categories include: normal, at-risk, and deficient). In the present study, total scores of the child on the pre-and post-tests of the FEAS, administered at session 1 and 26, were compared to assess the amount of the child’s progress in each capacity. Assessment and Evaluation Procedures All of the sessions were conducted in the school’s music therapy treatment room, approximately 500-square feet in size. The room was equipped with a video network system which was used to record all sessions. The musical instruments used were from the current music therapy instrument inventory at the school; they included various pitched and unpitched percussion instruments (e.g., drums, tambourines, cymbals, maracas, xylophones, marimbas, and a variety of sizes of drum sticks and mallets), an acoustic piano, an electric keyboard, and electric and acoustic guitars. The child received a total of 26 sessions. Two sessions involved pre-and post-testing on the FEAS, and the other 24 sessions consisted of NRMT. Each NRMT session lasted 5-30 minutes and was dependent upon on the child’s tolerance. The sessions were given twice per week, on Mondays and Wednesdays. At the end of session 25, an independent observer (an experienced,

board-certified, Nordoff-Robbins therapist) evaluated the child’s progress by selecting the outcome level on each child’s GAS that best described his or her musical responses in the session, as compared to the original evaluation. When the child made significant progress during treatment, goals and outcome scales were adjusted accordingly for the next period. In the first session, the child participated in a pre-test FEAS, facilitated by the researcher, who has had extensive training in DIR®/Floortime™ Model. The researcher used the following five steps of Floortime™: 1) observation, 2) opening circles of communication, 3) following the child's lead, 4) extending and expanding play, and 5) facilitating the child in closing circles of communication. The pre-test FEAS was videotaped and then scored by a rater (school psychologist experienced in rating FEAS). Following the FEAS scoring, the researcher reviewed records at the school to gather information about the child pertinent to formulating initial goals and treatment plans for music therapy treatment. In addition, the researcher interviewed the child’s parents, teachers, and therapists. Based on this information, the researcher established preliminary therapeutic goals pertinent to FEAS and NRMT. In sessions 2 and 3, each child received NRMT sessions conducted by the researcher and co-therapist. The co-therapist was a music therapy intern who had been working at the school under the supervision of the researcher, and was therefore knowledgeable of both NRMT and DIR®. Following the first two treatment sessions, 4–6 individualized goals were created for the child based on her performance on the FEAS and clinical observations. An independent observer (an experienced, board-certified, Nordoff-Robbins music therapist) assisted the researcher in creating 4–6 goals for the child. The researcher then incorporated these goals into the format of Goal Attainment Scaling by specifying levels of outcomes and weighting their therapeutic significance. Therapy continued bi-weekly for sessions 4 through 13, according to the established goals. At the end of the 25th session, the child’s progress in meeting NRMT goals (GAS) was evaluated by the independent observer. At the 26th session the FEAS was administered again by the researcher, as a post-test measure of child progress. Again, the rater of the post-test was the school psychologist. Below is the sequence of pre- and post-test measures and their timing in relation to treatment. Sessions were scheduled twice a week on Mondays and Wednesdays. Session 1: Researcher administered the FEAS (pre-test) to the child while implementing Floortime™ techniques. School psychologist (rater) viewed video-recording of the FEAS and scores the results. Sessions 2-3: Music therapy treatment began with the primary therapist (researcher), co-therapist and child (clinical assessment and formulation of goals). Session 4: After two music therapy treatment sessions, and before the third treatment session, 4–6 goals were formulated by the researcher and independent observer (e.g., experienced board-certified NR therapist). Session 25: The child’s progress was evaluated following music therapy treatment session twenty-five by the independent observer (an experienced, boardcertified, NR music therapist).

Session 26: Researcher administered the FEAS (post-test) to the child while implementing Floortime™ techniques. School psychologist (rater) viewed videorecording of the FEAS and scored the results. All sessions were video-recorded. The researcher viewed the video for each session given prior to the participant’s subsequent session. This was done so that significant responses of the child could be noted and musical ideas that elicited responses could be transcribed for use in subsequent sessions. Session videos were transferred to the researcher’s portable hard drive and stored on the researcher’s personal home computer. All data stored on the computer were protected and secured by a password that was known only to the researcher. The researcher also kept a clinical journal on each participant. The clinical journal included brief descriptions of each session, including: what the therapists did, how the child responded, and what happened from a therapeutic standpoint. The computer files for these journals were stored in the researcher’s personal home computer; printed copies were stored in a locked file cabinet at the researcher’s home. Only the researcher had access to the cabinet. All written materials on each subject generated through the FEAS and GAS were stored in a locked file cabinet at the researcher’s home. Only the researcher had access to this cabinet. All electronic data generated for each subject were stored in the researcher’s home computer, which was password protected to provide access only to the researcher. The researcher conducted one-hour, weekly supervision for the co-therapist specifically to support the clinical work with each child, such as to review treatment planning, and therapeutic process. Relationships Throughout this study the researcher played multiple roles, such as researcher, clinician, and clinical supervisor. In order to adhere to the highest standards of intellectual honesty and integrity within this research study while also ensuring the integrity of the clinical work with each child, the researcher participated in peer supervision with the independent observer (e.g., an experienced, board-certified, Nordoff-Robbins music therapist) during weeks three, six, nine, and twelve). All written materials on each subject generated through the FEAS and GAS were stored in a locked file cabinet at the researcher’s home. Only the researcher had access to this cabinet. All were stored in the researcher’s home computer, which was password protected to provide access only to the researcher. The researcher conducted one-hour, weekly supervision for the co-therapist specifically to support the clinical work with each child, such as to review treatment planning, and therapeutic process. Data Analysis The FEAS pre-test ratings for the child were added together for subtest scores, as well as a total test score. Pre-and post subtest and total scores were compared for each child to

determine if progress has been made in each subgroup as well as in the total test score (Greenspan, DeGangi & Weider, 2001). The GAS system includes a statistical procedure for analyzing the extent to which the participant is meeting all of the individually weighted goals. GAS emphasizes both the idiographic approach to measuring the uniqueness of the individual, while also arriving at nomothetic conclusions about these individuals (Kiresuk, Smith, & Cardillio, 1994). Although GAS was originally developed to evaluate mental health treatment outcomes, it has been used in many disciplines including education, rehabilitation, medicine, corrections, nursing, chaplain training, social-work, and chemical dependency (1994). At the end of the study, the researcher and independent observer used the raw score conversion key for GAS, developed by Cardillo (1994), to convert the outcome scores that best described each child’s progress on his or her goals. Raw scores were converted to T-scores with a mean of 50 and a standard deviation of 10 (Kiresuk & Lund, 1976; 1978). A standardized score of 50 represented an acceptable outcome; a score of 60 and above indicated that the child’s progress has exceeded expectations, while a score of 40 or below indicated that the child had not achieved an acceptable outcome. Qualitative data on process and outcomes were used to confirm, illuminate and expand upon pre-and post-data comparisons from the FEAS and GAS. Two questions were posed in analyzing the qualitative data and its relationship to the quantitative data: 1) are the qualitative data and quantitative data consistent with one another? 2) to what extent do the qualitative data illuminate or explain the quantitative data? The researcher then used these findings to write the following case study of Janet. The researcher also created a video documenting his work with Janet. Janet’s Background Janet, age 8 years and 8 months at the time of this study, was the product of an uncomplicated, full-term pregnancy and C-section delivery. She weighed 7 lbs., 13 oz. at birth, and no complications were indicated. Her medical history revealed mild ear infections at age 2. She reached developmental milestones for sitting and crawling within normal limits, with independent walking appearing at 11 months. Janet was reported to have babbled during her first 6 months, was responsive to speech and was not an unusually quiet baby. She developed several words such as “peek-a-boo” and “David” (her brother’s name); however at 18 months of age, she stopped using words all together. She was diagnosed with autism at 22 months. Janet lives at home with her mother, father, and her 11 year-old brother. Prior to entering the Rebecca School Janet attended another school where she received occupational and speech therapies five times per week, and Applied Behavioral Analysis 20 hours per week. Janet has been attending the school since September 2007, where she is receiving occupational and speech therapies three times per week and music therapy two times per week for 30 minutes. Assessments

DIR® Profile The following DIR® profile is based on: 1) pre-test scores of the FEAS (See table 1); 2) interviews of staff; 3) and observations of Janet in various settings throughout the school day, including the classroom, occupational therapy, and speech therapy. Janet is an energetic child who displays difficulty maintaining engagement (level II) and 2-way purposeful communication (level III) with caregivers for extended periods. She constantly engages in perseverative body movements, displays difficulty with simple motor planning tasks, and presents with low muscle tone and poor balance. She likes vestibular input (swings, hammock, etc.), but seems to have difficulty sensing her center of gravity. In addition, she exhibits visual spatial processing difficulties, wandering aimlessly, moving from one thing to the next, and bumping into things frequently because of difficulty in scanning a room systematically. Janet displays the ability to problem-solve (level IV) and get her needs met. She has a plethora of memorized phrases, scripts, and words that she often repeats, but is unable to build ideas onto these scripts. In short, she does not appear to have an internal flow or cohesion of ideas. Rather, she appears to be observing or hearing a stream of random visual or audio snippets, like a ticker tape of ideas or words, which she verbalizes as they come to her. Music Therapy Assessment The music therapy assessment, guided by Greenspan and Weider’s Functional Emotional Developmental Levels (FEDL) (2006a), focused on seven areas of musical responsiveness: 1) Musical Awareness: the child responds or reacts in a reflexive or intentional manner related to any of the musical elements being offered. 2) Musical Relatedness: the child exhibits the ability to engage musically in an intentionally and related manner to the therapist’s music. 3) Relationship within Musical Play: the child exhibits an emotional interest in connecting with the music and therapist, based on the child’s own initiative. 4) Music Interresponsiveness: the child exhibits the ability to imitate or copy a musical idea, and then incorporate it into the musical play with therapist. 5) Musical Communicativeness: the child exhibits the ability to open (initiate a musical idea) and close circles of musical communication (end or complete a musical phrase) during musical play; including the ability to engage in call-and-response inter-play. 6) Musical Interrelatedness: the child exhibits the ability to connect his/her musical idea with the therapist’s idea, and then elaborate on it during musical play. 7) Musical Expressiveness: the child exhibits the ability to play using a range of musical expressiveness (e.g. dynamics, tempo, etc.) during musical play. The music therapy room was set up with a variety of percussive and melodic instruments, an assortment of different size mallets with various handle textures, pitched horns, and a variety of sensory based items (e.g., scarves, play-doh, mini-trampoline, etc.). The assessment focused on Janet’s ability to interact during musical play with the therapist.

Janet’s assessment took place during the course of two 30 minute sessions. During the assessment, Janet’s primary modes of interacting were through movement, instrumental play (primarily the drum and cymbal), gestures, and memorized scripts. She exhibited a moderate level of musical awareness. Her vocal responses, although tonal, appeared to be reflexive rather than intentional. Words that she sang/spoke were often repeated scripts that she tended to revert to during moments of stress or excitement. Janet displayed discomfort and anxiety to the new environment, as she engaged in constant motion, moving rapidly from playing one instrument to the next. Finally, when she would stop moving, she usually sat on the window ledge, near the heating pipe, and would attempt to hide behind the pipe. It appeared that she thought that Jean and I were unable to see her (the pipe is only two inches wide). Janet required visual prompting and direction in order to engage in musical play. During these moments, Jean held out a buffalo drum in one hand and a cymbal in the other directly in front of Janet. Janet usually responded by playing on the beat for one to four beats, and then either walked away, or began beating in an excited and unrelated manner, in which she became over-aroused and over-stimulated. Janet demonstrated some rhythmic perception through brief and fleeting moments of beating the drum and cymbal. She displayed an ability to join with the tempo of my music, however, she never initiated musical play and rarely referenced Jean or me at a distance. Physically, she played the drum using only her arms and upper body, as she swayed her body with arms outstretched. Her musical responses, either through vocalizations or instrumental play, displayed a limited expressive range, playing only very loudly on the drum and cymbal, and, when vocalizing, exhibiting no range of affect. In addition, her beating was inconsistent, sporadic, and inflexible in relation to my music. Janet demonstrated difficulty in initiating a relationship within musical play, requiring prompts and hand-over-hand support. In addition, she kept herself at a distance from Jean and me and constantly withdrew from musical and physical contact. When Janet entered into a musical interaction, she displayed the ability to close circles of musical communication (completing or filling in the endings of musical phrases) when prompted, however, she showed difficulty initiating circles of musical communication. In summary, Janet’s inability to maintain musical engagement and relatedness for sustained periods prevented her from experiencing a continuous flow of musical interaction. In addition, contributing to her difficulty in relating for extended periods, were issues dealing with visual spatial processing and motor planning combined with her poor body awareness. Finally, because of her intense ABA program, prior to entering the current school, she learned to engage only through prompt and repetition. She was accustomed to a memory-based approach to learning, whereas the DIR® model is a thinking-based approach. Thus, her previous learning through prompts and external rewards made it difficult for Janet to think spontaneously and to initiate ideas. Treatment

Janet’s treatment consisted of twenty-five sessions over a five month period. During this time, Janet passed through five distinct stages. In the first stage, she displayed difficulty engaging in musical play due to her being in constant motion; this resulted in scattered, perseverative and inflexibly loud playing. During the second stage, Janet became increasingly engaged and related as her perseverative movements became transformed into interactive dancing. During Stage three, Janet’s musical participation moved from movement to instrumental play. Stage four consisted of Janet increasingly becoming communicative and related in and out of musical play. Finally, during stage five, Janet began to display the ability to connect her ideas in the context of musical play. Stage One: Everywhere But Nowhere: Where’s Janet? Janet entered each of our first five sessions in an ambivalent and cautious manner. Generally, after entering the room she spent a lot of time moving aimlessly, playing each instrument in her sight while in constant motion. Her playing was scattered, perseverative, and inflexibly loud. In addition, although she exhibited some sense of musical awareness and moments of relatedness, it seemed as though Janet’s playing was more about her meeting some kind of sensory need, than it was about connecting to the music being played. Her need for motion made it difficult for her to get into a continuous flow of musical contact, thereby impeding the development of any kind of musical relationship. At times Jean (intern) followed Janet, as she moved continuously around the room, and held a drum out in an attempt to capture Janet’s attention and bring her into musical play. The plan for subsequent sessions was to help Janet develop greater body awareness while “slowing” her body down, thereby facilitating her self-regulation (ability to be calm and available for interaction), musical engagement, and musical relationship. To that end, more emphasis was placed on embracing Janet’s perseverative movements through music and dance; less emphasis was put on Janet’s ability to make music. The idea was to use music and Jean (intern) as a way to create form, both physically and musically, which would help organize Janet’s movements into a meaningful interactive experience. Stage Two: Transforming Perseverative Movements into Joint Interaction Sessions six through ten focused on transforming Janet’s perseverative movements into an interactive dance with Jean, thereby promoting engagement, relatedness, and relationship. To that end, I asked Jean to try and be more “hands-on” with Janet and engage her in a joint movement experience. In addition, I asked Jean not to “chase” or follow Janet around the room, but to always try to be in front of her (within her visual range). I also asked her to experiment with getting in Janet’s way, playfully obstructing her from wherever she was headed. This, in a sense, would force Janet to interact with Jean. Musically I experimented with several time signatures and song forms as I attempted to meet Janet’s movements in music. In addition, I incorporated legato type phrases, both vocally and in my piano playing, to create the experience of connection and “flow.”

Theme 1: From Scripted Words to Relatedness and Initiating Relationship. Theme 1 emerged from Janet’s tenth session. It illustrates Janet and Jean dancing to an improvised waltz. The music incorporates random words (scripted) that Janet initiates: “Puffpastries for ta, ta, ta” (These words would become important reoccurring themes in subsequent sessions). In addition, the excerpt displays Janet’s ability to initiate an interaction with Jean. At fifteen minutes and thirty seconds into the tenth session, Janet and Jean engage in an interactive dance. The improvised music captures a waltz “feel,” based on Janet’s movement, and the words that she initiates during the interaction. Jean incorporates Janet’s words into the song form while dancing. Janet recognizes the words while dancing with Jean and begins smiling. Janet accepts Jean holding her hands and appears to be excited during their dance, as they both are in synchrony with the music, swaying in ¾ time. On separate occasions, when Jean and I sing “Ta” and “puff pastries,” Janet becomes overly-excited and each time breaks away from Jean, skipping with excitement to the other end of the room. After several measures, Janet returns to Jean on her own initiative, each time holding her hands out to re-engage in dance with Jean. During the interaction, it appears that whenever Janet experiences sustained moments of engagement and relatedness with Jean and/or in the music, she becomes over-aroused and then engages in perseverative movements and loses the interaction. Stage Three: Moving into Instrumental Play Sessions eleven through fifteen concentrated on facilitating Janet’s ability to engage in instrumental play in a related manner. During this time, she exhibited difficulty with playing instruments due to her poor body awareness and difficulty with motor planning. To that end, I asked Jean to use a lot of prompts, such as holding the instruments in front of Janet (within visual range) in order to indicate when to play. In addition to visual prompts, I asked Jean to use a lot of affect (e.g., over exaggerated facial expressions and gestures) to help maintain Janet’s ability to be engaged and interested in playing. During this time, Janet began to display islands of capacities in the areas of two-way purposeful communication (musical communicativeness), connecting her musical ideas with Jean’s, and elaborating on musical ideas during musical play (musical interrelatedness). Theme 2: Cymbal Play to Increase Relatedness and Relationship. The second theme emerged from Janet’s fifteenth session, depicting Janet sitting in a chair for an extended period of time while musically interacting with Jean on the cymbal. During this excerpt, Janet and Jean get into a long series of back-and-forth musical exchanges, taking turns on the cymbal. During this interaction Janet is calm and engaged in musical play while socially referencing both Jean and me with eye-contact and smiles. At twelve minutes and twenty-six seconds into session fifteen, Janet is sitting on a rolling chair and is swaying back and forth. Jean holds the cymbal in front of her prompting Janet to play at specific moments within the music. Shortly after the interaction begins, Janet becomes increasingly interested and engages in the musical play, as they both take turns playing on the cymbal in a related manner to the improvised music. During the interaction, Jean utilizes affect and facial gestures to help guide and prompt Janet into interactive play on the cymbal. The quality in which Janet plays varies in touch and in

dynamics, based on the music. In addition, she demonstrates moments of musical flexibility and a desire to be connected to Jean’s playing. She also exhibits an emotional connection to Jean, smiling, laughing, and intently watching for an extended period while playing. In addition, at times Janet imitates the way Jean plays the cymbal (touch and motion), while incorporating her own ideas into the music play. Stage Four: Relating and Communicating In and In-between Musical Play Sessions sixteen through nineteen continued to focus on Janet’s ability to engage in instrumental play in a related and communicative manner to the music. The plan was to provide Janet with less prompt and more opportunities to initiate (open circles of communication) and connect musical ideas with Jean’s and/or mine (musical interrelatedness). Furthermore, at this point, I began to look and listen beyond Janet’s music-making responses in order to accurately evaluate her ability to relate and communicate. Because of Janet’s individual-differences (craving movement, getting over-aroused when over-stimulated, motorplanning issues, etc.), it was difficult for her to engage in deep, extended musical experiences. A lot of Janet’s relatedness and communication, musically and interpersonally, were evident when she was not making music (during moments of perseverate movements). Yet, she continued to display her emotional connection to Jean and me through: joyful facial expressions, eagerness to come to music; getting excited while engaged in music-making; and the ability and desire to work through sensory issues to engage in related music-making experiences. To that end, when Janet’s music making was interrupted by her perseverative movements, she continued to exhibit relatedness and communication to the music (and Jean and me) through movements, gestures, and affect. Theme 3: Working through Perseverative Movements for Musical Communicativeness. The third theme occurred during session 16 and displays Janet having difficulty maintaining a basic beat due to her perseverative body movements. She intermittently plays the drum, while constantly swaying back-and-forth in her chair. She engages in a related manner to the music, either though movements or through her playing. Finally, during the moments in which she interrupts the music with her perseverative movements, Janet appears to be trying hard to work through these movements so that she can beat in tempo with the music. Theme 4: Working through Perseverative Movements for Musical Communicativeness (Part II) The fourth theme is taken from Janet’s nineteenth session in which Jean (co-therapist) prompting Janet to beat the drum, using gestures combined with high-affect singing. Janet’s playing is connected and related to the music, as she watches Jean and is listening to the music. At the start of session nineteen, Jean kneels down in front of Janet, and mirrors Janet’s swaying while she sings a melody on “la.” Janet, for the first time asks Jean to sing by simply saying: “Sing.” Jean begins singing 5ths, in an operatic style combined with over-exaggerated arm movements, prompting Janet to play. Janet plays the drum interchangeably with swaying back and forth, but all the while is watching Jean intently. Janet then initiates a dynamic change, playing more softly while playing a basic beat for three measures. Stage Five: Connecting Ideas While Maintaining Engagement and Relatedness

In the past stages, Janet withdrew from an interaction when Jean or I attempted to connect an idea to hers. In addition, she generally fixated on being self-directed in expressing her unorganized and random ideas; any attempt to build on her ideas to facilitate spontaneous thinking would result in her withdrawing from the interaction. To that end, sessions twenty through twenty-two focused on helping Janet to connect her ideas (musical play, words, gestures, etc.), either to mine or to her own, to facilitate internal organization. My intervention at times included imposing my ideas (music, words, etc.) onto Janet’s before she moved on to an unrelated topic, while still helping her to maintain engagement and relatedness. Theme 5: Using the Spanish Idiom to Help Organize and Facilitate Initiation. Theme five emerged from session twenty-two and in which Janet engaging in drum and cymbal play within a Spanish style improvisation (without the use of prompts from Jean). The music appears to help her organize her beating as she plays in a related fashion. Her beating is interrupted by her desire for movement, however, her movement is related to the tempo of the music. Eight minutes into session twenty-five, Janet is seated in front of the drum and cymbal and is preoccupied with the mallets. She looks down and withdraws, as I sing, “We’re waiting for Janet…,” while I wait for her to initiate play. She looks in my direction and sings, “ta, ta, ta.” I begin to improvise in a Spanish style and she begins to play on the drum in an unrelated manner, stops, and becomes withdrawn. This is followed by her becoming musically engaged, and related, beating in tempo to the music. She stops playing, as I sing again, “we’re waiting…,” as Janet comes back into beating at times using big arm movements and alternating hands while beating. The musical interaction is soon followed by Janet withdrawing from the interaction. I begin singing, while playing the piano, “we’re waiting for Janet… .” Janet begins playing the drum and seems to realize that the music was waiting for her to initiate play. I incorporate the familiar melody and sing “Ta.” Janet recognizes this musical pattern from previous sessions and begins playing in a consistent and related manner on the drum. She plays the drum with big arm movements, and initiates changes in tempo and dynamics while referencing me though eye-contact and brief smiles. Theme 6: Take a Walk to the Moon: Joining and Staying in the Interaction. The sixth theme is taken session twenty-five in which Janet playing the piano with me for the first time. She initiates a random lyrical idea: “Take a walk to the moon.” My music and singing become more expressive than usual, as I sang back only three words of her phrase: “Take a walk,” and then I change the phrase to, “take a walk to the wild side in music” (connecting an idea of mine to Janet’s). Janet attempts to “correct” what I’m singing, so she could hear “Take a walk to the moon.” I quickly organize my music in a pop-rock form using expressive singing in order to maintain her focus to the task at hand. She regains focus and begins playing the piano in a rhythmically related manner to my music. The momentum of the music builds, and Jean (intern) begins to dance and sing non-verbally, however, the moment Jean begins to sing with words, Janet becomes distracted and withdraws from the interaction. I again begin singing. Janet once again comes over to correct me, as she says, “Take a walk to the moon.” While she says this, she pretends to draw a moon in the air (demonstrating symbolic thinking), desperately trying to figure out a way (problem-solving) to get me to sing “Take a walk to the moon.” Theme 7: Take a Walk to the Moon: Joining and Staying in the Interaction Part II. Theme seven, also emerging from session 25 depicts Janet’s piano playing displaying some

flexibility, both rhythmically and dynamically in relation to my music. I begin singing the familiar theme. This time I sing back Janet’s words, however, when I get to the word “moon” I sing it expressively with a melodic leap to generate additional affect, while attempting to prompt Janet to sing with expressiveness and inflection. Janet responds positively during the last phrase, by singing the word “moon” with inflection and a melodic leap. Evaluation While Janet continued to receive music therapy, the 25th session was the final clinical session of the present research protocol. The Functional Emotional Assessment Scale post-test was administered and Goal Attainment Scoring followed Janet’s final session. Functional Emotional Assessment Scale (FEAS) In addition to the qualitative case study analysis of Janet’s treatment process, two quantitative measures were used to evaluate outcomes of music therapy: the Functional Emotional Assessment Scale (FEAS) and Goal Attainment Scaling (GAS). The FEAS (Greenspan, DeGangi, & Weider, 2001) was used as a pre- and post-test measure for Janet’s progress in achieving social-emotional goals. The GAS (Kiresuk, Smith, & Cardillo, 1994) was used to evaluate Janet’s progress toward musical goals. Table 1 gives a comparison of Janet’s pre- and post-test scores on the FEAS. The table shows raw scores for each developmental area, level of functioning, percentages, and the number of functioning levels changed out of three possible levels (e.g., deficient, at risk, and normal). Scoring is based on a 2-point scale: 0 = behavior is not seen or is briefly observed, 1 = behavior is present some of the time or observed several times, and 2 = behavior is consistently observed or observed many times. The ratings were summed to obtain subtest scores for each area, as well as total test scores (Greenspan, DeGangi & Weider, 2001). Total scores are compared to cutoff scores to determine if the child is: normal, at-risk, and deficient. Table 1 Comparison of Janet’s Pre- and Post FEAS Scores Pre-Test Raw Scores Sub-scores

Post-Test Raw Scores Sub-scores

Change in Functioning Level

I. Self-regulation

11 (At risk) 78.5%

12 (Normal) 85.7%

+1

Attentive to play with toys Explores objects/toys freely Remains calm during play

2 2 2

2 2 2

Areas

Touching textured toys & caregiver 2 Shows content affect 1 Focused without distraction 1 Appears over aroused 1

2 1 2 1

II. Forming relationships and engagement

16 (Normal) 100%

11 (Deficient) 68.75%

Emotional interest in care-giver Relaxed when near care-giver Anticipates with curiosity Uncomfortable with care-giver Initiates closeness to care-giver Avoids care-giver Socially references care-giver Communicates from across space

2 1 1 2 2 1 2 1

2 2 2 2 2 2 2 2

III. Two-way purposeful communication

5 (Deficient) 50%

7 (At risk) 70%

Opens circles of communication 0 Initiates intentional actions 1 Closes circles of communication 2 Uses words, or sounds, or gestures 2

2 1 2 2

IV. Behavioral organization and problem solving

3 (Normal) 75%

4 (Normal) 100%

Communicates in several modes Copies caregiver & incorporates

1 2

2 2

V. Representational capacity

3 (Deficient) 21.5%

7 (At risk) 50%

Engages in pretend play Communicates intentions Expresses dependency Expresses pleasure/excitement Expresses assertiveness Creates 2 or more unrelated ideas

2 0 0 0 0 1

2 2 1 1 0 0

VI. Representational differentiation

1 (Deficient) 10%

4 (Normal) 40%

Bridges 2 unrealistic idea 1 Bridges 2 realistic ideas 0 Use pretend to express dependency Use pretend to express pleasure 0 Expresses assertiveness in pretend 0

0

2 2 0 0

0

+2

+1

0

+1

0

Janet’s ability to self-regulate and show interest in the world (area I) increased by one point bringing her total score from 11 to 12. Her ability to be engaged (area II) increased by five points bringing her total score from 11 to 16, and she also showed improvement in her ability to communicate purposefully (area III), increasing her score by two points bringing her total score from 5 to 7. In addition, Janet’s ability to problem solve (area IV) increased by one point bringing her total score from 3 to 4, and her ability to think symbolically (area V) increased by four points bringing her total score in from 3 to 7. Finally, Janet’s ability to build bridges between ideas (area VI) also increased by three points bringing her total score from 1 to 4. To summarize, during the pre-test Janet was regulated, but was not particularly interested in the outside world. She showed difficulty in her ability to attach, and generally reverted to isolated behaviors and scripts, fragmenting and/or discontinuing the flow of interaction. In addition, she showed limited ability to use communication purposefully (in context to a situation), reverting to scripts and echolalia. She displayed the ability to problemsolve and get her needs met during the pre-test; however, she displayed difficulty in her ability to think symbolically and connect her ideas with the therapist’s ideas. During the post-test she continued to demonstrate the ability to be regulated, but was interested in interacting with the therapist, and displayed the ability to engage in a related manner. She also exhibited the ability to be more purposeful while communicating, using fewer scripts, and generating language appropriate to the situation at hand. In addition, she displayed the capacity to create and build bridges between ideas, engaged in symbolic play, and showed islands in the capacity to think emotionally. Figure 1 shows the amount of change in functioning levels made by Janet in each developmental area: 1 represents deficient, 2 at risk, and 3 normal. As shown, Janet improved by one functioning level in three areas, two levels in two areas, and stayed the same in one area. Figure 1

Changes in Developmental Levels (FEAS) Changes in Developmental Levels

Pre Post L e v e l s

2

1

0

Area I

Area II

Area III

Area IV

Area V

Area VI

Goal Attainment Scaling (GAS) The quantitative data analyzed below used GAS to evaluate progress made toward Janet’s musical goals. Musical goals for Janet were created following session two, by the independent observer, and then were evaluated after session 25. Four music therapy (MT) goals were formulated for Janet, all were weighted equally. The first goal was “musical relatedness,” that is, for Janet to play in a related way to the music that the therapist improvised. Upon beginning music therapy, Janet’s music related to the therapist’s improvised music less than expected (-1); she rarely played in a related manner. Upon completion of therapy, she exhibited more than expected success (+1); her playing often related to the therapist’s music. The second MT goal was “relationship within musical play,” which involves Janet being able to initiate some kind of relationship with music and the therapist, vocally and/or instrumentally and/or through movement/gesture. Upon beginning music therapy, Janet exhibited a less then expected outcome (-1); she rarely initiated relationship within music. However, upon completion of therapy she displayed a more than expected outcome (+1), often initiating relationship within musical play throughout the session. The third MT goal for Janet was “musical communicativeness,” that is, for her to be able to be spontaneously communicative in relation to the therapist’s music, opening and closing circles of communication during musical play (e.g., the ability to engage in call-and-response interplay, punctuate the end of a phrase, initiate the opening of a phrase, and/or notice therapist’s music and respond contingently by elaborating on it). Upon beginning music therapy, Janet’s musical communicativeness was a less than expected outcome (-1); rarely using music communicatively. At the conclusion of therapy she exhibited a more than expected outcome (+1), often using music communicatively throughout the session.

Finally, Janet’s fourth MT goal was “musical interrelatedness,” that is for her to be able to connect a musical idea of her own to the therapist’s idea, and elaborate on the idea during musical play. At the start of music therapy Janet’s music was interrelated to the therapist’s music less than expected (-1); she rarely played in an interrelated manner. However, upon completion of therapy, she demonstrated more than expected success outcome (+1), often using music in an interrelated fashion throughout the session. Figure 2 shows all four goal areas and the amount of change Janet displayed as a result of music therapy. The figure shows raw scores for each goal area (-2 represents most unfavorable outcome; -1 less than expected outcome; 0 expected level; +1 more than expected success; and +2 most favorable outcome). Taking all of these goals collectively, Janet improved by two levels in each of her four goal areas. These changed scores on all goal areas were converted to a “T- score,” according to the formula of Kiresuk and Sherman (1968). Janet’s T-score was 64.51, based on the assumption that together these scales have a mean of 50 and a standard deviation of 10 (see Kiresuk & Sherman). Figure 2 Changes in Goal Attainment Levels (GAS) Changes in Goal Attainment Levels Pre G A S e v e l s

Post

2 1 0 -1 -2 Musical Relatedness

Relationship in Musical Play

Musical Communicativeness

Musical Interrelatedness

Musical Goal Areas

Client Process Stage one, “Everywhere But Nowhere: Where’s Janet?,” consisted of the first five sessions in which Janet engaged in moving aimlessly around the music room, playing each instrument while being in constant motion, impeding her ability to self-regulate and engage. Although she displayed some sense of musical awareness and relatedness, it appeared as though Janet’s playing was related more to her meeting some kind of sensory need, than it was about connecting to the music being played. Any attempt to engage her in a continuous flow of

musical play for an extended period, was interrupted by her need for constant motion. This stage ended when the therapist changed strategies, which included embracing Janet’s perseverative movements both physically and musically and transforming them into a meaningful interactive experience. Stage two, “Transforming Perseverative Movements into Joint Interaction,” featured sessions six through ten. It consisted of guiding Janet’s perseverative movements into interactive dance with Jean (intern), facilitating self-regulation, engagement, and relatedness, musically, physically and interpersonally. This stage ended when the therapist changed clinical strategies, based on Janet’s ability to self-regulate for extended periods, to engage her in musical play that involved music making. Stage three, “Moving into Instrumental Play,” consisted of sessions eleven through fifteen. During this time, Janet demonstrated a greater ability to self-regulate and to be seated in a chair (based on her own initiative) for extended periods, making her “available” for musical interaction. Although she exhibited difficulty in playing instruments during musical play due to poor body awareness and motor planning difficulties, through prompting, she displayed an ability to engage in musical relatedness and communicativeness; however, the quality of the musical interactions was fragmented and intermittent. This stage ended when the therapist changed strategies by reducing prompting, and taking greater notice to Janet’s non-musical behaviors. “Relating and Communicating In and In-between Musical Play,” Stage four, consisted of sessions sixteen through nineteen. During this stage it became more evident that, biologically, it was difficult for Janet to engage in a continuous flow of musical interactions. Although she displayed this difficulty; Janet exhibited relatedness, communication and emotional connection to Jean and me through facial expressions (smiles and laughter), and social referencing (gestures and eye-contact) from across the room. This stage ended when the therapist changed strategies, and focused on connecting (bridging her ideas to mine) Janet’s ideas and/or music to help her develop internal organization. Finally, Stage five, “Connecting Ideas While Maintaining Engagement and Relatedness,” consisted of sessions twenty through twenty-five. During this stage, Janet’s usual behavior of fixating on expressing random and unrelated ideas (including musical play, words, gestures, etc.), while rejecting any attempt by the therapist to connect her ideas (musical play, words, gestures, etc.) began to diminish. She began to display some capacity in her ability to connect her ideas (musical play, words, gestures, etc.) with the therapist’s while maintaining engagement and relatedness. Therapist Method Embracing and respecting a child’s self-stimulatory or perseverative behaviors can be a gateway into interaction. These behaviors can be looked at and responded to in a creative manner to facilitate engagement and relatedness. For Janet, her perseverative movements turned into dancing, which led the way into developing relationship, communication, and socialization. Dr. Stanley Greenspan (2007) writes:

Whenever there is a momentary pause in the interaction, see what the child is doing next. Remember, she’s always doing something, even if it’s wandering around the room. Wandering may be the doorway to a new dance step, for example, or a new musical symphony where the music changes with each step (the caregiver makes the music coming from their wonderful vocal cords contingent on how the child moves). (Greenspan, 2007, pp. 2–3). Rather then “force-feeding” Janet with ideas, and trying to lead her into our world (“get” her to do what we thought was the “right” thing), based on our own needs and expectations; we took her lead and “allowed ourselves to join into her world.” We took her direction, followed her lead, and let her guide our intervention. In following Janet’s lead to help her guide our intervention, she taught us to truly listen and watch for things beyond musical responses; to see what’s “really happening, observably,” as opposed to what we assumed was happening based on our own prejudices and orientation. Because of Janet’s individual-differences on a biological level, there were certain things musically that she was unable to experience. The “outsider,” may interpret this as her not wanting to engage in musical play, or a cognitive deficit of her not understanding the concept of joint musical play, or her just not liking music. It became imperative then, to not only listen to her responses during her musical play, but also to watch and listen to her responses when she was not engaged in music making. Although at times Janet withdrew from music making, especially during the in-between times of musical engagement and withdrawing from musical play, she was emotionally and relationally connected to the music, the therapist and intern. Relationship between FEAS and GAS Results of Janet’s FEAS pre-test and GAS indicated differences in several categories. During the FEAS she showed an ability to be calm, attentive to play toys, and emotionally interested in the therapist. During GAS, however, she displayed difficulty remaining calm and attentive to instruments; displaying anxiety while constantly being in motion. While she displayed contrasting characteristics in her ability to self-regulate and be attentive to play toys/instruments during both procedures (FEAS and GAS), she showed similar difficulties in her ability to focus and use the toys/instruments in an interactive manner. Similarities in both settings (FEAS pre-test and GAS) were reflected in the area of twoway purposeful communication, specifically in Janet’s difficulties initiating ideas and communication, musically and interpersonally. Similarities were also evident in both settings in Janet’s being uncomfortable and avoidant of the therapist. Furthermore, similarities during the FEAS and GAS also surfaced in Janet’s ability to problem-solve and understand the concept of cause-effect, musically and interpersonally. Finally, in both settings, she displayed difficulty in creating ideas, as she constantly reverted to memorized scripts and words and lacked the capacity to bridge ideas with the therapist’s. Results of Janet’s FEAS post-test and Goal Attainment Scale indicated several similarities. During both procedures she demonstrated her ability to self-regulate and engage with the therapist, being relaxed and emotionally interested in the therapist. In addition, during

both, FEAS (post-test) and Goal Attainment Scale, she exhibited her ability to: open (initiate) and circles of communication (musically and interpersonally), engage in symbolism, communicate her intentions during play, and bridge ideas with the therapist’s, musically and interpersonally. Relationship between Qualitative and Quantitative Data Janet’s areas of strengths and weaknesses were consistent in most areas between qualitative and quantitative data. Inconsistencies appeared in area I (self-regulation), specifically in “remaining clam during play,” in which the FEAS scored Janet as “constantly being calm,” however, clinically, she appeared to require support in order to maintain calm throughout each session. To that end, in general, the quantitative data had difficulty revealing the “quality” of certain outcomes relating to Janet’s abilities, with regard to how much prompt and support was or was not needed in order for her to reach a particular developmental milestone. A key similarity, in both quantitative and qualitative data, was in Janet’s difficulty in the area of two-way purposeful communication. Although she demonstrated an ability to engage in two-way purposeful interactions, her inability to maintain a constant flow of back-and-forth dialogue for extended periods was reflected in both qualitative and quantitative results. References Aigen, K. (2005). Music-centered music therapy. Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (1987). Improvisational models of music therapy. Springfield, IL: Charles C. Thomas. Carpente, J. (2009). Contributions of Nordoff-Robbins Music Therapy within the Developmental, Individual Differences, Relationship (DIR)-based Model in the Treatment of Children with Autism: Four Case Studies. Unpublished Doctoral Dissertation, Temple University. Ann Arbor: ProQuest/UMI, Publication Number AAT 3359621. Greenspan, S.I., & Weider, S. (1997). Developmental patterns and outcomes in infants and children with disorders in relating and communication: A chart review of 200 cases of children with autistic spectrum diagnoses. The Journal of Developmental and Learning Disorders, 1 (1), 87–141. Greenspan, S.I., & Weider, S. (1998). The child with special needs: Encouraging intellectual and emotional growth. Da Capo Lifelong Books. Greenspan, S.I., DeGangi, G., & Weider, S., (2001). The functional emotional assessment scale (FEAS) for infancy and early childhood: Clinical and research applications. Interdisciplinary Council on Developmental and Learning Disorders. Greenspan, S.I., & Shanker, S. G. (2004). The first idea: How symbols, language, and intelligence evolved from our primate ancestors to modern humans. Da Capo Lifelong Books.

Greenspan, S.I., & Weider, S. (2006a). Engaging autism: Using the floortime approach to help children relate, communicate, and think. Da Capo Lifelong Books.

Greenspan, S.I., Weider, S. (2006b). Infant and early childhood mental health: A comprehensive developmental approach to assessment and intervention. American Psychiatric Association. Kim, Y. (2004). The early beginnings of Nordoff-Robbins music therapy. Journal of Music Therapy, 41 (4), 321–339. Kiresuk, T. J., & Lund, S. (1978). Goal Attainment Scaling. In C. Attkisson, W. Hargreaves, M. Horowitz, & J. Sorensen (Eds.), Evaluation of human service programs. New York: Academic Press. Kiresuk, T. J., & Lund, S. (1976). Process and measurement using goal attainment scaling, In Glass, G. V. (Ed.), Educations Studies review manual, (1), Sage, Beverly Hills, CA. Kiresuk, T. J., Smith, A., & Cardillo, J. (1994). Goal Attainment Scaling: Applications, theory and measurement, Hillsdale: Lawrence Erlbaum. Nordoff, P., & Robbins, C. (1964). Music therapy and personality change in autistic children. Journal of the American Institute of Homeopathy, 57, 305–310. Nordoff, P., & Robbins, C. (1968). Fun for four drums: A rhythmic game for children with four drums, piano and a song. Theodore Presser Company Nordoff, P., & Robbins, C. (1968). Clinical experiences with autistic children. In E.T. Gaston (Ed.), Music in therapy (pp.191–193). NY, NY: The McMillian Company. Nordoff, P. & Robbins, C. (1971). Therapy in music for handicapped children. London: Victor Gollanez, Ltd. Nordoff, P. & Robbins, C. (1977). Creative music therapy. New York: Harper and Row Publishers.

Nordoff, P. & Robbins, C. (1983). Music therapy in special education (revised). St. Louis: MMB Nordoff, P. & Robbins, C. (1992). Therapy in music for handicapped children. London: Victor Gollanez Ltd. Nordoff, P. & Robbins, C. (2007). Creative music therapy: A guide to fostering clinical musicianship. Gilsum, NH: Barcelona Publishers. Robbins, C. & Robbins, C. (1991). Self-Communication in Creative Music Therapy. In K. Bruscia (Ed.), Case studies in music therapy (pp. 55–72). Gilsum, NH: Barcelona Publishers. Solomon, R., Necheles, J., Ferch, C., & Bruckman, D. (2007). Pilot study of a parent training program for young children with autism: The play project home consultation program. Autism: The International Journal of Research and Practice, 11 (3), 205-224. Sorel, S. N. (2005). Presenting Carly and Elliot: Exploring roles and relationships in a mother-son dyad in Nordoff-Robbins music therapy. Unpublished doctoral dissertation, New York University, NY.

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

CASE FIVE Growing Up Alone: Analytical Music Therapy with Children of Parents Treated Within a Drug and Substance Abuse Program Juliane Kowski Abstract In this case study, I will present my work as an analytical music therapist with a group of eight- to 12-year-old children who attended an afterschool program at a family health and support center within a drug and substance abuse program in Brooklyn, New York. The children, who were seen once a week for forty-five minutes over a period of eight months, are emotionally disturbed and exhibit behavioral problems; some exhibit tendencies of attention deficit disorder or post-traumatic stress disorder. I will discuss the ways in which I have adapted analytical music therapy methods and techniques, developed by Mary Priestley, to this population. I will use musical examples to explain the methods and techniques that I employed within a framework of structure and free-flowing improvisation. Furthermore, I will describe an “improvisational attitude” and the consequent challenges that arise for the music therapist. Introduction I was hired to develop music therapy at a family health and support center within a drug and substance abuse treatment center in Brooklyn, New York. The children were picked up after school by counselors who supervised their homework. They attended dance, music, and art therapy sessions while their parents received therapy or other services provided by the center. I worked with the children, who were divided by age into two groups, once a week for forty-five minutes for twenty-seven sessions in total. I will describe the group music therapy with the older children aged eight to 12. Eight to ten children attended the group. Before I explain my work, I would like to describe my theoretical background. I am a humanistically-oriented music therapist. I use a client-centered approach, which means that I rely upon the client for direction within the therapeutic process. I believe in the concepts of self-actualization and peak experience that are elaborated upon in the writings of Carl Rogers and Abraham Maslow. The analytical music therapy (AMT) music therapists Mary Priestley and Benedikte Scheiby are the main influences on how I understand and practice AMT. I have been in training and supervision with Benedikte Scheiby for the past five years and I have developed an eclectic, dynamic style that allows for my techniques to evolve with the circumstances. I work with individuals, groups, and families, and am always challenged by AMT. In this case study, I will focus on the therapeutic process itself and my own evolution within the process, rather than on the results of the process.

Priestley’s writings have helped to guide my work with children. She offers some interesting thoughts in Essays on Analytical Music Therapy about what she calls “Preliminary Music” with so-called “normal” children even though she declares herself too inexperienced to write in-depth about how AMT works with children. She writes: Children are acting out their fantasies in this way all the time, working them through in play. It is only when they get trapped in them and cannot develop any further that their learning and behavior suffers and they need help. Therefore the analytical music therapist’s aim with a child-patient is to restore to her, or introduce to her, the ability to involve herself in the important “work” of self-healing play, together with the freedom to use her natural curiosity and creativity (Priestley, 1994, pp. 275-276). Reflecting on when music therapy with children ceases to be analytical, Priestley writes: I would say it is when the use of words becomes wholly superfluous because of the child’s lack of comprehension due to mental handicap. But even when there is no interpretation by the therapist because the child is already working and playing in a self healing way, the analytical music therapist’s exploratory approach will influence the way he helps to shape the movement of the therapy. With his assistance, the child will be led into controlling his environment in a creative way. As Winnicott (1971) wrote: “To control what is outside, one has to do things, not simply to think or to wish, and doing things take time. Playing is doing” (p. 47). And analytical music therapy can provide an opportunity for such playing (1994, p. 284). Grounding myself in AMT, and adapting its techniques to the needs of these children, has provided a basis for analytical in-depth work in conjunction with music that maximizes therapeutic potential. Under normal circumstances these children have very little control over their lives. Under my guidance, within the framework of AMT, they had an opportunity to work and play creatively, to control how and what things were done. Background Information Ninety percent of the children at the center were of African-American background; 10 percent were Hispanic. Some lived with their parents; others had been separated temporarily until the parent graduated from the program. Many had been in and out of foster care or spent time with relatives. Most had one or more siblings. Due to histories of drug and substance abuse the parents were mandated to attend this program in order to keep their children. The children lived with issues such as neglect, emotional, and/or physical abuse, lengthy separation from their parents and homes, exposure to drugs and, as a consequence, meddling with the law and being involved with legal authorities. They trusted hesitantly, had poor communication skills, and harbored lots of anger and frustration. Their frequent inappropriate behavior resulted in constant problems at school and within the program. I worked with these children over a period of one school year. I met regularly with the program director, dance therapist, and counselors to coordinate goals, and to share thoughts

about the therapeutic process and the children’s progress. It took time to establish trust and to lay the foundation that would enable us to reach the goals set by the team. Working within AMT with this population in a large group setting required an improvisational attitude. Many challenges arose which forced me to adapt more traditional AMT techniques; however, there were moments in the music and in the verbal processing that demonstrated AMT at work with this population. Treatment In this case study, I will use two sessions to describe my work with these children. In the first example, near the beginning of treatment, I am using the AMT techniques: the holding technique and patterns of significance. In the second example, near the end of treatment, I am using the therapeutic technique of songwriting. In each example, I will discuss my work in terms of transference, counter-transference, and resistance. Throughout my work with this group of children, the main goals were: acknowledgment and expression of feelings; anger management; Increasing self-esteem; developing communication skills; and helping with conflict resolution. Example 1: Free-Flowing Improvisation Description of Session 5.“What are our Christmas wishes?” suggested itself as a theme after we had sung several Christmas songs and I suspected that this direction might be a fruitful avenue of pursuit. Choosing this theme corresponds with the AMT technique, “Patterns of Significance.” This technique involves the therapist and the client(s) choosing a theme that characterizes a significant event in the client’s life. They improvise music together and process verbally afterwards. “This technique is used to discover the inner patterns and feelings surrounding significant events in life,” (Priestley, 1975, p. 141). Priestley recommends using this technique with individuals who are post middle-aged adults; however, I was able to adapt it successfully to my work. When adapting it, I tried to provide a common musical basis for interaction and to develop therapeutic musical and verbal interventions for a group setting. Sometimes, at the very beginning of the session when the children could not settle down, I asked them to just play what they felt and how they perceived these beginnings. They played and called it “chaos.” This was a recurring theme, an undercurrent in their lives that I felt I could substitute for a specific “significant event.” We did this repeatedly and it helped them to settle down, to expel the chaos, organize, and contain themselves. They grew more aware of how this “chaotic” musical interaction inhibited their ability to communicate. When I initiated the improvisation with the title, “What are our Christmas wishes?” I felt a heavy mood come over the group and I could only imagine what these children might miss at a time when other families celebrate. The choice of this theme included a significant risk that I might touch upon something that would be very difficult to process within the group setting. So, I made sure to keep some time available afterward to process with a child alone if necessary. Christmas was obviously a difficult time for these children. In the following sessions, they

initiated more thematic playing. Some even wanted to play alone. Issues such as neglect, loneliness, and the longing for a healthy and harmonious family surfaced. Seven children, whom I will call Andy (cymbal), Bert (kid’s djembe), Carl (snare drum), Dan (triangle), Eva (buffalo drum), Fanny (small conga drum), and Gladys (marimba phone), picked instruments. I prohibited the use of the big floor drum because I was afraid it would dominate the music. I encouraged everybody to express what they felt and to listen to the other group members. Gladys started playing the marimba phone very quietly. Fanny responded and went along with Gladys on the small conga drum looking at Gladys briefly and then down to the floor. Andy, at first grinning and looking at Carl for reassurance, hit the cymbal once pretty hard. I started playing the guitar, strumming D minor, A minor (picking up the pentatonic scale of the marimba phone: F G A C D), establishing a holding environment. I tried to send the signal that I was there to hold (using the AMT “holding technique”1), protect and encourage them, and not to stop them unless somebody acted in a destructive manner. Eva started playing the buffalo drum in a 4/4 rhythm, joining the girls. I felt that they were really trying to get together and to support each other. Bert sat quietly and scratched away on his drum. I could not tell yet if he was with the group or if he was demonstrating resistance. Andy picked up on Bert’s scratching and made screechy sounds on the cymbal. Carl laughed. Eva gave Carl an angry look and her playing became louder. The rhythm became more intense, like strong heavy footsteps in 4/4. I was not sure whether to intervene or to let this dynamic play itself out. Carl picked up Eva’s stronger buffalo drumbeat on the snare drum. Gladys established a melody that she repeated over and over again. Transcription:

An image elicited from the music of Gladys sitting all alone on Christmas Eve crying out for her mother arose in my mind. I supported her with gentle strumming on the guitar and gave her a reassuring look. Bert picked up the rhythmic pattern of Gladys’ melodic playing as if he were joining her, although he avoided looking directly at her. Others followed this rhythm. For a short time the group developed a strong musical message. I looked at Dan. He sat there, seeming spaced out, holding on to his triangle, swinging it back and forth, not playing it. Where was he? Neither the group nor I seemed to reach him. Meanwhile the group sounded as if they had composed their own little “Klagelied” (German word for wailing song) until Carl started hacking away on the cymbal, purposefully destroying the unity. The girls stopped playing and the other boys joined Carl. The group had split. I accompanied the boys’ emerging power by playing sliding bar chords moving in half steps on the guitar. The 4/4 rhythm fell apart. The boys played a loud, angry sounding chaos. They were laughing, looking at me for reassurance. I kept following them, “telling” them that it is o.k. to play chaos. Perhaps chaos is what they had experienced at Christmas? I tried to

encourage them to vent their feelings. They kept laughing. I felt their anger very much, and their resistance as well. They were hiding behind that musical chaos. Their laughter seemed to protect them from feelings that really hurt deep inside. The girls withdrew. I raised my hand to initiate the end. I wanted to give the boys some space for their male energy, but also to return to the girls with their female energy that was obviously quite different. I encouraged a few seconds of silence in order to let the music settle in, but the boys were unable to calm down so I moved on to verbal processing. These 2 1/2 minutes of music had passed so quickly. I asked Gladys what she thought of the music. She said that she had liked the first part more. I asked her why and what she had tried to say musically. She replied, without looking at anybody, that her wish had been to be with her whole family for Christmas. The room got very quiet. I responded that her wish was entirely normal and that Christmas should be celebrated with the whole family. I acknowledged her sad feelings and uncertainty over whether her wish would come true. I also let the group know that she had demonstrated a lot of courage by sharing her thoughts musically and verbally. I asked the group if anybody shared these feelings and if they had heard these feelings in her music. Fanny said that Gladys’ melody had made her feel sad and that she had played along with her. I asked her what she was trying to say and she said that she did not know, but that she wanted to be happy. The boys started giggling again. I was feeling the group falling apart anew. What could I do to keep them together? I mentioned to Andy that by scratching his cymbal he had demonstrated that he had not wanted to join the girls at the beginning. He replied that that was girls’ stuff and not for him. I asked him how he had tried to express his wishes for Christmas. He said that he had wanted to have fun and I told him that that also was a viable wish. I asked the group how they felt when they were together musically for a moment, and what it had sounded like. Fanny said that it had sounded sad, like a sad Christmas song. Eva supported her, nodding. Andy and Carl started giggling and talking again. I felt angry; the “teacher” was arising in me. I felt powerless to handle the situation. It seemed that whenever we were getting somewhere we had to stop. I decided to ignore the troublesome boys to some extent and asked Dan why he had not played at all. Dan said he had not known what to play. I asked him what he had wished for. Very quietly he said that he had wished that no bad stuff would happen. Bert and Carl laughed loudly. I asked them to explain their response to what Dan had to say. They kept giggling, enjoying the attention. Bert said that Dan never participates. I said that Dan was probably shy and that the group needed to help him to feel more secure. I decided to get back to the music and asked Carl what he thought about the second part of the music when the girls had not played. Carl said it was fun to play like that. I tried to dig deeper by asking him to describe the character of the music. Carl said that it had been fast and happy. I passed this on to Andy, asking him what he thought. Andy said that he thought that the music was very strong, happy, and wild. I asked who else agreed with this description. Gladys said it had sounded like guns and that that was why she had stopped playing. Eva agreed with a confirming facial expression. Fanny said that she had felt scared. Andy and Carl laughed again and acted as if they were proud of what they had accomplished. I felt I needed to react, to let them know that I think that everybody has a right

to express their feelings and that we ought to respect each other. I also acknowledged what the girls were feeling and why they had stopped playing. I mentioned that I might have heard anger in the chaotic part and I wondered if others were feeling the same. I could tell that I had hit a nerve. A wall of resistance sprang up. I repeated myself, stating that I did think that it would be very normal to feel angry because one had not had a nice Christmas. The boys began to hit the drums randomly. Were they trying to stop me? I asked for their attention, struggling with the bad feeling of having lost them. They refused to pay attention and I knew that I had to wrap this up. I acknowledged everybody’s active participation as well as the importance of listening. I realized that this was only Session 5 and that I should not expect too much from these children at such an early stage. I did not want to scare them off. I wanted to give them some time to process individually before we had to end the session so I suggested that we continue exploring these Christmas themes next time around. Feelings of sadness, anger, abandonment, and loneliness surfaced in subsequent sessions related to Christmas. I heard stories from children who received no gifts, saw sad eyes talk about missing family members and celebrations. Unfortunately, I was usually aware that we would probably be unable to work through these issues and feelings sufficiently to bring about real and profound change. There was simply not enough time, too many children bearing heavy burdens, and the constant interruptions caused by the ever-present and powerful resistance emanating from several of the boys. Discussion of Session 5. As transference, countertransference, and resistance are integral to my work, let me first provide descriptions of each as I understand them. Priestley refers back to Freud in defining transference as as “wrong association,” as he recognized that some of his patients were regarding him with emotions that were relevant to previous relationships in their lives, usual parental.... The therapist, however, does not react in the way that earlier object— whether parent or parent substitute—did in her early life, and his response and interpretations enable the patient to liberate herself from her repetition compulsion and begin to experiment with new ways of acting and responding (1994, p. 77). The following is a clear and simple definition of countertransference: “Broadly speaking, countertransference describes the emotions that the therapist develops toward the client in response to the client in sessions,” (Pavlicevic, 1997, p. 166). Priestley describes it further: The therapist may find that either gradually as he works, or with a suddenness that may alarm him, he becomes aware of the sympathetic resonance of some of the patient’s feelings through his own emotional and/or somatic awareness. Often these are repressed emotions that are not yet available to the patient’s conscious awareness (1994, p. 87). Austin and Dvorkin describe resistance in psychoanalytical terms: “...a paradoxical phenomenon regularly encountered in the course of insight oriented psychotherapy” (1998, p. 423). Priestley’s work with resistance is based on the classical psychoanalytical model. She

described how levels of resistance surface in music and are used diagnostically in work with psychotic patients. I found the following definition by Bruscia to be useful for my description and analysis of the resistance that occurred in my work. “Like defenses, resistance is healthy when it serves to protect the client from a harmful or premature lifting of repression and it is unhealthy when it prevents the client from benefiting the most from therapy and living a full life,” (Bruscia, 1998, p. 41). Transferences in Session 5. Transference was continuous within the group. The neglect and abuse that normally occurred in the children’s lives was reflected unconsciously in the music and expressed as constant chaos. They came from chaotic situations; they had no consistency in their lives, no limit setting, and no stable parental love. They were abused. In return they needed to do the same to the group, and to me. Perhaps this familiar pattern made them feel safe. The music helped to translate this transference, to bring it alive and into awareness. When I started working on this case study I listened once again to all of my recordings. I found it shocking how chaotic most of the sessions had been. Many began with children yelling at each other, laughing, and cursing. It usually took me a long time to focus their attention. I had this picture in my head of wasps flying around the room frantically trying to sting each other. I had to find ways to break through the resistance and chaos, to show them different ways of interacting, to create a comfortable place for them without the chaos. In this session, my role shifted, or was two-dimensional. For the girls, I took on the role of the “good mother,” providing them with a supportive shoulder, embracing their sadness, and encouraging them to express it. I chose the guitar as a harmonic instrument of soft presence in shape and sound. I strummed D minor and A minor, providing a holding musical container that represented the “good mother.” I chose the minor mode as a response to the open, sad sounding melody that had developed. For the boys, I was sometimes the “bad mother” who neglected them and upon whom they therefore projected a message of anger and frustration. I struggled during the moments of interruption and obvious resistance. I felt powerless, anxious, and at times angry. Was it all their anger that I felt, or was it my own anger that had been triggered by them that I needed to work on? In supervision I learned that I did experience some of their anger expressed in the music or verbally, sometimes to a point where I felt tense physically. I had to keep my focus, to accept that it was not my own anger, to take a deep breath, pause, and relax and then to go on. To reiterate, it seemed that the children, especially the boys, had to “transfer” their “abuse” onto me because that was the method of relating that they knew and understood. I had to look at my own memories, my past. Before my present incarnation as a music therapist I had been a schoolteacher and I had to discipline the children. I remembered feelings of inadequacy. I struggled with the idea that their expressions of anger had not been directed at me personally, but at that point in my life I lacked the training to properly evaluate this dynamic. I am now able to comprehend it intellectually, but still need to revisit this issue in supervision. The girls brought in different dynamics by choosing to express their sadness. In some sessions they joined the boys in the musical expression of anger although they often needed encouragement, which implied to me that they were normally afraid to bear the consequences of expressing their true feelings. Over time, I learned how to flow with this resistance and what the resistance symbolized for these children.

Countertransference in Session 5. My own countertransference emerged. At times I wondered, “Am I a ‘good enough mother’ for them?” These feelings stem from my own personal struggle as the mother of two little boys. I always want to be the perfect mother and have had to learn that there are limits, to accept my weaknesses, and to let go of my overly high expectations. There were times when the children’s verbal or musical actions mirrored their feelings of low self-esteem and inadequacy. When projected by the music these feelings made me, the therapist, feel inadequate. Often I was unsure how and why I ended up feeling this way. I am aware that this explanation might sound diffuse and leave the reader dissatisfied, but, eCountertransference, as Priestley calls it, is a very difficult countertransference to describe or analyze in measurable terms. Working with Resistance. Resistance occurred verbally and musically in this session with these children. Their resistance protected them from getting hurt where they had been hurt before, i.e., a healthy form of resistance. I observed verbal resistance when the children were laughing, interrupting, and opposing during moments that opened up issues that addressed family life, home, holidays, and parental love. Whenever musical or verbal interventions touched their vulnerability, the children responded with healthy resistance, banging aggressively on drums, cymbals, and triangles. It was not always clear to me whether these were expressions of pure pain or resistance. Sometimes they played their resistance in raps and blues in such a way that they used funny words and metaphors to represent serious, sad issues. I had to find ways of working with their resistance in order to keep them protected. At times, I just let them play or state their resistance. There is a method, explained by George J. Thompson (1983), called “verbal judo,” which I tried to incorporate into my work, based upon the idea that in order to break resistance one has to go with it. This can be done verbally as well as musically. I allowed them to play “chaos” which sometimes resolved the tension, and gave ways for them to work together. When Andy “resisted” at the beginning of our musical example by hitting the cymbal like a warning after Gladys initiated the soft, sad melody on the marimba phone, he needed reassurance from his friends. He needed to couple up with Bert and later with Carl He clearly stated in his music: “Not me! I am not going there.” He was not ready to expose himself and/or his feelings. He was protecting himself. He showed healthy resistance. The children have needed this type of self-protection in order to survive their worlds. To do away with it, they would have to go through an extensive learning process in which they would have to be taught how to meet their needs. I sent a message of sympathy to him by letting him be, and to the girls by joining and staying with their music at the beginning. Giggling and laughing are very common resistance behaviors. Unfortunately, this behavior often led to group conflict. Children who felt laughed at shut down, and it sometimes took a substantial amount of negotiation by the therapist to enable both sides to express themselves. That is why I would identify this as unhealthy resistance. It obstructed the therapeutic process for individual children, as well as for the group as a whole. How do I work with this resistance? When Andy’s “resistance” first surfaced, I focused my musical response on the girls, hoping to draw them out. I tried to encourage them not to back down through facial and body expression. Later, when Andy and Carl coupled up, I let the group take responsibility. When Eva gave Carl an angry look, I decided not to intervene, but to

let things flow until a moment of musical and emotional togetherness developed. When Carl’s cymbal smashing, a sign of resistance, interrupted us once again I was hesitant, not knowing what to do. The girls stopped and the boys kept on. I did not want to end the music entirely. I felt that perhaps the boys had a different message to convey, or needed to explore their resistance, so I went with them. In retrospect, I feel certain that it would have been a mistake to stop them. They needed to express their anger even though they were not able to acknowledge the feeling. I pointed out, in the discussion that took place during verbal processing, how unhealthy resistant behavior can hurt others’ feelings and prevent them from sharing any issues in the future. The children stated their resistance in the music by expressing emotions, but they were usually unable to connect these expressions to their thoughts afterwards. Often there was a disconnection between what had been expressed musically and what was said verbally. Some children played very repetitive motifs, melodies, and rhythms demonstrating resistance. Others stopped precipitously or refused to play at all. Sometimes the tempo, or a sudden change of tempo, indicated resistance. In summary, the children often expressed healthy resistance in order to prevent a premature and potentially harmful lifting of repression at this early stage of therapy. Unhealthy resistance surfaced when the children acted very disruptively and prevented the most basic exchange of ideas or feelings. At times, this unhealthy resistance triggered feelings of annoyance and anger in me. I had to address this issue over and over again in supervision, to look carefully at my own anger. Reacting in the moment required an ability to identify the type of resistance and to apply suitable interventions. When I felt overwhelmed, I often just took a deep breath, spoke to myself, and went on. Resistance is a very big issue in my work with these children and a constant field of battle. Example 2: Song Writing Description of Session 25. In this session I started talking about termination. We improvised on the emotional issues involved with saying good-bye. At the last session I suggested that the group create a rap with the title “Good-Bye.” I split the group in half and asked a few boys to write the lyrics and the other half to create the music. Here are one boy’s lyrics. I call him U. and chose his lyrics because he was leading this group and his lyrics were most significant. It’s Hard to Say Good-Bye It’s hard to say good-bye Why? Because it seems like the person You say bye to gonna die Some people will cry when they say bye, Just be strong and say “Hi” Just be like me And don’t cry

Act like as if you was gonna see the person again and say bye Chorus: It’s hard to say good-bye Afterward I acknowledged U’s courage and ability to put his thoughts and feelings into rhyme. The group had supported him nicely by providing a tight rap rhythm. They had worked independently, but as a group, on a piece of music communicating their ideas. I asked the children what they thought about what U had to say. One of the boys (W.) said: “He is right, we just say bye and know that we see you again some time.” I had to explain that I would not be coming back and that only the accidental chance of running into each other remained. I could tell at this point that they were hoping for some reassurance that this was not in fact the end. I shared with them how I felt saying good-bye and that I would miss them. They wanted to know exactly why I had to leave, and once again an angry dynamic surfaced. The group started acting out, children were laughing, screaming at each other. When I mentioned that my two little boys needed attention too, some children quieted down a bit. We ended the session with a long “good-bye” song wherein everybody again expressed what they had to say. I realized afterward that it would have taken years of trust and relationship building with them in order to process their feelings in a more profound manner. Transference in Session 25. I again took on a role of an adult in their lives who had abandoned them. I accepted and understood their feelings of anger. I thought mentioning my own responsibilities as a mother of two boys helped them in accepting my parting. Countertransference in Session 25. When the children played the rap and this boy rapped his own words, tears came into my eyes. Their good-bye pains were completely conflated with my own feelings. How well they had learned to not allow themselves to feel the pain of saying good-bye. Here I was “abandoning” them, a presumably recurring phenomenon in their lives. And I, too, could relate to their feelings. My mother worked full time during my childhood and was an elusive presence. I had also to face my own feelings of guilt and responsibility. I tried to find a good replacement for myself to help alleviate some of these feelings. I used supervision to take a fresh look at other partings in my past. I live an ocean away from my own family. Being separated and saying good-bye to them over and over again has spurred a whole set of personal issues. While attempting to “rescue” these children, I needed to attend to my own neglected inner child, to concentrate on these issues in order to enable myself to feel and understand the countertransference that surfaced repeatedly in my work. Resistance in Session 25. Again the children expressed a lot of anger, sadness, and healthy resistance when acknowledging any feelings of pain. Some children laughed paradoxically while playing and singing. Some looked rather sad. It was a strange dynamic in the room. I wanted to help them to experience the feelings of a real good-bye, but I understood and accepted the denial that allowed protection. Other Challenges. Lastly, I would like to mention another challenge that arose in this work, the cultural gap between the children and myself. I had to learn about their values and cultural upbringing, which are very different from mine. Many of these children grew up in religious homes, where music is always an important aspect of their lives. Many of them have such a good feel for rhythm and bring a natural understanding of the blues, gospel, jazz, and rap into the work. I suspect I did not feel much resistance to me, even though I am a white

person, because I brought music, and because I knew their music. The underlying issues of whether I understood or could accept the way in which they were brought up, the way they interacted, remained. I feel that music can really be a wonderful bridge between cultural groups. The implication of these cultural issues for music therapy is a topic unto itself and should be discussed and researched separately. I can only refer to the writings of Joseph Moreno (1988), who contributed much to my understanding of cultural issues arising in my work with these children. Discussion This case study has shown how AMT techniques can be utilized, with adaptations for a group setting, with this population. Through this work, it became clear to me that these techniques were essential for in-depth work. They helped the children to become more aware of their feelings and conflicts, to develop better communication skills and to express their feelings appropriately. My method fluctuates between free-flowing improvisation and structure. Structure is absolutely necessary in this work. It gives the children a feeling of belonging, containment, and safety. The structure was provided by the use of pre-composed songs, and creating blues and raps. It offered a musical container in which the children learned how to express themselves. The free-flowing improvisations usually had a theme to begin with. When less structure was provided, the children had to learn how to express themselves appropriately. The challenges I faced in this work were varied. I had to learn to develop an “improvisational attitude,” by which I mean that I had to dispense with rigid plans and be willing to let the session flow in a more spontaneous and extemporaneous fashion. Every session was different and often started out in chaos. Children came in with a whole spectrum of energies after a long day at school. It often felt as if everything was out of control, which was very difficult for me because I like to be in control. There was no way to prepare or to have a plan. I had to find ways to ground them. I solved this problem by drumming and chanting at the beginning of the session which then developed into a natural way of inquiring about their day and how they felt. They often responded by saying that they felt either happy or sad. The children did not seem to know subtle shades of feelings and I believe that the music helped them to better express these nuances. Over time, I developed a typical session structure: 1) Hello, 2) Drumming and chanting, 3) Use of pre-composed songs/songwriting (blues or rap), 4) Free flowing improvisation, and 5) Good-bye. I often wished that I could see some of the children individually in order to meet their needs more effectively. So many issues arose that never had a chance to be sufficiently processed within a group setting, both musically and verbally. Statements of resistance too often interrupted moments of deep musical connection. On the one hand, the group’s dynamics did not always support a real therapeutic outcome, and yet, on the other hand, the group setting protected children from being overly exposed. They had a chance to model and to learn from each other, to develop a strong bond and community that might be of help in times of distress and loneliness. Conclusions

I will end now with some thoughts and conclusions about some of the positive outcomes for the children and myself. Music therapy came to be a special time for the children, a safe place where they were allowed to express what they had been suppressing. They probably showed affection toward me because I was one of the few adults in their lives who did not yell at them and who treated them with respect and love. Music is clearly a meaningful medium of expression for them, since they bring a rich, strong musical background with them. All of them were talented and music gave them a field of immediate gratification as well as a base for practicing their communication skills. For this kind of work, my organizational strengths and love of control seemed not to do me any good. I had to learn to improvise constantly, to feel comfortable having no plan and to let go. I learned to enjoy that side of the work. It is delightful to experience the spontaneity of a child. Slowly, I was able to “go with the flow,” to read body language, to react quickly to very subtle expressions, and to turn them into meaningful therapeutic events. These children contributed immensely to my understanding of how AMT works. I had never wanted to work with children on the verge of adolescence because I was afraid of the challenges, but I have become convinced that this work can be very gratifying and fun. It was a joy to see them grow and change, and it has motivated me to seek work with this age group in a public school system in the near future. References Austin, D. & Dvorkin, J. M. (1998). “Resistance in Individual Music Therapy.” In K. E. Bruscia (ed.), The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Bruscia, K. E. (1998). “The Dynamics of Transference.” In K. E. Bruscia (ed.), The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Kowski, J. (2002). “The Sound of Silence--The Use of AMT-Techniques with a Non-Verbal Client.” In J. Th. Eschen (ed.), Analytical Music Therapy. London: Jessica Kingsley Publishers. Moreno, J. (1988). “Multicultural Music Therapy: The World Connection,” Journal of Music Therapy, 25 (1), 17-27. Pavlicevic, M. (1997). Music Therapy in Context. London: Jessica Kingsley Publishers. Priestley, M. (1975). Music Therapy in Action. St. Louis, MO: MMB Music. Priestley, M. (1994). Essays on Analytical Music Therapy. Phoenixville, PA: Barcelona Publishers. Robbins, A. (1994). A Multi-Modal Approach to Creative Art Therapy. London: Jessica Kingsley Publishers. Scheiby, B. (1998). “The Role of Musical Countertransference in Analytical Music Therapy.” In K. E. Bruscia (ed.), The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Thompson, G. J. (1983). Verbal Judo: Words as a Force Option. Springfield, IL: Charles C. Thomas Publisher. Wigram, T., & De Backer, J. (eds.) (1999). Clinical Applications of Music Therapy in Psychiatry. London: Jessica Kingsley Publishers. Winnicot, D. W. (1971). Playing and Reality. London: Tavistock Publications. Yalisove, D. L. (1997). Essential Papers on Addiction. New York: New York University Press.

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

CASE SIX Speaking Without Talking: Fifty Analytical Music Therapy Sessions with a Boy with Selective Mutism Wolfgang Mahns Abstract In this case study, analytical music therapy with an eight-year-old Turkish boy with selective mutism is described. Within fifty individual sessions, and regular discussions with parents and teachers, he was gradually able to rediscover his vocal expression. In this child therapy it is shown that the whole spectrum of symbolic interactions (music, drawing, playing) is needed. Institutional aspects (special school) are discussed, as well as cultural aspects, and reflections on the function of music, musical instruments, and improvisation in a child therapy approach. Introduction In recent years, therapeutic treatment has been introduced into various schools (comprehensive schools, special schools, and regular primary schools) in Hamburg, Germany, to enhance traditional approaches with special programs for dealing with learning and behavioral disorders. The methods employed include play-, client-centered, and music therapy and can be viewed as a balanced combination of pedagogy and therapy in order to both prevent having to send students to special-needs schools and to provide full-time therapeutic treatment for psychological needs. One thing is common in all cases: the knowledge that educational institutions in the future need to be more demanding not only in terms of improving the quality of methodological and didactic practices, but also in terms of possibilities for improving the quality of diagnosis and treatment of children with emotional/behavioral disturbances and meeting the psychosocial needs of these students. The justification for therapeutic treatment within schools can be shown simply by the fact that referral for therapy through medical insurance or regional educational consulting centers for those in lower socioeconomic groups is rare or given far too late. Consulting or preventive teachers and therapists within schools can respond much more quickly, because they are available as a starting place right “in the field.” Furthermore, an interaction with their teaching colleagues is possible without any of the misunderstandings that so often arise between the different service providers of psychosocial care for disturbed children and adolescents in educational settings.

For a number of years now, I have been working as a music therapist in a school in Hamburg for children with learning difficulties. In addition to providing music education, I spend a few hours per week providing individual sessions in music therapy. In arrangement with my colleagues, selected children that are applicable for these sessions are treated in a separate therapy room. This room offers the needed protection/privacy as well as the possibility to make lots of noise. The acceptance and understanding for my work has grown over time in this school. From my point of view, music therapy is a psychoanalytically oriented treatment for children and adolescents who experience disturbances in perception, behavior, school attendance, or physical activities. I try to give them the opportunity to express their concerns and needs through therapeutic play and discussion. Furthermore, I try to help them to increase their expressive ability and to understand their unconscious motivations. Music offers a way to this understanding. Using instrumental as well as vocal and movement improvisation with the children, music provides a variety of rich experiences and layers of emotional expression. In such improvisations, the work with the spontaneous, unplanned, and the unforeseen is where the special value of music therapy lies. Even before the expression can be verbalized, the reaction is already being expressed through a different medium, which also means that it allows the client to express feelings that have usually been impossible to verbalize. Other forms of symbolic expression that I incorporate into sessions include painting, puppet play, and other similar activities. When working with children, one needs to particularly consider the following. A child’s disturbed interaction, often seen in various neurotic symptoms, is accompanied by the problem of differentiating between inner and outer worlds (fantasy and reality). Often these children are able to express their emotions, anxieties, and needs, despite the most extreme troubles faced within their family environments. This expression acts as a “transitional object” to facilitate the pain (Winnicott, 1971, p. 13ff). This can become symbolized and overcome through art, music or play. A child that faces the loss of a relationship and is not able to express this pain, for instance, is in a terrible situation and has only one option: to flee into a psychological manifestation; a neurotic symptom, so to speak. By using music, play, and art, and by relearning the ability to claim objects, these symptoms can be transmitted into symbolic expression. These therapeutic treatments have great success in healing. The use of music therapy with children is not about using set music for a set purpose. Such an understanding of music and of therapy suggests it be used as a substitute for medication or surgery. Rather, it is more like preparing a field for symbolic actions, allowing rigid boundaries to flow freely again. Using only one form of symbolic expression, i.e., musical improvisation, is not very effective from my experience. For specific emotional layers it seems to be more effective to use concrete therapeutic forms of play or art therapy, to build a tower with woodblocks or to paint a fantasy picture. The child feels the resistance of the material which needs to be overcome or has the pleasure of a finished relatively imperishable product. The musical improvisation, on the other hand, offers the opportunity to intensify a feeling or produce a sense of achievement without making mistakes. Unconscious feelings are thus sounding in the flow of time. The created musical shape can be explored in terms of inner states and ambivalences. These connections are further intensified through exploration and then the extensive clinical material is documented.

Background Material “Osman” This case study examines the music-therapy work I conducted with a Turkish boy named Osman.1 I worked with him for nearly two years, while he was visiting our special school. He did not speak at all. An examination in the audiology department of the university hospital found no organic cause. Selective mutism was the diagnosis. It was suggested that Osman’s parents should bring him to an educational consulting center, where in the safe, anxiety-free environment of play therapy, he may speak. The parents refused to follow this advice, but Osman’s social worker suggested trying music therapy. Before I discuss the process of the sessions in detail, the symptomatology, history and diagnostic picture of selective mutism will be explained. I will also outline my plan for the therapy. Finally, after describing the music therapy treatment, I will illuminate the progress Osman made in music therapy and discuss possible reasons for this. Symptomatology Osman did not speak. The eight-year-old Turkish boy could speak, his parents knew, but in school he did not speak. The first time I met him was in his first grade music class. He participated as long as he did not need to produce any loud sounds. He did not sing or play any brass instrument, as this would be very close to singing. Whenever the class was singing a song, it did not seem to reach him at all, although his eyes and mouth would twist. When children in the class were laughing, it was very hard for him not to do so, and when he cried, it happened without any noise at all. It looked as though he wanted to punish himself or his environment. Osman was the main topic in staff meetings. He was making people feel insecure, sad, and even aggressive. The question was, should he really be in this school at all, or should he visit another school for speech disturbances or even for children with developmental delays? It was absolutely unclear what he was able to do or was not and whether he could follow the lessons or not. Also his classmates had ambivalent feelings toward him — partly aggressive, partly indifferent. It even seemed as if Osman’s silence weakened the rules of interaction. All that was important in terms of communication in school lost its significance (questions and answers, encouragement and admonishment, praise and punishment). This symptom of not speaking was not only examined in relation to his social context at school; it had consequences both socially and for Osman’s educational development. Anamnesis (Case History) I gathered information about Osman’s life from various resources: reports from his preschool and the special school, an opinion from the audiology department of the university hospital in Hamburg, as well as discussions with his social worker and a visit with his family. The usual first interview (a personal history) was not feasible, as Osman would not express himself verbally.

When Osman began individual music therapy sessions he was about eight years old. He had two sisters, three and four years older than he. His father was fifty, his mother thirty-five years old. Both parents had moved to Germany to work and save money to enable their siblings to have a better life when they returned to Turkey in the future. Mr. G. was quite disappointed that he had produced only girls at first, but his son finally arrived three years after his second daughter, and he was very proud. Immediately after Osman’s birth, the family moved to Germany. Osman learned to speak quite late, when he was four years old. He realized that most other children around him were speaking in a different language. He tried to communicate with them, but this was very difficult, as even his sisters could not assist him at all, because they did not leave the house except to go to school. It was during this period of his speech development that a traumatic event occurred. He was hospitalized for six weeks due to dizzy spells and sudden fevers. Because the hospital was far away from their home, Osman did not have many visitors. His mother reported that each time they had to leave it was very difficult for him. She recalled that after the stay in the hospital he acted very differently. Incidentally, the results of the medical examination remained unclear. Both parents were working, but they arranged their shifts so that one of them would always be at home. Mr. G. can be described as warmhearted and very close to his children, especially to Osman. However, he was not often at home, doing shift-work and a lot of overtime. His wife, in complete contrast to him, showed very little emotion. Her face had hard features; she looked as if she had worked her entire life. The housework was done completely by the two sisters, while the mother took care of Osman. Osman enjoyed the advantages of the typical gender-specific conditions of his Turkish upbringing. However, what deviated from the typical model was that Osman was exposed to physical and sadistic punishment when he pushed the limits. Even more unusual was that the punishment was received from his mother, and the comfort from his father. The family of five lived in a two and a half room flat. The larger room was used as a kitchen, the smaller one as a living room. This was where the two girls slept. Beside it was the half room, which served as the parents’ bedroom, and in which Osman also had a mattress. The living conditions were extremely poor. No luxury goods could be afforded, as the majority of the money was supposed to go back to Turkey. Even toys, dolls, cars, etc. were hardly found anywhere. Admittedly, they did purchase a large color television, a video camera, and a variety of electrical devices as status symbols of great worth that would be taken with them when they returned to Turkey to live. The onset of Osman’s silence was a visit to a public school. Before regular primary school, children should go to a preschool. He reacted with panic at the thought of another separation. His whole body trembled as his mother left him at the preschool. He responded to this completely strange world by being shy and hiding. He even attempted to go back home with his mother when she left. As soon as he recognized his hopelessness, he gave up. His mother always accompanied him to school, but as soon they entered the building, he refused to talk at all. He did not speak to anyone; not to the teachers or the children. Various attempts to integrate him into the group, verbal and nonverbal, were totally unsuccessful. He had to repeat the preschool class, but when no progress was seen at all, he was transferred to the

special school. In a small group setting of ten children with a very warm and caring social pedagogue2 he began to feel more comfortable. His nonverbal communication skills developed well in this new learning environment. He enjoyed playing and enjoyed listening to stories. His drawings were very expressive. This talent was nurtured by the social worker. From that point on, whenever he drew a picture, he expressed his moods, feelings, and fears in an imaginative manner. In place of getting a personal history from Osman, I asked him to draw me a picture with a definite theme, the theme being “My Friend” (picture 1). The drawing depicts a young boy with his hand held high, in his right hand a knife, which is pointing toward a cloud directly overhead. In the cloud is his name. There are various possible interpretations of this picture. It could be that Osman was representing himself, a cloud over him, to equally protect him and to stand between him and others. The knife as phallus symbol is expressive of wishes, aggression: pushing through the silence, or being in conflict with others. Another detail would allow for a different interpretation: The cloud at his mouth could be seen as a “call” in comic-style technique, so that we could assume that he indeed has a friend, whom Osman wants to call, to get in contact with him. Most likely both definitions are realistic. “I am my best friend,” and “A friend is out there calling my name.” More likely, the ambivalence of his silence seems to be saying: I would like to talk, but that is impossible as I have to show my teeth for that. And that is dangerous.

Picture 1 Diagnostic Picture In the biographies of mute children, there is almost always an occurrence of an early separation, or a deprivation, that leaves them destabilized. In addition to the initial loneliness, there is wider environmental damage. The development of a personal vocabulary is blocked, due to a lack of encouragement; a younger or older sibling may have grown up with preferable

treatment. Additional demands, such as achieving at school, inhibit language for formulating thoughts, thus leading to repression, because at the basis is a self that is not fully developed and has not been assimilated (Dührssen, 1982, p. 184ff). “The starting point lies in the Epoche, in the affective meaningful sound, and not the articulated word making a connection between the infant and his environment” (Ibid, p. 189). The deprivation experience, or rather the demands generally placed on children with particularly sensitive personality structures, can lead to a reaction of mutism, sometimes acute and dramatic, sometimes gradual and insidious. Only seldom will a person be faced with complete silence (“totally mute”). “In the majority of cases, verbal communication is refused in significant groups, while generally, in the context of the family, at least a certain amount of speech contact is maintained” (Ibid, p. 184). I speak here of “selective mutism” or “partial mutism.” Mutism is in no way, as is often misconstrued in lay circles, a defiant reaction of the child. That is why the earlier term of “chosen silence” is misleading. Innate adverse factors rarely play a role. Rather, the mute child experiences a number of unfavorable factors, which together prevent him/her from communicating with others. These general statements about the disorder of mutism are pertinent to Osman’s case. Several unfavorable factors were interacting with each other. His mother was unable to give him the love and warmth he needed. One can assume that she could not understand the extent of his fear of loneliness and separation. Furthermore, she had taken over the role traditionally inhabited by the father in a Turkish family. So, as the only male child, contradictory expectations were requested from him. On the one hand he was the “prince,” whom everyone served, yet on the other hand he was a disappointment to his family because he did not behave appropriately for his age. It is important not to forget the difficult conditions facing a Turkish family living in Germany. The parents saw their roots in Turkey. They come from there and would return there to live. In the meantime—for more than ten years—they continued to maintain their traditions and cultural practices in the midst of an atmosphere of hatred toward foreigners. The Turkish children attending school, however, were able to understand the difference between them and their schoolmates. They usually had no chance to compare the differences to their parents. They had to adjust their behavior, educational practices, and language in some ways in order to survive their German school experience. Often they felt as though they could not understand and fulfill expectations in the school situation. Because their parents usually could not help them to understand, this failure to learn could result in psychosomatic or neurotic disorders. When Mrs. G. reported that the reason Osman did not speak at school was because he was ashamed, this indicated a fear of appearing inadequate. However, the underlying problem lay more deeply. When he “punished” his teachers and schoolmates with silence, he was actually meaning to punish his mother. However, his anger over his mother’s aggression toward him, over his failure to fulfill his wishes, could not be pointed directly toward her. This was forbidden by the taboo of the “good mother.” So, Osman redirected his aggression toward the hostile school and anyone who gave him an obvious reason to do so, by speaking another language. Admittedly this anger was not expressed as outward aggression, rather it appeared at first as a mute reaction. Therapy Plan

The ability of music therapy to include nonverbal expression seems to offer alternative healing prospects to those who are mute. This is not just because the mute person is provided with an alternative language. This would not produce a lasting result, just as when one gets a stutterer to sing. Other forms of symbolic expression (art, dance, music, play, etc.) are much more suitable in order to create a bridge between inner and outer worlds, between experience and action, between fantasy and reality. Winnicott speaks about these transitory phenomena, which take on great significance in overcoming the separation experience (Winnicott, 1971, p. 12). Therefore, music therapy with Osman must include the following guidelines: He must have individual music therapy. Only in a one-to-one situation would Osman be able to overcome his fears, and to abandon parts of himself with the added value of being able to take it back if it caused him undue anxiety or felt too premature. Along with musical expression, children frequently benefit from playing with toys, and above all Osman’s passion for drawing should be involved. In this way one can engage the transitional phenomena through various modes. At least two to three years of therapy are essential, because such a deeply embedded disturbance as mutism can only be resolved gradually. The school environment, more specifically the special school, even with its clearly defined boundaries, is not always favorable. In Osman’s case, however, it is exactly what is indicated, because the silence occurred at school. This had consequences for his educational progress. Furthermore, it allowed for the possibility of support by his teacher. The supportive therapy room, particularly important in providing the entitled anonymity, is especially necessary in the therapy with Osman. In this way he would be able to make important progress within therapy while still not reconciling with the public. I planned on having individual therapy sessions for forty minutes per week for a period of at least two years. Discussions with his teachers and parents would also take place on a regular basis. Osman would be informed of this involvement of those around him. In addition to the usual variety of musical instruments available in the music therapy room, cloth puppets, building blocks, and a small oven were also provided to meet additional needs a child may have. In Osman’s particular case, a variety of diverse drawing and painting materials were also always available. After speaking with Osman’s teacher, it seemed important, at least in the beginning, that he be picked up from his classroom and brought to the therapy sessions. In this way, the adjustment to the new environment would not be so drastic, as compared with him walking over by himself. I had never had a client who was mute, let me make myself clear, so I had great expectations on all sides: When will he start to talk? I have to clarify the expectations I had at that stage, even though they were unconscious. I also must say that I did not feel that using the “ISO-principle” (Altschuler, 1948; Benenzon, 1983, p. 165) would be appropriate in this case. That would entail beginning in the same state of the absolute speechlessness. That would reduce opportunities for experiencing the normal external world as it is. Treatment

I worked with Osman in music therapy for almost two years, for a total of fifty sessions, one session per week. The beginning of the treatment focused on exploring the therapy room and its possibilities. Osman remained rather passive, especially when it came to the musical instruments. His main focus was still on drawing, which I accompanied with piano music. I saw my main function as accompanying Osman in his activities inside and outside of the music therapy room. Now and then, I reassured Osman that in music therapy he would not be forced to do anything he did not want to do. I knew that he would not speak, but was sure that he had his reasons. Sometimes it was a bit confusing to have a silent individual in front of me: to suggest, to inform, to show feelings, but at the same time realizing the intense feelings inside of him: the anger, the sadness, and the rage. I tried to understand his actual needs and wishes without language. But then I had the idea of using gestures for yes/no, with thumb up for yes and thumb down for no. Thankfully, Osman utilized this new option imaginatively. Through a combination of both symbols he even created a gesture for “I don’t know.” During the third session Osman discovered a candle and matches that I kept in the cupboard for festive events. He lit one match after another and let them fly through the room like rockets. Because of this, I moved the following session outside, where we lit a small bonfire. With this significant action he showed me how much fire he had inside, the desire for a warm center, for a mother that would understand his feelings. Playing with fire can also refer to the unresolved Oedipus complex: a desire for his mother that could not be satisfied because she could only show her hard side. The music therapy room has the theme “beat and be beaten.” The following occurred during the fourth session: Osman found the animals and puppets and started to throw them around, pull them, and finally beat them up. “Osman, shall we make some music?” I asked, as the puppets lay scattered and he was taking a rest. He nodded, and walked in the direction of the bass drum and the bongos. I accompanied him on the piano, and expressed the pain I experienced during his outbreak of rage. When we finished I said: “That sounded like you beat someone up.” Osman did not react; instead he took a pencil and a piece of paper and started drawing. The drawing showed a person crying (picture 2). He drew with a lot of pressure, which nearly forced the pencil to break. By using the agreed upon gestures, I found out that it was about his mother.

Picture 2 Viewing the three scenes in combination (beating puppets, beating drums, and drawing his mother crying), one could conclude that this was a representation of a real experience. I had discovered through conversations with his parents that he had received physical punishment by his mother due to his aggressive actions and because of his temporary mutism. The tears of his mother are therefore ambivalent. In one way it could show her helplessness in terms of his not fulfilling her expectations. Alternatively, he probably projected himself into the picture: as the person who was beaten. In the seventeenth session, after about half a year, Osman decided to build a cave in the therapy room. He had done this several times before, most often with the piano at the center of his cave. Tables, chairs, and a climbing board, with hung blankets, functioned as walls. He chose not to build a door. On the piano he placed some flowers, so the whole cave was very comfortable. I was to make music in the cave, but he did not want to enter the “living room.” Instead he painted a series of pictures: either at the table, or on drawing paper on the floor. While I played the piano, I sang and explained to him what I saw in his pictures. He drew dragons, snakes, and sometimes a little child in the middle of all these beasts (picture 3). In this session, the cave was built with more tables and was darker inside. A few bongos, the portable cassette recorder, paper, and markers were inside. I carefully asked him: “Osman, what do you think about allowing me to enter the cave with you?” He thought about it for a little while, then raised his hand with pleasure to symbolize the yes sign. Inside the cave he painted more pictures that provided additional information about his inner conflicts. On the bongos, we played at times mysteriously, at other times wild music. I continued to comment on his pictures and he would agree or disagree with it.

Picture 3 This first picture (picture 3) shows an ill person in a bed, surrounded by dragons, snakes, a ghost, and a spider. It looks ominous in regards to how the snakes spread their poison. The two dragons seem to come to help him out, by grabbing the snakes with their claws. In the next picture (picture 4) a giant snake surrounds both a child and a dragon, attacks the child with its poison, but is hit by the dragon and is dripping with blood.

Picture 4 The third picture (picture 5) finally shows the snake lying in its own blood, the child walking on it celebrating in triumph.

Picture 5 After this picture, Osman left the “cave,” took a cymbal out of the cabinet, and started playing a rhythm. I took a rattle and joined him, singing, “We are celebrating, because the snake is beaten.” He finished by throwing the cymbal on the floor and kicking it. It was apparent that by overcoming his inner conflicts through his art he experienced an obvious release, the snake symbolizing his mother. In my conversations with Osman’s parents, his mother never seemed to understand, although the teachers stressed it again and again, the importance of not forcing him to speak. Osman’s mother, however, suggested draconic actions, through an operation, like tongue correction, or in an educational way, through beating. I tried to be understanding of her feelings of helplessness, but also asked her to please be patient with her son. In the following weeks, Osman experienced very extreme feelings. In one session, he left the therapy room in total chaos, flooding the floor with a container of water. This manifested punishment fantasies in me; these probably mirrored the expectations that Osman directed toward me. In the very next session (19), for the first time, I experienced Osman tenderly embrace his favorite animal, a big monkey. Right after that he threw him straight across the room again. I tried to support this action with a matching phrase on the piano. I also loudly cried: “Ouch, ouch, you hurt me,” whenever he beat or threw the monkey. Some of what Osman did to the monkey had been done to him. In this musical-scenic play I was a kind of “substitute-I” that expressed the pain that Osman was not able to express. At the end of this session, Osman climbed up onto the instrument cabinet and gave me signals to come over and catch him. Osman enjoyed this game so much that he wanted it to be repeated over and over again. I was pleased by the fact that Osman obviously developed more and more trust in me catching him—and symbolically, too. Some major changes occurred in his pictures at this time. Superman replaced the dragon to protect the child from the bad snake. The child was now lying in bed or in a kind of prison. The musical part of this experience now involved vocal sounds by Osman. He placed microphones and bongos on a table, and from this elevated place he produced electrically supported sounds. He stretched himself to appear bigger, and, lost in the protection of the microphone, he had no fear of his own voice.

The twentieth session, after eight months of working with Osman, marks a significant turning point. It was hard to understand his suggestions and demands that day. “Osman, sometimes it is not easy to understand what you want me to do. Don’t you think it would be easier to tell me what you mean?” Osman did not react at first. We improvised, beginning with a calm mood and becoming disturbed by wild drum rolls once in a while. After we finished, I asked him if he wanted to draw a picture. He nodded.

Picture 6 His picture (picture 6) showed two people in the center, a small and a big superman fighting a snake, a dragon, and a ghost. One object was puzzling to me. Through questioning, I found out that it was a bomb. I asked: “Osman, do you think that something dangerous will happen, like a bomb blowing up, if you start talking?” He reacted very impulsively. He scrunched up his picture, and held it in his hand undecidedly. “What would you like to do with that picture?” He found an empty coffee can in the cabinet and put the picture inside of it. I named it the “secret can” from then on. That seemed to please him. From then on all his pictures went in that can. Everything that held value for him had a safe place. The following session (21) began somewhat unusually. Outside there was some bulky refuge lying out. Osman discovered this large amount of trash that was waiting to be taken away by the maintenance staff. He literally dragged me outside and indicated that he wanted to examine the trash. He examined the different heaps and quietly whispered what he discovered. He took some things like markers, chalk, and a comic with him. On the way back, I recognized that his whispering got quieter. The closer he got to the school, the less intense his talking became. Back in the therapy room I asked him if his treasure should stay here or go home with him. He signified that it should remain here. In the following sessions, Osman redefined his activities. The drawing activities decreased and the musical activities increased in the therapy room. Except for some clearly understandable whispered statements he was still not talking. I did not pressure him at all about the big event of him talking for the first time. In the twenty-fourth session, on the way from the classroom to the therapy room, Osman went into the secretary’s office and wanted to

make a phone call. So we talked to each other on the phone, Osman using the secretary’s phone, and I from phone in the principal’s office. A small conversation took place; a little question and answer game or, rather, an amusing vocal improvisation. More important than anything was the hanging up and calling again procedure. In this play, was I the friend from Osman’s first picture who is calling him? In any case, Osman had rediscovered and dared to show his voice “publicly.” This event spread through the school like wildfire. Everybody took an interest in it as if it were a miracle. It was very important that he did not get too much attention now, because that would completely destroy all of the hard work. Also, the relationship between Osman and his mother seemed to improve. One day he proudly presented his warm, colorful, handmade sweater from his mother. She had given him something that would keep him warm and wrapped up during the cold winter. Osman drew the last picture during the twenty-seventh session (picture 7). It depicted a house with a straw roof and smoke coming out of the chimney. Outside of the house Osman was raising the Turkish flag. For the first time there were no animals, dragons, snakes, or supermen. Maybe this was a sign that his fears had diminished and his ego-strength had developed. Through the connection with his country he may also have been saying: I am at home. I am a Turk in a German school, in an environment that at first was full of danger, threat, and discomfort, but here I can also have the feeling of being “at home.” Following that picture I put on a cassette of Turkish pop music for him, which I had in my cupboard for working with foreign children. At first he was surprised, but then he smiled, gave the bongos to me, and grabbed himself a guitar. We were now a Turkish band. All we needed was an audience and a few belly dancers.

Picture 7 From then on, Osman often asked if his friend Olaf could join the session. Such a desire often plays a significant role in therapy with children. It sometimes functions as a defense in response to the intensity of the relationship between therapist and child — someone should come between the two. Maybe this was the case for Osman. But it soon became apparent that the addition of Olaf to the therapy helped in achieving the next therapeutic step. Olaf was proof

for all the things that Osman and I experienced. Besides, Olaf was an object for Osman to dominate and to rule. He was also someone who, spontaneously and without questioning, followed my directions and suggestions and, therefore, motivated Osman to do the same. In particular, the music activities took longer. When Osman was sad, we played sad music. When words like “Gypsy,” “dried flower,” “watered flower” or “travel” were mentioned, we played music using the therapeutic technique of “associative improvisation” (Eschen, 1983, p.41 ff). Then, a sudden end to music therapy with Osman occurred because the family decided to leave Germany and return to Turkey. The last session was a long prepared for celebration for three — Osman invited Olaf. The final piece of music was a lengthy improvisation based on a melody made by Osman with the words “bella, bella, bella.” Osman imagined that he was a Gypsy and traveled throughout the world. Once in a while, the Gypsies celebrated a fest and sung their “bella, bella, bella.” Osman and I sang out as loudly as possible. I played the piano and Osman played the drum. Olaf preferred to stay in the background with his rattles. I was very impressed with how Osman was using his voice during the improvisation. I was not sure what the meaning of the words bella, bella were. I was not aware until I looked them up in a Turkish dictionary that they meant “misfortune, evil.” Of course, separation is always a bit sad, however the music did not sound sad at all. The music therapy treatment with Osman ended with a last visit with the family. Everybody was there, between cartons and suitcases. It was very surprising for me that the evening ended in a three-hour festive dinner. Mr. and Mrs. G. were very grateful of my efforts, and even invited me, and my family, to visit them in one of their apartment houses in Izmir, Turkey. Discussion and Conclusions In the fifty sessions, Osman was given the chance to play through and experience various forms of symbolic expression of situations that until now he had missed out on in his development. I will take the opportunity to talk once again about my first visit with the family. This visit was a little difficult. First of all, there was the language barrier. Second, I got the feeling that Mrs. G. did not understand much of it and could not relate to it emotionally. She strongly believed that Osman was bad and that the teachers should just be tougher, like they are in Turkey. The atmosphere relaxed somewhat when Mrs. G. brought out the photo album. This provided an opportunity to talk about a lot of other things. She indicated that she felt that the basis of Osman’s silence was because he was embarrassed at school. Other photos were of his hospital stay and of Turkey. Osman was in the room the entire time. He was mostly silent, without even reacting to what was said. His mother and sisters continuously encouraged him to talk, without any success. He was stuck in an inner conflict. This was usually a place where he talked. To him, I was part of the “enemy” world. After a while, he tried to get some attention. He threw some cars through the air, turned the television on and off, turned the volume completely up, and filled his mother’s tea with spoonfuls of sugar until the cup overflowed. Mrs. G. set no limits. It was easy to see her anger in her facial expressions and her gestures, but she simply ignored her son. From this, I came to understand the reason for his silence: a deep-rooted wish to express his enormous anger and his strong desire to be acknowledged and to be given clear limits. I tried to

explain again to Mrs. G. that Osman would not be forced by us to speak. She seemed to feel that Osman had made a positive connection with me. The very last comment I heard from her was the following: “Take him with you; take him home with you. You can keep him!” What does it take for a mother to say that she wants to give her son away! Osman had to struggle with several separation experiences: his stay in the hospital, the fact that his mother was working most of the time, as well as the move to the German school. In addition, a sensitive child like Osman had greater difficulties dealing with living in two worlds: Turkey at home and German at school. Furthermore, it is important to realize that he was not given the chance at home to resolve this difficulty he had with these transitions. His mother did not have a sense of a child’s need for toys as vehicles for understanding. Playing, according to her, was just a stage before becoming an adult. And this stage should be squashed quickly, even if it hurts. Thus, Osman’s relationship to his toys at home and to the things in the therapy room made sense: erratic and destructive, without respect. It was probably a lifesaver that he discovered drawing as a way to express himself. Other transitions in the process from fantasy to reality were also seen: making a fire, using a microphone, using the telephone, playing hide and seek, and building a cave. His progress in individual music therapy was predictably difficult. The trust given to me increased when given the possibility to play and express things symbolically. In this way, it was possible for him to trust his voice again. I would now like to comment about the function of music therapy in Osman’s case. In the beginning, the idea of making music seemed to be dangerous for him. The first improvisations were simply to indicate the beginning and the end of a session. In addition, the musical accompaniment that I offered him as background music for his activities was significant. This gave a kind of “musical foundation” which made my presence known, holding him in the activities without any pressure or expectations of him. For Osman, drawing was a more concrete way to explore his fantasies. Through an improvisation, music can certainly intensify an emotional state, and the picture completed this for him. Through improvisation, things were expressed in the outer world that he was not ready to express verbally. In one improvisation, which I later named “beating up,” the sound was dramatic, and this was also reflected in his drawing. Perhaps the music here had the effect of encouraging, stimulating, and allowing him to “talk” about his experiences and feelings; in his case, through pictures. Through this multimodal approach to music therapy (music-speechmusic; playmusic-drawing, etc) it is possible to examine similarities and differences in the transformation process. One example of this was when wild music followed a “nice” story. Another function of the music was the specific appeal of the different musical instruments. Of course, it took Osman a long time before he chose brass instruments. Relatively early on, he discovered the rattles and the bongos and bass drums. The rattles fit with his desire to walk around, so of course he chose them first. They were his companions. The bongos and the bass drum allowed him to be wild and to show his impulses and the real fire inside him. These sound pictures were usually very short. They had more of a cathartic function. To perform longer lasting music with piano accompaniment was not appropriate for him. In music therapy with children instruments are often used as toys. This was true for Osman. Tone bars were used as construction blocks; sticks as knifes, swords or guns. His growth process went hand in hand with the act of rising up on the table and extending the microphone stand. But more than anything, Osman had a preference for the toylike character of the bongos;

perhaps for him it was like the puppet. He carried it through the room, beat it up, threw it on the floor, picked it up, and touched it gently. Furthermore, the bongos were the only instruments he allowed into his cave. This important role of the instruments was further captured when he expressed his first vocal sounds through the microphone. Just as one can identify and connect with a musical instrument, naturally one can also feel threatened by an opponent while fighting against it. In one situation, in Osman’s fantasy, the cymbal was dressed up as a snake and was therefore seen as an enemy that needed to be beaten. Therefore, in addition to their traditional functions, instruments can be objects of play. They can be filled with life because of their outer appearance and what they are made of. When this is the case, the sound experience may be subordinate. In the whole spectrum of symbolic interaction (music, drawing, and play), sound was the very last form that was recovered and was only important later on when a third party was involved. I was particularly touched by the gradual development of the voice: from the sound over the microphone, to the childlike whispering on the telephone, to the loudly given orders to his friend Olaf. Finally, Osman’s singing voice was an incredible discovery. He was able to understand and reproduce melismatic Turkish quarter-tone music, as well as to build bright sounds from the piano into his melodies. During the course of the therapy with Osman the music-making became more and more central. To summarize, I will list the different functions of music in Osman’s treatment. It is very interesting to see that music found its place in the final phase, when Osman was already using language: • • • • • •

Structuring the sessions Wrapped in a sound (musical nourishment) Intensifying emotions being experienced in the moment Adding sounds to certain impulses Identification and argument with the musical instruments (toylike qualities) Contact and dialogue

I would like to end this case study with some statements about the end of Osman’s therapy: Osman’s contact with his same aged peers is considered to be normal. He is not bothering anyone with silence or aggression. On the other hand, he is not yet able to understand the limits of his power, so he sometimes gets into trouble with stronger classmates. Had it not been for the sudden end to therapy, due to the return to Turkey, the sessions would have been continued for a while. The goal would have been to stabilize his condition and include him into a group setting, where he would have learned group processes having to do with confrontation and agreement. How the new environment, the different treatment of students in Turkey, and the lack of understanding will influence his further development is difficult to predict. Maybe he will resort to selective mutism in stressful situations. However, I hope that he became stable enough through the treatment he received in the special school, the individual music therapy sessions, and his understanding teachers to handle other problems better. His rapid development through music therapy lead me to believe that his chances are good. In addition,

his parents now have a far more positive attitude toward him. They bought him a bicycle right before they left. Osman showed it to me on one of my home visits and, for the first time, I saw a glimpse of being proud of her son in Mrs. G.’s eyes, as he was circling around, waving and smiling at us. References Altschuler, I. M. (1948). “A Psychiatrist’s Experience with Music as a Therapeutic Agent.” In O. Sullivan & M. Schoen (eds.), Music and Medicine. New York: Schumann. Benenzon, R. O. (1983). Einführung in die Musiktherapie. München: Kösel. Dührssen, A. (1982). Psychogene Erkrankungen bei Kindern und Jugendlichen. Göttingen, Zürich: Verlag für Medizinische Psychologie im Verlag Vandenboeck & Ruprecht. Eschen, J. Th. (2002). “Analytical Music Therapy — Introduction.” In Johannes Th. Eschen (ed.), Analytical Music Therapy. London and Philadelphia: Jessica Kingsley Publisher. Winnicott, D. W. (1971). Playing and Reality. London: Tavistock Publications Ltd. ________________ Note: This article was first published in Isabelle Frohne (ed.) (1999): Musik und Gestalt — Klinische Musiktherapie als Integrative Psychoherapie. Göttingen: Wandenhoeck & Ruprecht. The German title is: “Die musiktherapeutische Behandlung eines achtjährigen mutischen Kindes.”

CASE SEVEN The Impact of Creative Music Therapy on a Child’s AbilityTo Relate Interpersonally John F. Mahoney Abstract This case describes a course of Creative Music Therapy with Carlos, a seven-year old boy who was born prematurely in the 24th week of gestation. He is visually impaired, delayed in speech, and although he struggles with other developmental issues, he is a musically gifted child. Through his participation in music therapy, Carlos has made significant progress in his ability to communicate and relate to others. Background Carlos was born after 23 weeks of gestation, weighing 23 ounces, on October 7, 1999. Carlos’ parents are from Mexico and Ecuador. Spanish is exclusively spoken at home, while English is exclusively spoken at school, although there are several bilingual staff members who occasionally speak to Carlos in Spanish. Although he has had six surgeries in an effort to attach the retina to his brain, so far Carlos exhibits little usable vision other than perception of light and large objects. In addition to various developmental delays, Carlos is visually impaired (Retinopathy of Prematurity, Retinal Detachments). Developmentally, he lifted his head at 1 year and said his first word at 2 years of age. Recently, at the age of 7, he began to combine words, but he still is not toilet trained. Carlos’ IEP states that he possesses few communication skills, other than the ability to cry when he is upset and to smile when he is happy. Carlos requires individual assistance to participate in most daily activities. His parents express concern about Carlos’ motor skills, physical coordination, attention span, and his behavior in general, and they are specifically concerned about his inability to play or otherwise interact with other children. Carlos does not take regular medication. His IEP stated that when upset, Carlos would frequently thrust his head and body backwards with little safety awareness and often hit his head on the floor although this behavior was never observed by this therapist by the time we had begun our work together. Carlos received occupational therapy and physical therapy at his pre-school in Manhattan, which specializes in work with visually impaired children. As a participant in group music therapy at school, Carlos typically spent most of the sessions banging rapidly on the floor with alternating hands as he spun his body around in circles. The staff generally discouraged this behavior because of its perseverative quality, and they viewed this behavior as a manifestation of Carlos’ tendency for social withdrawal. However, the music therapy team at the school, of which I was a member, saw an opportunity to reframe his rhythmic capability into interactive musical activity, and Carlos was referred for individual music therapy at the

Nordoff Robbins Center at New York University. We began our work together in September, 2003. Music Therapy Assessment Although tentative and shy during his individual music therapy assessment, it was apparent that Carlos possessed a great deal of innate musicality, along with the physical ability to execute rapid rhythmic subdivisions on a drum, cymbal, mallet instrument, or on the floor. There was little of his typical “floor slapping,” perhaps due to the presence of carpet on the floor. He appeared to derive pleasure from having his musical expression “accompanied” and met by the therapist at the piano. Though very rhythmic in his playing, Carlos showed little interest working with unpitched percussion instruments such as a conga or a drum, preferring to explore a small xylophone (xylimba). He played without much apparent regard for specific tones, but rather moved up and down the range of the instrument playing with two drum sticks. He made no vocalized sounds other than to complain when it seemed he wanted to leave after 10 – 15 minutes. Method Carlos’ treatment followed the traditional format of the Creative Music Therapy approach of individual therapy, with two therapists working as a team, the primary therapist playing the piano and the co-therapist facilitating the ongoing musical interaction as needed. The music was predominantly improvised. Relationships evolved primarily through and in the music that was created. During early treatment, Carlos was the dominant initiator of the tempo and mood of the music, with the primary therapist providing musical “scaffolding” on which Carlos could build his musical ideas. The metaphor of building scaffolding comes from Vygotsky’s learning theory (Miller, 2002) in which a student is viewed as constructing an edifice that represents development. The construction starts from the ground, the foundation that which is already known. The teacher provides the scaffold that supports the ongoing construction upwards into the atmosphere of what was previously unknown. The teacher, or therapist in this case, provides the support, the processes, and the language for the client to approach the task and to develop the abilities to meet it. Nordoff and Robbins’ concept of holding the client at the “developmental threshold” (Nordoff and Robbins, 2007) is closely related to Vygotsky’s concept of “zone of proximal development (ZPD) in which development occurs in the region which lies just beyond what the child can do alone. A child’s new capacities can only develop in this “zone” through collaboration in actual, concrete, situated activities with an adult or more capable peer. With enough assisted practice, the child internalizes the strategies and language for completing the task, which then becomes part of the child’s psychology and personal problem-solving repertoire. Therapy sessions occurred weekly at the Nordoff Robbins Center. Carlos would usually arrive with his mother who brought him from their home in Queens on the subway. Sessions typically were thirty minutes in length. Carlos worked with a two therapist team while his mother waited outside the treatment room. While the writer remained the primary therapist

throughout the course of therapy, the clinicians serving in the role of co-therapist changed from year to year due to factors involved with training policies and schedules. A person in a separate room operated a video camera to record the sessions and all sessions were videotaped. In observance of standard Nordoff Robbins Center protocol, Carlos’ parents signed a release form granting permission for video taped excerpts to be used for educational purposes. Treatment Process Following the typical clinical protocol of the Nordoff Robbins approach, video tapes of Carlos’ music therapy sessions were analyzed in a process called “indexing,” in support of ongoing assessment and treatment planning. From these tapes, a series of excerpts was compiled on DVD with the intention of providing an audio and visual summary of the process that took place during the first four years of Carlos’ music therapy. Carlos’ regular therapy sessions were scheduled to take place in an uncarpeted room that contained two pianos, a grand and a spinet, as well as a celeste, and space to contain a variety of other musical instruments, both pitched and unpitched. Year One: Sessions 1 - 29 Main clinical goal areas at this time involved the acquisition of the ability to communicate in music, a stage of assimilation and accommodation, congruent with theory developed by Piaget (1955). According to Piaget’s theory, developmental adaptation, or learning, occurs through 1) assimilation or internalization of new information to existing cognitive structures and 2) accommodation, or adjustment to new information through the formation of new cognitive structures. The movement from assimilation toward accommodation involves solving problems through pushing beyond the limits of an existing information structure. When assimilation is joined by an emergent sense of accommodation, but not overwhelmed by it, experience is optimal. Carlos, as with many children born so prematurely, displays an innate and spontaneous feeling for the deeper communicative possibilities inherent in actively making music. In his own way he has a “natural” musicianship. He seems to have been born with a musical proclivity that allows him to bypass conventional processes of skill acquisition. Session 1 DVD: Carlos—Excerpt 1 (Session 1) In his first sessions, Carlos returned to his familiar banging on the floor with his hands, and some exploration of instruments playing them in a similar manner. Working with Carlos individually, without the restrictions involved with working in a school setting was on the one hand exciting, but on the other hand challenging: “Now that I am free to work with Carlos however I feel will be most beneficial for him, how does that translate into musical interventions?” Trying to establish connections through musical interaction at an early stage of therapy with clients that offer little in the way of intentional, purposeful instrumental or vocal

initiative, often involves working to reframe responses of any kind—a bang of the foot, a clap of the hands, a tap on a drum —into a musical context that will encourage the client to do more, and to begin to recognize, and find pleasure in the aspects of human interaction and communication present in the situation. So I played with his floor slapping, imitating his patterns, adding the element of harmony to his rhythms. Session 2 DVD: Carlos—Excerpt 2 (Session 2) As at his intake session, Carlos was drawn to pitched percussion instruments but showed little interest in drums or the cymbal. This came as somewhat of a surprise to me, thinking that a logical developmental step from the slapping his hands on the floor might be to beat a drum with his bare hands. Instead, Carlos chose to play the Xylimba with mallets, preferring to hold the head of the mallet in his hands and playing with the handles. Although he appeared to prefer the mallet instruments, he did not play with much apparent awareness of the actual pitches, playing with rapid alternating handed beats which seemed to transfer from how he perseveratively beat his hands on the floor when we first met him. He gradually became aware that there was another person making music with him and he came to enjoy the idea that he was being accompanied. At this early stage the musical relationship was one in which Carlos initiated musical ideas which were then framed and reflected back by the therapist in a way that Carlos gradually came to understand that he was being listened to, accepted, and engaged by the therapists. There was little accommodation by Carlos at this point to musical ideas that were not initiated by him. That is, Carlos did not change his musicmaking to fit with the therapist’s music. During the early sessions, Carlos worked with a small xylimba that contained the 5 tones of the C Major Pentatonic scale. In this excerpt, Carlos’ face shows a quality of discovery. The idea appears to be forming that there are possibilities for him in this musical relationship. He senses that he is being heard and responded to. Carlos has noticed that we start together, we stop together, that we are sharing something that feels good, although he may not consciously know what it is yet. Session 10 DVD: Carlos—Excerpt 3 (Session 10) In this excerpt we can hear that Carlos is refining his playing technique, and that the range of his creative musical expression is on an increase as well. Rather than showing an occasional awareness that there is another person creating music with him, Carlos now appears to be constantly cognizant that the therapist is moving with him wherever he goes. He appears to enjoy the experience. We have expanded the range of tonal options by offering Carlos a xylophone tuned to a C Major diatonic scale ranging two octaves. Carlos has begun to develop the capacity to play and recognize musical phrases, single tones, and to vary his dynamics. His constant alternating handed playing has developed to the point where he can now play with a variety of rhythmic motifs. He still moves up and down the instrument with not a lot of

apparent interest in making specific melodic choices. He is still playing the pitched instrument percussively, and we work to develop his awareness of individual pitch differences, but there are new musical possibilities. There is a greater sense of give and take, so that the music is more relational. Carlos is moving from inner exploration to shared exploration. Session 18 DVD: Carlos—Excerpt 4 (Session 18) Carlos has reached a point where we are able to play more freely, with rhythmic flexibility and a greater sense of musical flow as we explore the Phrygian mode on the metallophone and the piano. The switch from the xylophone to the metalophone was made with the idea that the longer decay time of the metallophone might cause Carlos to slow down his playing so he would be more discerning in his melodic choices. As we improvise our cocreated music, we are building structures that reflect an aesthetic order, spontaneously moving together in music through time. Session 19 DVD—Carlos Excerpt 5 (Session 19) The music is becoming more co-active as Carlos reacts to and incorporates ideas initiated by the therapist into his musical expression. His interest in melodic choices is on the rise as well. His playing at times takes on a more self-reflective quality. Carlos continues to work with the metallophone set up in a Phrygian scale. He is more poised for creative melodic ideas. Session 22 DVD: Carlos—Excerpt 6 (Session 22) We have begun to encourage Carlos to begin to develop his ability to communicate utilizing his voice. He had made prior verbalizations such as “Ma” and we encouraged Carlos to sing on other phonyms, which might provide him with the scaffolding needed to further develop his speech. Carlos sings “mee, ma, mo,” and “moo.” The co-therapist picks Carlos up and brings him closer to the piano and his vocalization of “Wa” prompts the therapist to develop a 30’s – 40’s style “Ee Wa Wa Wa” song. Carlos anticipates the melodic direction within the harmonic context of the song and moves with the therapist and the music as he sings. Year Two: Sessions 30 – 60 The second year of work with Carlos followed along a similar direction as the first. He attended regularly, and his sessions were described by his parents as being the most engaging and purposeful events in his life. While I continued as Carlos’ primary therapist, a new cotherapist assisted us. Primary clinical goal areas continued around the area of furthering the

development of communication skills through musical interaction, as well as the further refinement of Carlos’ technical ability, specifically; how to use sticks and mallets with more precision. During his second year of work, Carlos’ playing began to include more subtle rhythmic patterns, and an increased flexibility to move comfortably between a variety of musical styles, modes, and idioms, including swing style, jazz waltz, Mozart themes, Spanish idioms, romantic ballads, double and half time rhythmic feels, Barrelhouse, and Ragtime. The song form from the previous year, “Ee Wa Wa Wa,” was a frequent request from Carlos and became a familiar structure that was adapted through the use of variation. Session 44 DVD: Carlos— Excerpt 7 (Session 44) In the following excerpt, Carlos is working on the diatonic xylimba playing with two sharp sounding drum sticks. We continue to dialog through improvisational playing that is more freely structured, both tonally and rhythmically. Further development of communication through interactive music making continued to be the thrust of the work throughout our second year of work. Year Three: Sessions 61 – 87 The third year of work began with a third co-therapist. This year of therapy moved into an Educative Stage. Although not typically a primary clinical goal, the acquisition and refinement of functional musical skills may occur as a by-product of a course of music therapy. Carlos developed an interest in increasing his ability to hear and play intervals, identify tonic and dominant harmonic relationships, and learn about the physical relationships of white and black keys on the piano. Most of this work took place with Carlos playing the spinet at a considerable “working distance” from the therapist and co-therapist. “Mi Mi Mi Mi Mi” was an improvised song/exercise based on the first five notes of the major scale and was used frequently during this period to explore these areas. When Carlos was engaged in this type of work that emphasized more of a practical rather than aesthetic return, he did not sing or play the piano in a particularly self-expressive way, other than to occasionally bang the keyboard when he was not successful in finding what it was that he was looking for - Carlos was in “Theory Class.” Past and ongoing research projects show that knowledge gained from music training bears on spatial-temporal processes (Raucher, 1999). Such processes are used in tasks that require combining separate elements of an object into a single whole by arranging them in spatial order that matches a mental image. Cognitive skills required for such tasks include spatial imagery, temporal ordering, and symmetrical recognition (Rauscher, 1999). These activities possibly relate to music because the elements of a musical piece are also organized in space and time. Specifically, Rauscher reports that following music training or keyboard lessons, the spatial-temporal scores of children improved substantially. On other occasions during this period there was an emphasis on further development of speech initiated by Carlos himself as well as encouraged by the therapists. We created a song that we named, “Carlos’ Animal Song.” In this song, Carlos was offered the opportunity to fill in

either the name of an animal or the sound that a particular animal makes. The lyrics evolved to include objects and people. Carlos had to listen intently as the lyrics never remained fixed and were left intentionally open for expansion and development. The melody and harmonic structure remained more constant in order to provide a familiar structure within which to work. An example of an interaction through the use of this song follows. Therapist: “The dog says…” Carlos: “Bow Wow.” Therapist: “And the cat says…” Carlos: “Meow.” Therapist: “And Quack says the …” Carlos: “Duck.” Therapist: “And Honk Honk says the…” Carlos: “Truck.” Therapist: “And Carlos is a …” Carlos: “Boy” Therapist: “And Carlos says…” Carlos: “Meow!” Laughter. Therapist: (Spoken) “Carlos says Meow???” Carlos: More laughter… A new behavior of throwing sticks appeared. Without warning and at no musically related place, Carlos would suddenly toss his sticks across the room in what felt to be bursts of rebelliousness or resistance. We make up a song, “He Threw the Sticks” which we soon left behind after considering that singing about behaviors that interfered with his musical participation was not going to be an effective means of encouraging him to redirect those impulses. Session 83 DVD: Carlos—Excerpt 8 (Session 83) The following excerpt is an example of the previously discussed, “Mi Mi Mi Mi Mi” song with which we worked frequently during Carlos’ “Educative Stage.” He showed great interest in and devoted serious concentrated energy to learning about pitches, intervallic relationships, both physical and acoustic. Carlos began to learn the correlation between sonic distance between two pitches and the physical distance he could expect to need to move up or down on the keyboard to locate the pair. Throughout this phase of work he chose not to sit together with the therapist at the grand piano, preferring to maintain a distance sitting at the spinet. Session 87 DVD: Carlos—Excerpt 9 (Session 87)

In the following excerpt from the end of the third year of work, working with a small electric keyboard, we reviewed songs we had played during the year, interspersed with a kind of “Flight of the Bumblebee” variation that provided a container for Carlos to release cathartic energy between sections of concentrated effort. Carlos has developed the ability to think contrapuntally, he creates melodies around and through the main melodies played by the therapist. At a parent conference following the end of the clinical year, Carlos’ parents disclosed information of a more personal nature than they had shared up to that time. We heard that Carlos never really wanted to be cradled or held by his mother, and tolerated her affections rather stoically. His father reported similar responses to his attempts at displaying physical affection. Little personal interaction between Carlos and his parents took place other than those having to do with satisfying his needs of having clean diapers or procuring food. When the ice cream truck passed by their home, Carlos begged to be brought outside but refused the ice cream; he wanted to get close to the music emanating from the truck. They described his diet telling us that Carlos does not like the taste of sugar. They told us that he eats yogurt, white rice, but no meat. He drinks ice tea, water, and milk, but does not like apple juice. He rarely cries. When he is reprimanded, he goes to his room and closes the door. They reported that Carlos, now in a new school setting with five children in his class, had begun to kick and bite teachers, though not other children. When visiting his cousins, Carlos’ father said that if one of the other children does something that Carlos does not like, such as pushing him down, Carlos will wait for up to thirty minutes for the opportune moment to exact his revenge, and when that opportunity arrives, Carlos is determinedly unforgiving. This cold and calculating aspect of Carlos’ personality was described as being a cause of concern for his father, and Carlos’ mother concurred. Year Four: Sessions 88 – 118 In his fourth year of music therapy, Carlos used words more frequently to express his preferences, name objects, and to join in songs. He gave his primary therapist a name (“Sola”). It was not until this fourth year that he showed a wish to join his primary therapist at the grand piano. This seemed to be a direct expression of the trust and sense of companionship he was now feeling for him as a person. Again, the new clinical year brought us a new co-therapist. Prior to the first session of this year, the new team made some general clinical decisions about how they would address behaviors that had, on occasion, impeded Carlos’ full musical and interpersonal involvement in the past. These behaviors included the throwing of sticks or mallets, banging the piano, and climbing on tables. It was decided that Carlos had reached a point in his development that he would be able to tolerate firmer limits being set for him without losing his enthusiasm and enjoyment in his sessions. In addition to taking a firmer stance regarding Carlos maintaining a greater degree of control over his impulses, we decided to look for ways of inviting Carlos into deeper, more intimate and personal moments of relating to his therapists, the idea being that by encouraging a more empathic, caring part of Carlos to develop, we could help him live a richer, more meaningful life. As though he had somehow been made privy to our plans, Carlos entered the first session of the new clinical year and

reached out to explore the face of the co-therapist as she sang, as though to greet her and to find out who she was. This was the most active interest that Carlos had displayed in getting to know another person’s physical characteristics up to that time. In the past, although it was obvious that Carlos appreciated the people who were helping him experience the music he was so passionate about, there was a sense that although the actual people served a function that Carlos wanted to be met, his emotional involvement with those people did not reach far beyond their capacity to fulfill these needs. Carlos returned in the fall vocalizing more frequently and sounding more natural in his vocal production when he did vocalize. At the beginning of the first session of the new clinical year, he sauntered into the room calling out, “Hello, hola!” Sessions during this period were typically preceded by Carlos protesting loudly in the waiting area when his mother denied him access to the elevator button. He did not appear to want to enter the elevator, but rather seemed to enjoy its mechanical operation, the causal relationship between the button and door opening, or perhaps the sense of accomplishment he enjoyed from the predictable response of the elevator door opening after he summoned it. Resistive behaviors, such as tossing mallets and knocking over instruments continued into the fall, but diminished as the weeks passed as firmer limit setting was incorporated into our treatment strategy. Session 89 DVD: Carlos—Excerpt 10 (Session 89) This improvisation was based on the musical structure of the song we had created earlier, “He Threw the Sticks,” and as mentioned previously, we had abandoned the lyrics. Carlos is feeling comfortable remaining for longer periods of time in close proximity to his therapists. His singing has become less forced in production, more natural, and less pushed in sonic quality. Although we were pleased that Carlos was working with us in closer physical, and presumably emotional, proximity, soon after this session we decided to encourage Carlos to continue to develop his singing from a position other than on the floor. A sense of interpersonal connection continued to develop and on October 26th, during our 94th session, Carlos entered the room crying and sought consolation from the co-therapist. It felt as though Carlos was beginning to view his therapists as people and was developing emotional connections with them that enabled us to create music together that reflected these deeper feelings. Session 97 DVD: Carlos—Excerpt 11 (Session 97) In this excerpt Carlos is playing the xylimba gently with his hands. He pauses and the music holds suspended waiting for Carlos to move. He begins to sing in a high register and the therapists musically support him. The co-therapist sings and the piano part is light and unforced, Baroque in style. Carlos’ creative leap from G up a major 6th to E sounds reminiscent of a Mozart aria. There is a feeling that Carlos is somehow “softening” and that he is sharing increasing feelings of intimacy with his therapists.

Session 107 DVD: Carlos—Excerpt 12 (Session 107) Carlos still experiences ambivalence around our increasing intimate interpersonal contact. In this excerpt we sing to Carlos, inviting him onto an environment of warmth and connection. He seems to enjoy the feelings, yet he needs to avoid them at the same time. He spins his body around until he makes himself dizzy. He bangs the keys on the piano although he laughs, applauds, and exclaims “Woo woo!” when we finish. He runs to the far side of the room and groans as though the feelings are difficult to tolerate as well. We encourage him to soften his piano playing, telling him that we are making “Music, music, music!” In March, 2007, Carlos became the brother to a new sibling baby girl. His mother continued to bring Carlos to his music therapy sessions during the pregnancy, and Carlos missed only two sessions after the baby was born. The little girl was born full term, and appears to be healthy and developing normally. Session 116 DVD: Carlos—Excerpt 13 (Session 116) We have been working with Carlos more specifically on impulse control. As he develops physically, his mother complains that it is getting difficult to travel with him using public transportation. Although he travels easily with her to his music therapy sessions, getting back home is getting difficult when Carlos pulls away from her or flops to the floor of the train or subway platform when he wants something. In this excerpt we are working with a song that incorporates a part intended to stop and wait. During the pause, we can either count aloud, recite the alphabet, or remain quiet for ever extending periods of time before resuming. Carlos is able to extend his counting, which had previously been up to the number five, to sixteen. At the next “holding area” we work with the alphabet. Again Carlos indicates his ambivalent feelings by running across the room and groaning, “Oh no!” but moves to the celeste to play the Alphabet Song. Significantly, Carlos makes the choice to return to the therapists to continue the song which evolves into another four handed piano improvisation built on the harmonic structure of the song. The co-therapist supports this entire musical framework playing the conga. Session 118 DVD: Carlos—Excerpt 14 (Session 118) This excerpt begins with us working again with the structure from the previous excerpt. We reach the “holding area” after a virtuosic run from Carlos up the keyboard. Again he runs away, cries, “Oh no!” and moves closer to the piano to discover a full sized marimba. He warns himself to be “Careful!” and after we set it up, he begins to explore the instrument and, in contrast to his choice almost four years earlier, he chooses to play the instrument with the

head end of the mallet rather than the stick. He plays rhythmic patterns in sequence that cross over the “strong” beats, no longer restricted to alternate handed playing of one note per hand. Discussion and Conclusions Over the 40 months of therapy, Carlos evidenced growth in many areas. Of particular importance were his musical, cognitive, emotional, and interpersonal development. Musical Growth We created music with Carlos with the belief that through creative, relational play, Carlos would develop a deeper understanding of himself as a person as well as to come to an awareness of how he can relate to the world around him. This reflects a philosophy that views human beings as open systems, accessible to change throughout their life spans, and responsive to conditions of remediation - providing that intervention is appropriately directed to the individual's need. Cognitive Growth Music is an ideal modality for cognitive assessment and therapy for the visually impaired, as the tactile tasks involved offer an opportunity to develop mental images of objects they cannot immediately perceive with their eyes. Active tasks, such as improvising music, engage children in dynamic learning experiences, as they create spatial-temporal frameworks. While cognitive deficiencies differ from individual to individual, certain skills, especially those related to spatial-reasoning, pose particular difficulties for the visually impaired. (Gouzman and Kozulin, 2000). This situation leads to both a narrowness of the perceptual field, in which a complete entity remains beyond the spontaneous grasp of the learner, as well as a blurred and sweeping perception, especially concerning size, direction, and proportions of two-dimensional tactile images. Lacking exploratory methods, students refrain from spontaneous exploration, resulting in a lack of objective references and critiques. This in turn leads to difficulties in assessing the precise proportions of parts within a whole. Once again, whereas seeing individuals also suffer from these impairments, the problem is more severe among children with special needs. Emotional Growth During the course of his therapy, Carlos became more relaxed as his need to maintain a feeling of control decreased. He gradually moved into participation in shared activity and he became more responsive and willing to accommodate. He came to be able to relax his adamant grip on what he thought he needed, and he became more willing to enter into unfamiliar experiences, willing to take risks, and being less isolated. When we first met, Carlos insisted that others enter his world but eventually he became more able to work with ideas outside the sphere of his impulses. Carlos is more capable of exploration and more tolerant of tension and ambiguity, which will contribute to further development of impulse control. The development

of speech has been significant. His fine motor control has increased as he has become more interested in individual tones trather than cathartic rhythmic activity exclusively. Interpersonal Growth Lacking the ability to perceive another person as a whole entity makes the ability to relate to another person a daunting task. Getting to know another person through focused listening to their music offers an alternative mental representation of the other person. Carlos came to know me as a person by coming to know my music. In “The Development of the Person,” Czikszentmihalyi (1991) maintains that a person is a human being who can speak and be understood, who can relate to other members of a community. Prior to music therapy treatment, Carlos did not appear to be interested in interpersonal engagement with other people. His parents described him as being content to remain alone in his room busying himself with objects. In this context of isolation why would Carlos want to learn to speak? If not interested in people, or perhaps lacking an understanding of what or who other people were, why would he bother to learn to communicate at all? When I met him at his pre-school, he was a withdrawn little boy who preferred to remain by himself in a corner beating the floor with his hands. Carlos was not developing as a person. Piaget (1954) pointed out that disequilibrium between the processes of assimilation and accommodation is inevitable and needs to be continually addressed throughout development. From Czikszentmihalyi’s perspective, disequilibrium is signaled by boredom and anxiety, two inevitable life experiences. In the simplest terms, one escapes boredom by raising challenges, and one alleviates anxiety by raising skills. It is through this perpetual dialectical process that development proceeds; and it proceeds in the direction of greater complexity because optimal experiences cannot be recaptured through a regression of skills and challenges, but only through their progression (Czikszentmihalyi, 1991; Czikszentmihalyi & Rathunde, 1993). Music caught Carlos’ attention and drew him into a world of interpersonal contact that was interesting enough to warrant the effort to learn how to communicate. References Czikszentmihalyi, M. (1991). Flow: The Psychology of Optimal Experience. New York, NY: Harper Collins. Gaston, E. T., (1968). Music in Therapy, London: Collier-Macmillan Publishers. McNamara, A. de Juan, E. & Varley, M., (1991). Understanding Retinopathy of Prematurity, California: IRIS Medical Instruments, Inc. Miller, P. H., (2002). Theories of Developmental Psychology, Fourth Edition, New York, NY: Worth Publishers. Nordoff, P., Robbins, C., (2007). Creative Music Therapy: A Guide to Fostering Clinical Musicianship, Second Edition, Gilsum, NH: Barcelona Publishers. Perlman, J. M. (2003). The genesis of cognitive and behavioral deficits in premature graduates of intensive care, Minerva Pediatrica, 55 89-101. Piaget, J. (1954). The Construction of Reality in the Child, translated by Margaret Cook, New York: Basic Books.

Portowitz, A. (2001). Music Activities as a Cognitive Tool for the Enhancement of Analytical Perception, Comparison, and Synthesis for the Blind Learner, E Journal New Horizons. Serafine, M. L. (1988). Music as Cognition: The Development of Thought in Sound, New York, NY: Columbia University Press. Trief, E. (1989). Retinopathy of Prematurity, Journal of Visual Impairment and Blindness, Dec., 500-504.

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

CASE EIGHT The Knight Inside the Armor: Music Therapy with a Deprived Teenager Simona Katz Nirensztein Abstract Eli is a fifteen-year-old boy, who arrived at a boarding school for maladjusted teenagers, after an attempted suicide. At his arrival he refused to speak to anybody. Due to a premature birth and to a deprived family environment, Eli’s Self was fragile and not coherent. Anxieties, splitting, and emotional isolation made it impossible for him to adapt to normal life. The present chapter describes how Eli’s Self was “restored” during the process of music therapy he went through at the boarding school. Improvising in a holding environment, experiencing a continued “affect attunement” with his therapist, and being mirrored in an empathic way allowed Eli to get in touch with his feelings, to express them--in music and in words--and to feel the vital sensation of being understood. Finally, some ethical/theoretical issues about the pros and cons of the depth of this kind of intervention in such a limited setting are considered. Introduction The case study that I am about to describe has as its protagonist a fourteen-year-old boy who arrived, one cold December, at the boarding school where I work. This is a hostel for maladjusted teenagers. The boys, aged between 14 and 18, can be classified as deprived and with an anti-social tendency. The life of these boys is marked by deprivation, both material and affective. Their parents did not know how to, or could not, provide them with the experience of growing up in an adequate holding environment, nor did they protect them from traumas linked to material poverty, exclusion, drugs, violence, or sexual abuse. Many of the boys have serious learning problems; some of them have a psychiatric history. Their attitude toward other human beings and to their environment swings between violence and avoidance. D. W. Winnicott (1956), in his article on the antisocial tendency, stresses the fact that the antisocial act is an expression of hope, a plea to the environment to provide what is lacking. But he himself tells of the difficulty of taking up the role of providing a therapeutic response for these deprivations. It is not easy to have stones thrown at the windows, to have to interrupt a client that strikes with such violence as to tear the drums or burst the therapist’s eardrums, nor to face endless silences that express total void. But Eli, the subject of this case study, was not at all a typical personality within the school. His frail and introverted look made him seem younger and more fragile than his companions. The violence of the environment represented a further threat to him. His success

in his school studies accentuated his dissimilarity. Upon his arrival at the school, he closed himself inward and seemed determined not to open up either with his peers or with adults. Background Information Eli came to the boarding school after six months in a psychiatric day hospital, where he had been admitted because of a suicide attempt. He had locked himself in his home with a brother two years younger than he, and had threatened to jump from the fourth floor. Police came to avert the tragedy. In the hospital, Eli had been diagnosed as suffering from “Dysthemia. Primary type, early onset.” The family did not provide an environment suitable for dealing with Eli, so the psychiatric and social services decided to permanently separate him from them. Eli’s father suffered from a grave form of progressive muscular dystrophy that contributed to making him unstable, even from a psychological point of view, subject to frequent attacks of anger and violence. Even before his illness he had not held a permanent job. In his past he had had another family, wife and children, with whom he had no contact whatsoever. Eli’s mother, a woman with a weak personality and physically fragile, bore the economic and practical burdens of the family, working for a cleaning company. Eli had two older sisters and a brother two years younger than he, who all had serious behavioral problems. The family lives in great economic hardship and need the help of social services. During her pregnancy with Eli, his mother had suffered from pre-eclampsia (pregnancy poisoning); Eli was born prematurely at the seventh month, weighing two kilograms, and was in danger of dying. His mother tells that while he was in the incubator she prayed continuously. She made a vow that he would be given a name, which, in Hebrew, means “God has helped.” From that moment on, she says, Eli was her only hope, a hope that had not sufficed to give the child a happy childhood. The parents did not provide information on the first years of Eli’s life--his development is defined as normal in general terms. His school and social services had long realized that the boy was suffering--isolated at school, distracted, physically restless, and afflicted with facial tics. His scholastic performance had deteriorated visibly during the year preceding his hospitalization. Efforts were made several times to distance him from the family, but a complex bond of mutual dependence with the mother made this impossible. A report from the psychiatric hospital defined Eli as a boy with grave emotional problems: Where there is a need for emotional involvement there is a decrease in its potentiality reaching the loss of reality judgment. Painful emotions, such as depression, anger, and boredom, tied to thoughts of death, impose an enormous effort of containment, and threaten to overwhelm him and provoke anxiety attacks. In the effort to defend himself, Eli uses primitive defense systems, such as denial, repression, emotional insulation, isolation and splitting. Both the hospitalization and his admittance to the boarding school for maladjusted boys were carried out against his will. Eli refused to open his mouth in the presence of the

psychologist, which was the main reason he was referred for music therapy. The psychologist, being worried, asked for my help, but at the same time he told me, “Be very careful, his defenses are impenetrable and hard, but as fragile as a ceramic tile; if you touch it, you risk breaking it.” Theory, Methodology, and Techniques Working with adolescents whose life experience is one of severe deprivation has helped me to identify the influence of what is missing in the relationship with parental figures on the very early development of the self. In particular, I am convinced that much can be done by means of a psychodynamic approach within a music therapy setting. Music has, in fact, a series of characteristics which make it most adaptable for creating a type of therapeutic relationship whereby the client can express his own needs and what is missing and, at least in part, regain the use of psychological patterns that have atrophied or have never existed. According to D. W. Winnicott, “…a good enough environmental provision in the earliest phase enables the infant to begin to exist, to have experience, to build a personal ego, to ride instincts, and to meet with all the difficulties inherent in life” (1956, p. 304). What is missing for the boys at the boarding school is, first of all, that “good enough environment.” The concepts of “mirroring” and “holding,” as expressed by Winnicott (1960; 1971), are instrumental in my approach and have accompanied the entire therapeutic process with Eli. In Eli’s own story the holding was missing as much in the physical sense as in the psychological one, because of his premature birth, together with the extremely difficult family situation. We shall see how the sensation of having to, and wanting to, “hold” and “see” Eli was an integral part of the countertransference and his need to be “held and seen” constituted the transference. The “arms” and “eyes,” no less than their object, were created by the music: To listen and be heard, to express and be understood, even without words, was the backbone of the process. The music, and the silence as its alternative and container, permitted the creation of an unconditional holding that was adaptable for the various phases of development of Eli within the therapeutic process. The experience of merging with a maternal figure was the basis for the creation of the “transitional space” (Winnicott, 1971) where Eli could experience the feelings of creativity and omnipotence. Here, thanks to the presence of the therapist, he could feel his Self as an existing, significant, and valuable entity. The ability of the infant to participate in an interpersonal relationship from the very first days of life, according to Daniel Stern’s (1985) theory, is by its very essence amodal (without structure). All the senses are involved in the creation of a channel of communication between the personal experience of the child and the person who is taking care of him. The nonverbal character of music, the complexity of its components (united in their primordial character), its unavoidable physical counterpart, its capacity to address itself simultaneously to various senses, makes it an ideal medium for re-creating conditions comparable to the constitutive experience of the self. Music allows the therapist to provide a closeness that is suitable for the client at that given moment of his experience, without going through the process of symbolization and, in certain ways, of alienation of the experience in its totality, which is intrinsic in verbalization.

Stern’s theory gives a central place to nonverbal communication as a basic element in the creation of a relationship. The fundamental concept of the “vitality affect,” as the quality of the affective experience arising from the meeting with the other as early as the age of two months, in the sphere of the “sense of an emergent self,” (Stern, 1985) supports the basis for using a music psychotherapeutic approach, particularly because the feelings expressed are not verbalized and categorized in order to obtain a legitimization and a curative validation. On the contrary, the function of the music therapist becomes accentuated through the definition of one who can accomplish “the affective attunement,” the kind of act which is nonimitative, but absolutely regulated to the affect that lies behind the infant’s action. This process permits the sharing of the baby’s affective state and, consequently, the intersubjective exchange, which is indispensable for the construction of the “sense of subjective self.” One must keep in mind the fact that in the case of deprived teenagers the experience of affective attunement on the part of the adult is very often missing throughout the course of the entire life. In my work, I have been guided by the principle--which is more and more accepted by self-psychology (Kohut, 1984) and the intersubjective approach (Atwood & Stolorow, 1979)-that the mutative element in the therapeutic process is the relationship with the therapist, the therapeutic act, even more than the verbal interpretation. “‘Something more’ than interpretation, in the sense of making the unconscious conscious is needed” (Stern et al., 1998). In my understanding, music has all the characteristics to make it the vehicle for that “something more.” I have found the concept of the importance of “now moments” (Stern et al., 1998), those moments of authentic encounter connected equally to the life experience of the therapist as to those of the client, and which are capable of “modify[ing] the structure of the implicit relational knowing between the client and the therapist,” very illuminating. Furthermore, this is an experience that can, in turn, modify the “client’s implicit procedural knowing, his way of being with others” (p. 903). This is a situation in which the therapist must be in deep contact with his/her own countertransferential reactions, especially those that pass through and express themselves in such a way that they interfere with the client’s music (Bruscia, 1998, pp. 51-120). Therefore, in my approach, the energy is directed to be in maximum attunement with the client in the here and now. Through this particular type of attention, it is my intention to allow the client to integrate his experience and to insert it within the more complex framework of the bonds that tie the past to the present. The method in this case study, therefore, was absolutely nondirective and concentrated on the construction of a relationship that would allow for experiences that were lacking in Eli’s repertoire of intersubjective encounters. Free improvisation was the main musical vehicle, but other experiences included music listening and dance. Words and music alternated in a natural manner and, as far as possible, one that suited the needs of the client. The meetings, lasting fifty minutes each, took place once a week. The duration of the overall therapy was one year and seven months. The Treatment Process Daring to Be in the Presence of “An-other”

I must admit that the psychologist’s warning had alarmed me; I had an ambiguous mission--to create a contact, but without cracking the flimsy porcelain layer that separated Eli from the dangers inherent in any relationship; to be in touch with him without touching him. But Eli helped me. Right from the first session, he defended himself and opened up at the same time. He entered the room almost without looking at me; mumbling a greeting, he sat down next to the electric organ and began to play. A flow of sounds from his bony hands, the look on his face sharp, concentrated and intense, his body wrapped in a shapeless coat. From his hands came snatches of melodies that ran into one another; he liked to start from the high notes, to reach, descending progressively in thirds and fourths, to the low ones. Soon he moved over to the piano. He kept the right-hand pedal down, blurring and attenuating the limits of the melodic ideas that were taking shape. From time to time he played with both hands, creating hints of polyphonic dialogues. I listened and watched him with absolute intensity. Through the senses, I could perceive his existence and the obscure, confused, and painful nucleus from which that flow of music sprang. I could perceive the empty spaces. I could sense that nobody had ever looked at him this way, in an effort to reach his core-self. I perceived that music was an expression of something very authentic and very deep. Rich. I was struck by images of maelstroms, indistinct movements of dark and intense colors. The word “unintegrated” came to my mind. Speaking of the very first phases of development, Winnicott (1945) refers first of all to the process of integration and says “the tendency to integrate is helped by two sets of experience: The technique of infant care whereby an infant is kept warm, handled and bathed and rocked and named and also the acute instinctual experience which tend to gather the personality together from within” (p. 150). Perceiving Eli’s music as linked to a phase of integration, I felt I was providing him with a symbolic “infant care” by my looking and listening, while he dared to experiment and express his “acute instinctual experiences.” It seemed quite clear to me that my role should not be an active one. My listening and presence allowed Eli to exist and to begin to feel his existence in an environment that did not compel him to any act of change or adaptation, that did not threaten him in any way. His readiness to let himself go with the flow of the music can be seen as a demonstration of his life force, of his not giving up to the looming disintegration. During the second session, while I listened, I heard a fragment of melody that kept returning more and more insistently. I took some paper and noted the melody. Eli turned his head and asked for an explanation. I explained that I felt something taking shape and I did not want it to be lost. He nodded, satisfied. What reached through to Eli was an act of mirroring: I see you, therefore you exist, your music is noted down by me, I want to understand it and remember it; therefore, you exist. In a certain sense I offered him a mirror. Eli began to check whether my look continued to accompany him. “What does the baby see when he or she looks at the mother’s face? I am suggesting that, ordinarily, what the baby sees is himself or herself” (Winnicott 1971, p. 112). Daring to be with “An-Other” That fragment of melody developed into a real leitmotiv. In its structure there was something mirror-like, or, at any rate, in the nature of a dialogue, both in its rhythm and in its

melodic structure. To a theme based on a descending third, responded another, based on an ascending third. To the high C responded a low C that ascended gradually and attained it; all this at the very abyss of the end of the keyboard, toward the highest part, or, more rarely, at the lowest. One could suppose that Eli was expressing, through the very structure of the melody, his need for mirroring and relating and, also, his desire to bring the abysses of his anxieties into therapy. What was certain was that this melody became our common playground. The structure of the leitmotiv and the persistence of its regular reemergence, gave me the feeling that Eli had already been born in the relationship and was ripe for a musical interaction. Timidly, I began to play a sort of countermelody to his music, without trying to imitate it, but rather adapting my response to his proposal, in an effort to provide an experience of affect attunement. He replied to me. A wave of emotion engulfed us. I did not try to explain to myself in words what Eli was saying to me with his melody, or to categorize the feeling that he was expressing. I tried to “match” his melody and, above all, the affect that was behind it. In our musical dialogues, which from that moment on developed with ever greater freedom on both sides, we passed through a vast gamut of what Stern defines as “vitality affects.” “A quality of experience that can arise directly from encounters with other people.... These elusive qualities are better captured by dynamic, kinetic terms, such as surging, fading away... explosive, crescendo, decrescendo, bursting...” (Stern, 1985, p. 54). Not only did Eli have the sensation of “existing,” but in addition to this was the sensation of “co-existing” with someone who adapted her own vitality affect experience to his, rendering it a common one; someone who accompanied him within his dark maelstroms--those which may gradually be faced. The ceramic tile was not impenetrable any longer. Daring to Communicate with “An-Other” One day, after some improvisation together, Eli turned toward the stereo, looked at the discs, asked to hear a Mozart symphony, and began to talk. His words gushed out also in a “sottovoce e prestissimo” flood. It was difficult to understand him. To do so, I had to bring my ear close to his mouth, at times asking him to repeat. I was very moved. The quality of my listening and also my state of mind were complementary to those provoked by the music, but the introduction of words into our space had signaled another step toward “togetherness.” “In fact, every word...is the product of uniting two mentalities in a common symbol system, a forging of shared meaning” (Stern, 1985, p. 170). From then on our sessions assumed a structure. Eli would begin to play and sometimes I would join him in a shared improvisation. His leitmotiv would always appear and would at times undergo development and variations. The music helped him to get in touch with himself, reestablishing secure boundaries for our transitional space. My musical “arms” kept him warm and safe from the threat of disintegration, provoked by his own thoughts and feelings. But the music had another and not less important, function: to preserve the globality of Eli’s emotional experience, without submitting it to the inevitable fragmentation that language brings with it. As Stern (1985) states, “language is a double-edged sword...it drives a wedge between two simultaneous forms of interpersonal experience: as it is lived and as it is verbally represented” (Stern, p. 162). The music also reappeared at the end of the session.

In the middle there gushed out the flow of words with which Eli invited me to get to know his existence more objectively, more categorically. His life was presented from two deeply split angles. On the one hand, there was the home and a greatly idealized family, full of every kind of material good and affection without limit from parents, always full of goodness, obliged to send away their adored son against their will. The idealization made the reality bearable, altering it substantially, and it also expressed a need that had remained unresolved during Eli’s development. On the other hand, there appeared small episodes that spoke of sensations of abandonment, loneliness, boredom, desires that were not met, and unrealizable dreams. I interacted briefly, asking for clarification, pointing out connections, making comparisons, and, above all, expressing my presence which was authentic and felt. My presence, my listening, gave Eli a container, an “envelope” (Anzieu, 1989, p. 157) that embraced and united all the different parts of his self. Truth together with lies, desires together with disappointments, thought, and narrative. And, in this way, I felt myself to be a container ready to receive his words and his sounds. He began to take off his inseparable coat, in which his body was kept always hiding, and passed to a more symbolic and less cumbersome and less crushing protection--a pouch tied to his waist. Daring to Show Himself to “An-Other” We were drawing close to the end of the school year. Seven months had elapsed since the beginning of the therapy. When there were four encounters left before the vacation, on a hot day we began our session with a lazy improvisation on the metallophone. He began to sway to the rhythm and then, suddenly, he began to dance. His movements were surprisingly decisive, acute, and sharp--an orderly and very rapid sequence that certainly required some skill. He looked for highly rhythmical music and began his dancing anew several times. Every now and then he would glance my way to make sure that I approved. I was, more than anything else, stunned. His dancing did not resemble anything at all that I had shared with Eli until that day. From a certain point of view, I was amazed by the display of coordination and glad about the sudden involvement of the body in therapy--something I saw as a new important step. On the other hand, I felt very uneasy: There was something grotesque, exaggerated in that dance--a lack of vitality, flexibility. Observing him, I had a feeling that resembled shame. He told me, with a certain pride, that this dance was the fruit of hours and hours of hard work in front of the TV. He had been rehearsing it from the age of seven. Instinctively, I encouraged him to repeat it. I helped him find the most suitable music. But it was only later, and with the help of supervision, that I understood its significance. After seven months of therapy, Eli emerged from his coat with his “premature,” “inadequate” body, just as, after seven months of pregnancy he emerged from the poisoned womb where he began his existence. My bashfulness was a reaction to the inadequacy of his appearance. But, at the same time, I was deeply willing and happy to receive and accept him the way he was. On another level, Eli was showing me something very intimate, a picture of a child who, being totally deprived of models to follow, searched on the television screen for something to learn and with which to confront the world. It was not surprising that that “something” was

grotesque, especially now that that skinny body, already on the road to adolescence, performed it. The first to feel it, albeit unconsciously, as such, was probably Eli himself. In a certain sense I felt the shame for him. What, in another theoretical context, would have been called projective identification, I would define here as a “resonance with his unconscious feelings.” Only in our transitional space, suspended halfway between his internal world and a relationship with another human being, Eli the dancer could show himself and survive. At the end of the last session before the vacation, Eli also removed the pouch at his waist and forgot it in the room. Later, he showed his dance to his companions as well, eliciting admiration and amazement. Daring to Be Angry During the summer, I often thought about Eli and I wondered if our special atmosphere would survive the separation. Thus, I felt relieved when we met after the two months’ holiday and he began playing as though we had parted the day before. He immediately returned to his leitmotiv, but it soon became clear that the separation had left its mark. The soft minor third was transformed into a biting tritone. The sound, from being muffled, became percussive. My every intervention was refused and left outside his music; my questions remained unanswered. It was at the end of the first session that he told me simply, categorically, “I am angry.” The all too obvious explanation that the first object of his own anger was I myself, who had left him in his private hell for two months, was refused in words, but explored through the music; the percussive theme and the recurrent tritones became the leitmotivs for that period. Soon, another reason for anger was added: his sister, two years older, had been sent to the same boarding school. Eli was embarrassed and burdened down. He felt responsible and vulnerable. Most of all, he was concerned that his home had followed him here and he felt threatened that it could invade our private space. Parts of these feelings were expressed in words, parts I could feel between the lines, between the notes. In fact, the front of the idealization of the family was broken. The ceramic tile had cracked. One day, Eli did not find me in the room because of one minute’s delay: his anger imploded. Refusing my apologies, he started rehearsing his dance, but he was blocked after every two steps like a puppet whose strings had been cut. It was a despairing scene. Looking at me like a wet kitten he said, “I’ve forgotten how to dance.” The contact with his own feelings, which my lateness had “triggered,” had brought him close to a feeling of disintegration; the difference resided in the fact that now he could express this threat in therapy. A progress, in therapeutic terms, that had, however, a regressive character: the forgetting of the facade built over so many years of work. He tried and tried again, asking my help in finding the music that would enable him to re-create his dance. I felt that he was asking me to help him to be, even now that he felt his defenses were crumbling. I mirrored the anguish in not finding something so precious, I tried to be with him in his search. I also tried to encourage him in looking for a new dance, suitable for the Eli of the present. I tried to imbue him with my deep trust that he could find it. But we had to face the fact that this was not true. The music for Eli’s dance did not exist. He was not ready. Contact in Absence

Eli did not come for the next session--he was not even in school--nor a week later or the week after that. He refused to come back to school. The explanations I was given by the social worker were connected with a worsening of the situation at home and some negative episodes with his peers at school. The tension was dramatic because the parents, unable to force him to return to school, were also incapable of coping with him, together with the younger brother. Episodes of domestic violence happened day after day. At the same time, a court order calling for his compulsory removal from his home was hanging over his head, a removal which meant the risk for him of being held in a reformatory. But Eli seemed willing to fight the court order, and kept speaking of the school as a prison. I was pained and confused. I felt the void due to his absence and I realized that there was a message here also for me--the changes that Eli had confronted in therapy also threatened his relationship with external reality. His tendency toward self-protection forced him to slow down. If I wanted to give Eli a sign of the existence of our relationship in spite of his absence, and this was the only way I had to help him, I had to go outside of the setting and call him at home: To communicate, giving him a signal of the reality of our relationship, even giving up the transitional object provided by the music. I decided to do it. To telephone him at home gave me, at any rate, an important sound input. I heard the music in his house while I was calling him. I heard the sharp voice of his mother, the dominant television background, a fragment of rude and aggressive conversation. I imagined the unpleasantness on the skin of a “sound envelope” of this kind for a musical soul such as Eli’s. Our conversation did not tell me much. Eli was embarrassed and ill at ease on the phone. I confirmed to him that I was expecting him and that I would keep the hour free for him in the hope that he would come. He came the following week when I, alas, was ill. They told me that for a long time he sat, disconsolate, in front of my closed room. The week after, I called again and this time things were different. “The difficult thing for me,” Eli said, “is not so much facing life in the boarding school, and it is not as though being home is so pleasant, after all. What I can’t manage is to get away from here.” I felt that he was telling me something important about his tie to his mother, the dissolution anxiety that was hidden behind the act of separation. An aquatic image came to my mind and I told him about it: “It’s like being on the point of plunging into cold water, knowing that it will bring relief from the heat, but it gives you an unbearable shiver.” I felt through the telephone receiver Eli’s relief at being understood. Perhaps because the association emanated from my subjective life experience (my body, my hate/love for cold water), I believe that this was a “now moment” as defined by The Process of Change Study Group (Stern et al., 1998, p. 903). A week later Eli returned to the boarding school once and for all. The Return: Daring to Be “Real” in the Relationship Our telephone encounters had had an effect on the atmosphere of our meetings; they had imparted an acknowledgement of their link to reality. They had made our meetings more important and less magical at the same time. “After all, what are you?” Eli said, “You are a psychologist who works with music.” Not only had he uncovered my real identity, but also shreds of his true home were revealed to me. Music, however, remained the backbone of our meetings. First of all, through the improvisations Eli re-established his presence in the room and he let me understand his mood,

his deepest feelings. The “vitality affects” were released by his notes: rhythmic, biting, and obsessive repetitions, outbursts of rage, diminutions, and minorizations that pointed to thoughts of melancholy. the confluence of the two hands telling me of his longing for loving dialogues. And at times words, whispered and rapid, were introduced into the flow. Words: speaking about the inhospitality of the school, its unsuitability to give him the feeling of a real home. Words: speaking about sudden fantasies around death, cutting pictures of the father who raises his invalid’s cane to hit out, and the children who mock him, a grotesque Rigoletto, stealing the cane away from him, in order to threaten him in their turn. At times the vitality affects received a characterization: “What do you feel today in your music?” “I feel anger, sadness, boredom” “Anger towards whom?” “Towards mother, her voice that never stops, that gives me no peace, that follows me everywhere.” And, once again, we would enter the river of notes, to face together the unconfrontable. We reached the sixteenth month of therapy. The anger took the form of percussion. The piano was abandoned for the darbouka and later for the drums. There were two drums in my room: one beautiful and new, and one old and incomplete. He went to play sometimes on the one and sometimes on the other, giving me sometimes an accompanying role, and, at times the role of guiding him or even expressing, in his place, the fullness, the force, the anguish of that anger that he carried within him, also his repressed energy that was confined in the great overcoat of his defenses. On the old drum it was the little Eli, inadequate and too thin, who leaned on someone else to express himself. On the new one was big Eli in the process of becoming a man, who had the strength to face his own feelings. The last month of school came all too soon, after which we would have to part. We both realized that the longed-for release from the “prison” of the boarding school was accompanied by having to leave my musical arms. Eli, at first, denied this. It did not seem possible to him; it was too soon. And then, when he understood, he defended himself in his own way, turning away sotto voce, closing his coat slowly, button after button. He brought me a cassette to listen to together, so as not to have the time to play. He came late and even forgot our next-to-last session, for the first time in two years. For our last meeting he was not in school. Our real goodbye was over the telephone, emotional and almost silent. Diminuendo. Pianissimo. My own act of separation was later, painful, and outside the setting: I met the social worker of his place of residence to stress the urgent need for continuing to provide a therapeutic connection for Eli, possibly with greater frequency than the one provided by the school, and possibly music therapy. I stressed that Eli’s chance to continue to reconstruct his own self lay outside that particular school, together with youngsters whose problems were more similar to his. Eli was born, but he needed holding arms to continue his growth. Afterward, I felt as empty as an empty container, but with the feeling that I had done the right thing. Conclusion and Discussion

A process that had been so involving, and a finale in pianissimo! It would have been more satisfying to have had a beautiful cadence of twenty-four beats of dominant and tonic chords, with some drums and trumpets.... We know full well that the finales in pianissimo are sometimes accompanied by an indication of morendo (dying out), while others, on the other hand, by the moving sensation of something that had touched the soul and the results of which are unknown and laden with future. In asking ourselves into which category the finale of this story belongs, the question arises as to the validity and ethical quality of a therapeutic process that, in a certain sense, has brought the client to regress, relying on a relationship that contained its finite nature within itself. Some could say that having created such closeness, having brought Eli to lowering his defenses, only to abandon him to his fate may have had the opposite of the desired effect, recreating for him the sensation of abandonment and disintegrating loneliness. In order to confront this question I must, first of all, deal with my countertransference sensations connected with the end of the therapy. From the subjective point of view this separation was a real collision with the recognition of the inexistence of omnipotence on my part. In fact, I will go further, with the existence of my impotence. In the negotiations that I had to carry out with myself, I went through moments of pessimism, bordering on a sense of guilt; I then had detailed fantasies of adoption. It is from this point of view that the conclusion at which I arrived must be seen: the need to give up a future for therapy with Eli, which I wanted very badly, and the expulsive push I had given him toward a more all-embracing accompaniment in a less threatening environment. At the same time, if I ask myself the question as to whether I would do again what I had done, my answer is an unequivocal “yes.” First of all, for the simple reason that I could truly not have done anything else: The particular relationship between these two people, he and I, with our particular music, in that particular spatiotemporal context, could only be what it was and none other. And this, not anything else, was the context in which Eli was able to touch and share those dark maelstroms that threatened his integrity as a human being. It is my understanding that this type of relationship experience represents for Eli the indispensable basis for reconnecting with his own strengths and to set in motion blocked or atrophied mechanisms of psychological development. Only by being seen and accepted, and, let us say it, loved, in his entirety, can bring a human being as wounded as Eli had been, to want to live, confronting also his own dark feelings. It is true that experimenting with one’s own continuity of being within a relationship necessarily means exposing oneself to the dangers of suffering its disruptions, but the alternative can only be one of nonbeing, depression, void. A first sign of reconnection with his own strengths can be seen in the gradual way with which Eli was able to turn away from me, without drums or trumpets, and without allowing this umpteenth deprivation to shock him more than his defensive forces could bear. This faith in the person’s intrinsic capacity to develop and cure himself, given proper relational conditions, I also find in the most varied theories. One of Heinz Kohut’s central points in his theory of self states that the essential element in psychoanalytic treatment “is the opening of a path of empathy between self and self object, specifically, the establishment of empathic in-tuneness between self and self object on mature adult levels” (Kohut, 1984, pp. 65-

66). John Bowlby’s theory of attachment, which reexamines the central role of attachment to the mother figure in the formation of the self, reconfirms the importance of providing in therapy a relationship that constitutes a secure base as an indispensable starting point for the restructuring of one’s own representational and relational models (Bowlby, 1988, chapter 8). Then there is the transpersonal approach that stresses the curative value of the unconditional presence (Welwood, 2000). From another direction, the “music child” of Nordoff and Robbins also expresses, in an adequate musical environment, the tendency toward self-actualization through the reactivation of ego-functions, this in spite of the most serious handicaps (Bruscia, 1987, p. 57). To come back to Eli, I am convinced that the process I have just recounted was able to provide this for him--let us call it “good enough environment,” or “empathic response,” or “secure base,” or “unconditional presence”--without which a wounded self cannot be cured, just as our body can close wounds only in the presence of such basic conditions as hygiene and nourishment. For Eli, among other things, one of these basic conditions was represented by the music. I should like to stress that there is an intrinsic importance in the fact that Eli was able to discover the power of music as his personal transitional object, capable not only to unify his internal world, but also to serve as a communication bridge to another human being. His music and ours as well, stays with him, together with the feeling of having been understood. The gist of my thinking is well summarized in these sentences, taken from David Grossman’s “Words into Flesh” (1998): “Nobody had ever spoken to him this way. It is not only what you have written him, but the way you did it. Because this child was the object of attention, he had also received maternal care and tenderness... but only rarely had he experienced this pleasure: being understood. What a relief. The lifting of the armour that reveals within it the knight, still alive” (Letter dated the fifth of August). References Anzieu, D. (1989). The Skin Ego. New Haven and London: Yale University Press. Atwood, E., & Stolorow, R. (1979). “Faces in a Cloud: Intersubjectivity.” In Personality Theory. Northvale, NJ: Jason Aronson. Baker, S., & Baker, N. (1987). “Heinz Kohut’s Self-Psychology: An Overview,” The American Journal of Psychiatry, 144:1. Bowlby, J. (1988). A Secure Base. London: Routledge. Bruscia, K. E. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C. Thomas Publisher. Bruscia, K. E. (1998). The Dynamics of Music Therapy. Gilsum, NH: Barcelona Publishers. Grossman, D. (1998). Shetehi Li Hasakin (Words into Flesh). Tel Aviv: haKibbutz haMeuchad. Kohut, H. (1984). How Does Analysis Cure?. (Edited by A. Goldberg in collaboration with P. Stepansky). Chicago: University of Chicago Press. Stern, D. N. (1985). The Interpersonal World of the Infant: A View from Psycho-Analysis & Developmental Psychology. New York: Basic Books.

Stern, D. N., Sander, L. W., Nahum, J. P., Harrison, A. M., Lyons-Ruth, K., Morgan, A. C., Bruschweiler-Stern, N., & Tronick, E. Z. (The Process of Change Study Group), (1998). “Non Interpretive Mechanisms in Psychoanalytic Therapy,” International Journal of Psychoanalysis, 79:903. Welwood, J. (2000). Towards a Psychology of Awakening. London: Shambhala. Winnicott, D. W. (1956a). “The Antisocial Tendency.” In Through Pediatrics to Psychoanalysis: Collected Papers. New York: Basic Books. Winnicott, D. W. (1956b). “Primary Maternal Preoccupation.” In Through Pediatrics to Psychoanalysis: Collected Papers. New York: Basic Books. Winnicott, D. W. (1960). “The Theory of the Parent-Infant Relationship.” In The Maturational Processes and the Facilitating Environment: Studies in the Theory of Emotional Development. London: The Hogarth Press and the Institute of Psychoanalysis. Winnicott, D. W. (1971). Playing and Reality. London: Tavistock Publications.

Taken from: Nordoff, P., & Robbins, C. (2007). Creative Music Therapy: A Guide to Fostering Clinical Musicianship (Second Edition: Revised and Expanded). Gilsum NH: Barcelona Publishers.

CASE NINE Edward Paul Nordoff Clive Robbins At the age of five and a half, Edward began to attend the Day-Care Unit for Psychotic Children at the Department of Psychiatry, School of Medicine, University of Pennsylvania. Fairhaired, lithe and robust, he was naturally physically active, his movements directly expressing his feelings: jumping vigorously, bouncing and swaying when excited, pacing restlessly when distressed. Intermittently, he made about ten speech-like sounds that had meaning in context, for example “pop pop” for a soda, but made these sounds solely in imitation. At times, he spoke in a jargon. There was a sweetness about him, a kind of tentative friendliness that was by turns delicate, teasing, manipulative, and rambunctious. However, this was difficult to engage, for it was quickly obscured by his chronic anxiety. Usually with little provocation, he would become upset, begin to cry and scream, run back and forth, leap into the air and, as the intensity of his fear or anger increased, throw himself to the floor and roll — he could do this with the speed and grace of an acrobat. His outbursts could last indefinitely, and there could be several in a day. The staff of the Day-Care Unit reported that often when Edward was in a disturbed state he would seem to forget the original cause of his distress and continue crying and screaming because he was caught in that mode of behavior. From infancy, he had panicked quickly when startled or when his routine was in any way disturbed, and go into a screaming, crying tantrum. Panic reactions had also occurred when he was taken to unfamiliar rooms or to where a number of people were present. He had a history of feeding problems, prolonged rocking, and head banging. He withdrew from other children, had not related closely to anyone in his family, and was extremely clinging and dependent on his mother. She reported that he could not be toilet trained and had to be fed, washed, and dressed like an infant. During the period of evaluation prior to admission, he had begun to accept and respond to the testing situation, and it had been possible for the Unit psychologist, taking a gently playful approach, to lead him indirectly into executing some selected tests. On a day when he was unusually calm he had obtained a mental age of 3:0 on the Merrill-Palmer Scale, equivalent to an IQ of 67. His widely scattered scoring gave no etiological indications but did suggest that his intellectual potential lay at a somewhat higher level. The impressions of the diagnostic team were “a primary emotional disturbance ... an ego defect of psychotic proportions involving both autistic and symbiotic features.” The possibility of organic involvement was not ruled out. His behavior and moods in the unit were variable and unpredictable. In contrast to his rejecting, screaming outbursts, he could at times be engaged in a kind of playful wrestling which sent him into fits of excited laughter and hyperactivity. There were periods of trancelike withdrawal and

of obsessive preoccupation with spinning the wheels of an inverted tricycle. Occasionally, he would approach an adult and initiate a particular form of vocal game, repeating “ee-ee-ee ” rhythmically, inviting the adult to imitate him. When the adult answered, he would answer in turn, but any interaction of sounpatterns could not be sustained, for Edward, having just touched on the intercommunicative possibility, would collapse to the floor in excited laughter. His mother and the day-care staff shared the perception that music had always “calmed or stimulated him in a positive way.” Yet, in the reports of his limited vocalizations, there was no record of his ever having sung or hummed a tune — not even the jingle of a commercial — alone or with others. He had been attending the Unit for just two weeks before he came to his first session. The Course of Music Therapy Session 1 Having heard the intensity of Edward’s screaming and knowing his reaction to unfamiliar situations, we left the music room door open, and as the cotherapist brought him along the corridor, calm music in slow three-four time was improvised to create a mood, a gentle musicalemotional environment for him to enter. Audio File: Edward—Excerpt 1 (Session 1) [0:01 ] The therapist improvises in the Dorian mode on F-sharp (F# G# A B C#' D#' E' F#'). Edward Notation Example 1 [0:26] Edward enters, making soft, fretful sounds. Several are on F#', A', and slides from close to B', pitches in the tonality. The therapist gently sings “Good morning.” Edward makes a brief rhythmic sound — a pattern that is echoed in improvisation. He begins to pace the room looking lost and confused. [0:50] The cotherapist attempts to introduce the music therapy room to him by leading him first to the drum, then the piano, tapping them briefly. Edward’s anxious sounds fall on and immediately below F#' and briefly touch in the area of A' and B'. As he plays the piano keys (over a period of 14 seconds), the therapist sings to welcome him: “Good morning, Edward, good morning.” [1:16] Edward leaves the piano, starts to pace the room anxiously and cry (the cotherapist moves to one side to give him space and freedom). As the therapist continues to repeat “Good morning, Edward, good morning,” the timing of Edward’s crying indicates that he has some awareness of the vocal phrasing: four times, he begins a cry after the therapist sings “mor...” on the dominant C# of the mode. His range of pitch widens: he cries clearly on E" sliding down to A', then G#', and B' sliding up to

E"— tones in the chord being played. [1:38] Edward appears to anticipate the therapist’s return to the dominant C# and cries with him, almost matching the pitch. [1:40] As he begins to jump in agitation, the therapist accompanies him rhythmically, remaining in the mode. Several of Edward’s vocalizations are on or close to the dominant and tonic. His crying became louder and several times he threw himself to the floor and rolled. The therapist increased the tempo and dynamics and began to sing on “ah”; when he sustained a tone, Edward sustained a crying slide that began on F#", descended, ascended to G#", and descended again. To match the energy of his outburst the therapist beat the drum and cymbal with his right hand while playing the piano with his left; when he sang a long C#, Edward held a cry on the G# above. The character of Edward’s crying and his behavior suggested that he was unable to give himself completely to his tantrum; the music was engaging him and he seemed to be trying to fight his responsiveness to it. The cotherapist cried out and jumped with him. When the therapist briefly stopped playing, Edward’s screaming became less tonal. We applauded and cheered his falls and tumbles — trying to express that we appreciated him, that we were with him in his emotional intensity. Also, we wanted him to experience that we were in no way distressed by his behavior. We were aware that despite his agitation and the strength of his outburst, there were no tears. Audio File: Edward—Excerpt 2 (Session 1) The therapist answers Edward’s crying phrases with a new, short melodic phrase in octaves, again stressing C#. [0:05] Edward’s responds with a soft, tonally related melodic fragment beginning on G#' and including F' and C#".1 Edward Notation Example 2 The therapist repeats phrase three times. Edward’s responses consist of high unpitched screams that slide down to softer, more tonally defined vocalizations centering around G#' and the tonic F#'. [0:18] The therapist beats drum and cymbal with the right hand while playing the piano with the left. Edward cries briefly in the rhythm and [0:26] makes a slow, sustained, descending vocal slide clearly sounding G# — F# — C#. Edward Notation Example 3 The therapist repeats his original melodic phrase an octave higher. Edward is briefly silent, then

[0:39] makes his strongest tonal statement yet, half-screaming the fully formed melodic phrase F#" — C#" — B#'— clearly stressing the tonic and dominant and adding the subdominant before rising to conclude on a soft F#". The therapist stops beating the drum and cymbal and [0:43] plays a repeated chord. Edward makes a short, quick ascending glissando: Edward Notation Example 4 [0:46] The therapist pauses in his playing. Edward’s crying falters at first — then begins to build up. [0:51] He makes an ascending slide to F#". [0:53] Another slide that ascends to F#" and descends to G#'. [0:56] A high scream descending to F#'. [1:10] He cries rhythmically as he jumps; the therapist accompanies him. [1:21] Edward’s crying fades in a descending slide. [1:24] In imitation, the therapist plays a fast descending glissando. Edward screams, leaping downward from F#" to G#'. [1:29] He continues to jump in agitation; the therapist accompanies him. He sounds F#" repeatedly, sliding off it many times. He vocalizes a descending F# octave [1:47], followed by a scream. The music becomes softer. His screaming subsides and he continues to cry tonally, once singing a clear F# [2:01]. Thinking that it could be advisable to conclude the session, the cotherapist began to lead Edward out of the room, but the therapist felt that the session was incomplete. He was still experiencing Edward’s susceptibility to music and the effect this was having on his protesting behavior. He felt the need to test it further and asked to have Edward brought back into the room. Edward was quiet as he was taken out but when brought back came in voicing his protest and jumping. This was accompanied and then repeated. After he was brought back a third time, he was brought to the piano and we each took a hand and played clusters freely in the treble with him. He accepted this without protest, and his crying diminished to soft fretful sounds. The cotherapist put a mallet in Edward’s right hand, and hand-over-hand beat the drum and cymbal. The music became fast and syncopated, the rhythm of the drum and cymbal beating accompanying it. The mood was tempestuous as we attempted to express Edward’s agitation on the instruments. As we played he became quiet. After a brief goodbye the cotherapist led him out of the room. He was calm and made soft tonally inflected sounds as he was taken back to the Unit. The session had been almost eleven minutes in length. It was significant to note that on his return to the day-care milieu this quiet mood continued, there were no adverse repercussions to his experiences in the session. Commentary on Session 1

The therapist was aware of Edward’s sensitivity to tone from the moment he entered the room. His sounds had reflected the gentle opening of the session. The pitches of his soft vocalizations demonstrated that his tonal sensitivity was immediately responsive to the music being played and sung. This was evident in his response to the singing of “Good morning” (CD 1/1 at 1:16). After hearing this greeting phrase twice, he placed his responses to the two repetitions that followed, consistently after the first syllable of “mor-ning,” indicating some incipient awareness of the melodic form. That he seemed to pause for these moments to cry suggested that he was actually listening, that he perceived “Good Morning” as a musical phrase, and was drawn by the formed flow of the music, not merely to utter a response, but to do so in accordance with its form. In doing this he appeared to be showing primary attributes of musical cognition, namely recognition, memory, and anticipation. When his anxiety turned to protest and rejection, the therapist responded directly with musical-communicative intent. Fear, anger, irritation, crying, screaming, and emotional-motor tumult were normal to Edward’s life, and the therapist decided to accept his outburst as an expressive reality in the situation and meet it musically. This is how Edward was present, this was how he wanted to meet him! He played and sang to reflect Edward’s agitated state to him, attempting to engage his emotional intensity with the character and dynamics of the improvisation and through accompanying the rhythm of his jumping. It had become an experimental clinical procedure, when working with an autistic child who did not use the instruments, to take any habitual movement or sound and improvise to accompany and meet it — this could be a way of gaining an initial contact. We had also several times experienced that when emotionally congruent music was improvised to crying children they would cry or sob on tones of the music and in rhythmic relationship with its phrase structure. They had also cried more loudly when the music became louder, and varied the rise and fall in the pitch of their crying with the movement of melodic tones. Edward showed all these responses. As the therapist improvised for him he was continuously impressed by Edward’s tonal and rhythmic sensitivities. The later analysis of the recording of the session confirmed just how keen and immediate they were. The physical and emotional intensity of his vocal protests first took expression in the shrill forcefulness of a scream, which was often unpitched. But increasingly, as the initial vocal thrust of a scream tapered off, the softer expiration that followed carried sounds that had a more songlike quality, and definite pitches could be discerned that mirrored the tonal order of the music. Edward was showing the natural tendency of young children to imitate pitch and rhythm in ambient music. It was obvious that his crying protests were volitional and that at first the tonal correspondences were evoked, not intentional. The question arose: To what extent was Edward aware — or becoming aware as the session progressed — of how tonally embedded his vocalizations were in the music. For example, when he so clearly squealed-cried F#" — C#" — B' (CD 1/2 at 00:39), the principal tones, I — V — IV of the musical environment in which he was immersed — so making an emphatic completion to the therapist’s phrase — did his consciousness extend to any sense that he had “tonally placed” his voice into the context and flow of the music? Did he, in any way, feel that his protesting gained strength, a new relevance in sound as this happened? As he heard his cries in their tonal-rhythmic context, did he sense the expressive concurrence of his emotionally driven outcries with the music and with the therapist’s making of it — did he feel in any way that they were in a sense speaking the same language? If so, could this be the very first

stage of attaining a coactive musical relationship? When Edward became upset early in the session, it was not the therapist’s impulse to attempt to soothe or console him with music — his outburst was too reactive and had as much the character of protest as distress. 2 And as the therapist experienced Edward’s musical sensitivity and that its hold on him was preventing him from abandoning himself completely to a tantrum, he felt secure in challenging Edward’s anger by beating the drum while playing to accompany his jumping, by introducing silences, playing forcefully, and later by having him brought back into the room three times. He did not want Edward to leave with the sense that he could overwhelm us by screaming — it was important to release him from that expectation. If Edward could feel a warm purposefulness in our attitude, an emotional-musical-personal strength that would be meaningful to him, he would hopefully find a way of relating to it and come to rely on it. Neither did we want the session to end abruptly or in a negative mood. For these reasons, before closing the session we changed our approach, and led him directly to the piano, drum and cymbal, and into experiences of playing instruments that he himself could not have initiated. Due to illness and transportation difficulties in attending the Day-Care Unit it was not possible to work with Edward again until four weeks later. In the meantime, he was brought twice to the music room to increase his familiarity with it. Session 2 Edward nervously accepted the cotherapist’s invitation to “come to music.” He was apprehensive as he was brought along the corridor. Audio File: Edward– Excerpt 3 (Session 2) [0:07] Edward enters to a new motive in D-flat. He half-sings Ab' and Gb', the dominant and subdominant tones in D-flat, and prominent in the piano phrase. The therapist greets him with Good Morning To Edward, Good Morning … Edward Notation Example 5 As the cotherapist greets him and tries to engage him in using the cymbal or drum, Edward becomes anxious. Many of his rhythmic fretful sounds [0:18] fall on, and immediately below the tonic Db". Simultaneously, the therapist repeats “ho” on the dominant. [0:23] Edward sounds a quiet songlike slide that descends from Db" and fades close to Db'. The cotherapist briefly beats the drum and cymbal. The therapist repeats and varies Good Morning To Edward, Good Morning; Edward is silent. The cotherapist continues trying to interest Edward in playing the instruments. When he softly hits the cymbal, Edward’s reaction [0:38] is a quiet, high-pitched descending slide. As the therapist continues singing the greeting, [0:48] Edward joins him briefly with sustained tones that partially

iterate the melody. [0:50] Taking the last two tones of the melody, the therapist establishes an ostinato over which he continues singing “Good morning.” Edward, relaxed, responds with a few tonally related sounds and at [1:15] makes a single short, clearly directed songlike response on Gb' — F'. The therapist sings imitative responses on Ab — Gb — Ab, to which Edward responds closely in pitch. His fretfulness continued although he smiled briefly several times at moments of vocal response. Direct attempts to involve him in activity tended to increase anxiety. The therapist repeated variations on the greeting and also improvised light, rapid, and sometimes syncopated music to match Edward’s mood and reactions. The music appeared to be engaging his listening and making it possible for him to contain his anxiety —just. Playfully and lightly, we continued to turn his attention toward the instruments. When he did beat the drum for a few beats, it was in the tempo of the song. He was brought to the piano and played clusters impulsively in the treble for two seconds before protesting. Within half a minute he returned to the piano of his own volition and played random single tones for four seconds. He beat the drum twice more in short, fast, light impulses. Later he approached the piano again: Audio File: Edward—Excerpt 4 (Session 2) [0:00] Edward makes an emphatic body movement and sound expressing irritation, to which the cotherapist responds, then turns to the piano and [0:04] plays lightly. Therapists sing and say “Very good!” [0:14] Edward plays rhythmically —briefly; the therapist takes up his tempo. [0:17] He reaches for a pencil on the music rack. The therapist responds to Edward’s playing by repeating “Very good” — and adds “away,” indicating to the cotherapist that the pencil be removed. As this is done, Edward protests, the form of his vocalization being influenced by the therapist’s singing of “Good morning!” [0:24] He responds immediately to a repetition, showing a clear anticipation of the melodic-rhythmic speech pattern by participating strongly in the rhythm and emphasis of “morning.” He came to us, each in turn, and momentarily brought his nose close to our faces. Soon afterward Goodbye was sung and he was returned calmly to the Unit. Not wanting the session to lose its positive mood, we had made it short —just over five minutes. Commentary on Session 2 Despite its brevity the session had several notable, hopeful aspects: • • •

Notwithstanding Edward’s obvious uneasiness and insecurity, there had been no rejecting outburst or tantrum. His susceptibility to music was confirmed. He had again vocalized in the tonality, this time adding the tone F, from the new key, to the tones he had sounded before. Because he was not caught up in rejecting the situation, his vocalizations were more gentle and songlike.

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In responding so strongly and clearly to the intonation and rhythm of “Good morning” (CD 1/4–0:24) he had evidenced latent perceptive and expressive capabilities that might possibly be led toward speech development. Edward’s sensitivity to music seemed to have held his emotions in a certain balance and openness. From his facial, bodily, and vocal expressions, the therapist could often sense the immediacy of his response to new musical ideas and to repetitions and developments. As he played and sang, he could quite practically feel the potential of music to reach and influence Edward, regardless of the unpredictabilities of his behavior. The question arose naturally in the therapist’s mind: could this sensitivity result in music becoming an enjoyment for Edward, and would this then create a cooperative, interactive relationship between them, and with it, communication in and through musical expression? We had, in this session, just attained a brief moment of interresponsive singing (CD 1/3– 0:46). Did this indicate a possible mode of interaction and communication we might develop?

Session 3 On this day, a week later, Edward had been upset since arriving at the Day-Care Unit. We had heard him crying for over an hour; he sounded discontented and weary. When he was brought to the music room he was quiet for the first few minutes. He did not use the mallets he was given but squatted down and rolled them skillfully in circles on the floor. In an attempt to activate him, the therapist played the rapid syncopated music used at the end of the first session. He made sustained complaining sounds on tones in the key — the therapist paused between his phrases to sing his responses. At one point, Edward imitated the interval of a major third perfectly. The therapist changed the mood and sang and played simply and quietly. Edward, facing the therapist from across the room, began to answer in the key with his crying voice, obviously directing his vocalizations to him. Audio File: Edward—Excerpt 5 (Session 3) Over a long rising and falling piano phrase in the Mixolydian on F sharp, Edward makes tonal sounds including B', C#", F#", F#', and G#'. There is something of a quality of challenge in the way he makes his sounds. [0:17] A dramatic, clearly structured idea is developed. Edward seems to wait and listen, then begins to respond in the rests or with the chords; his vocalizations appear to carry musical intentionality. [0:29] The therapist replies, singing on “ah” with a vocal quality that expresses empathy and compassion, and also strength. He answers Edward — almost phrase for phrase. Vocal interactivity develops. Edward Notation Example 6

[0:57] Edward’s singing-crying becomes sustained, his phrases lengthen as he vocalizes with the therapist; [1:01] he cuts off with the therapist on the dominant C# (an octave apart). [1:14] The therapist begins to hold the pedal through the repetitions of the F# minor chord. Edward makes a crescendo with him on F#" — G#". [1:21] After the final chord of the pattern Edward sings a rising and falling melodically shaped phrase and [1:26] sings similarly, rising higher in pitch and extending the phrase. [1:31] On the last repetition of the phrase, the therapist makes a vocal fermata on tones in the second and third chords, then resolves to F sharp minor — thus making a IV–I cadence. [1:33] Edward responds by sounding the F#" of IV and then the A' of I, apparently anticipating the resolution. [1:40] He jumps; the therapist plays to accompany him. [1:57] He screams-sings against a crescendo. [2:03] He sings-cries a long phrase, repeating an interval in the harmony. Edward Notation Example 7 [2:12] He sobs rhythmically as the therapist concludes the session with a new resolution to Fsharp major. The therapists commend Edward as he leaves the session. He left the room quietly; it had been a seven-minute session. Commentary on Session 3 This was an encouraging session. Clearly, Edward’s crying was becoming song-like. His vocalizations enabled him to fully express his protests and feelings of discontent while creating and maintaining interpersonal contact. He was obviously listening and his crying consistently reflected the character of the improvisation — even as it was absorbed in the elaboration of its form. He responded tonally to harmony, answered increases of volume with his own, and often placed tones on chords or in rests with rhythmic precision. His sustaining of tones and slides also implied intentionality; several times he started and stopped with the therapist. Because he formed his tonal phrasing so powerfully, the therapist could answer him with empathic directness, and the beginning of a feeling of mutuality arose in the way they met in the interactive improvisation. It was extraordinary that a musically sensitive child who could teasingly offer (but be unable to sustain) the simple tonal-rhythmic motif of his “sound game” in a nonmusical setting should come to singing self-expressively only through singing his crying. Apparently, none of the music he heard at home or the songs from the children’s repertoire used by the day-care staff had any personally expressive significance for him; his own emotionally expressive vocalizations taking musical shape did. Because his volatile vocal spontaneity had repeatedly become embodied in the order and intensity of the music, it must have taken on a quality of communicative significance that was new to him. In a case review at this time, we noted that Edward’s course of music therapy was promising to be hopeful and interesting.

Session 4 Two weeks later. Apart from some fretful whimpering as he entered, he did not cry and made few sounds. We set out to maintain a light, active mood. The cotherapist worked again to interest him in the drum and cymbal, meeting with some success as he took Edward’s hand, put a mallet in it, and hand-over-hand beat the instruments to give him an experience of playing them. As the cotherapist led from one instrument to the other in a kind of playful dance, the music had to reflect and support this: Audio File: Edward—Excerpt 6 (Session 4) [0:00] The therapist accompanies the cotherapist’s hand-over-hand beating with Edward with a dancing variation of Good Morning. [0:24] The cotherapist leads Edward into making a cymbal beat. [0:35] Edward jumps briefly; the therapist adapts the music accordingly. The therapist returns to Good Morning To Edward, Good Morning. [0:56] Cotherapist suggests jumping as an activity. The therapist improvises Jump, Edward! the cotherapist encourages Edward to jump with him. As Edward and the cotherapist jump, the song is adapted to the tempo of the jumping. At times Edward and the cotherapist jump hand in hand, at times independently. Edward enjoys the shared activity. [1:26] He smiles and laughs. Edward Notation Example 8 The cotherapist incorporates two cymbal beats into the jumping. Edward makes a highpitched, rhythmically placed exclamation. Edward was then brought to the drum. He was nervous but tentatively beat in two short, rapid bursts. Jump, Edward was repeated, then led into a Dance, Edward variation in which the cotherapist, by posture, movement and voice, invited Edward to dance freely with him. Goodbye followed shortly; Edward came to the piano and briefly tapped the keys. He made a soft sound in the tonality as he left the room. This was a six-and-a-half-minute session. Commentary on Session 4 The need to meet Edward within his condition of nervous intensity set the pace and mood of the session. As in the second session, the therapist felt it was necessary to create music that met the qualities of Edward’s personality as these were expressed. For this music was required that was formed yet stimulating and active, music that derived its stability from definite musical ideas and its vitality and immediacy from extensions and variations of those ideas. There was also the need to respond to the dancing quality in the way that Edward moved: He was quick and light on his feet, and his head and eye movements were so free and responsive that making music for him — music that reflected him — often spontaneously called up a dancelike quality in the improvising. During the summer, a team of music therapy interns gave him six sessions. He accepted

the change without protest, but made no significant vocal responses; his use of the instruments increased slightly. By the fall, he was settling well into the Unit and forming a positive relationship with his child-care worker. His handling of toys and objects was still serious and intent, not at all playful. He was less fearful but still subject to frequent tantrums; it was generally felt that these were not quite so forceful or long. He appeared to understand commonly used commands. He was enjoying jumping on the trampoline. He continued to initiate the vocal game and often incorporated the sounds “aija” (hiya) or “awo” (hello) into it, but this interactive play continued to be impulsive and brief. He had been observed by the speech pathologist from his first days in the Unit and had been tentatively introduced to the speech therapy program. Here, his sound productions continued to be erratic and impulsive, but it was noted that he was capable of imitating phonemic elements. He strongly resisted direct attempts to get him to repeat words and any structuring of his response. In the day-care milieu and in speech therapy, his jargon was becoming a little more variable, at times seeming to sound almost like actual speech. By the end of the summer, he had imitated five new words. Session 5 Edward was spontaneously happy to see us on our return in the fall and came to the music room willingly. He beat the cymbal with some interest, then danced to the music and beat on the one-way mirror, his supple body movements gave a lively, haphazard rhythm to his beating. He made a few quiet, happy tonal sounds. Twice he exclaimed “awo!” and briefly imitated the therapist’s singing “la, la, la ...” He did not want to leave at the end of the session and cried, squealing an ascending tonic do–sol on the final chord of the music. This was a thirteenminute session. Session 6 He was in a quietly intent mood. He first rolled the mallets on the floor, but then, on his own initiative, picked them up and moved lightly and rhythmically around the room, beating on the floor, one-way mirror, piano keys, cymbal, table, cabinet, windowsill, and piano bench. For more than five minutes he was engrossed in his activity — his beating was light, his impulses were more sustained and regular. He was silent except for two short, high, tight sounds. The therapist mostly used musical ideas that were familiar to Edward and much of his playing was “thin,” unpressuring, and playfully free in tempo and expression. Halfway through the session Edward came to the cotherapist, who was kneeling, intentionally to be on his eye level, and gently put an arm around his neck. With a friendly inquiring smile, Edward looked closely into his face. He chuckled when the cotherapist made a game of whispering “hello” to him. There was the unmistakable feeling that an emerging contact was being delicately tested. The therapist took this up in the music, and we sustained this quality of closeness for more than two minutes. To see whether we could move this new turn in our relationship into coactivity, we became more stimulating in our approach. This led Edward and the cotherapist into elated jumping to the jumping song in a happy and excited mood. He

stopped jumping and, making a low throaty sound, again approached the cotherapist. His friendliness was gentle, perhaps a little more confident. The music reflected this, then broadened into a waltz: Audio File: Edward—Excerpt 7 (Session 6) [0:01] The therapist plays a waltz variation of Good Morning To Edward, Good Morning: The cotherapist beats to the waltz using a drum and two cymbals. Edward, calmly and with determination, tries to stop him. The cotherapist teases him by beating with whichever arm Edward is not holding. Edward removes the cotherapist’s mallets; the therapist continues playing; the cotherapist half-kneels. [0:41] Edward bounces on his toes briefly (the therapist accompanies him). He then approaches the cotherapist, and sits lightly on his knee, half-sitting, half-reclining in the curve of his arm. [0:46] The therapist plays and sings softly in the Mixolydian mode on D flat. The music becomes accepting and comforting, the broken octaves in the right hand gently articulating the prevailing mood. [1:01] Edward “speaks” to the therapists in a jargon. His voice is conversational and seemingly inflected in the tonality. The cotherapist answers softly with single words and quiet exclamations of agreement. The quiet mood continued into the Goodbye. Edward spoke in a jargon again, his tone relaxed and affectionate. He was in no hurry to go. He played a quiet “chuckling game” with the cotherapist. The therapist chanted and sang in a kind of jargon; he appeared to enjoy the friendly mood of this. As he left the session the therapist sang “bye, bye, bye, bye.” Edward replied, in a soft, musically inflected voice “a’bababah —.” Commentary on Session 6 We were impressed by the personal qualities of his approach to us as displayed in the subtleties of his behavior, in his facial expressions, his mood, his movements and sounds. He was motivated to approach us personally, seeming to wish to confirm the closeness of our relationship. The initiative was his, and the delicacy of his searching friendliness was clearly evident. At first he was tentative as if testing us, asking: “Are you approachable? Can I trust you? Are you really accepting and understanding?” As we responded with the same open friendliness, the way was open for him to take his approach further in whatever way he wished. When he came to the cotherapist a second time, it was with more sureness. On his third approach he was confident enough to take control of the situation by removing the cotherapist’s mallets to prevent him from playing the instruments. At this point he brought the relationship to its closest by sitting on the cotherapist’s knee, then “speaking” to us in his jargon. There was the impression that although Edward could never have experienced what a conversation was, he had seen and heard people conversing and smiling to each other. Recognizing that this was a vocal, personal behavior that showed friendliness and trust, he was spontaneously moved to express the closeness growing between us by initiating his

interpretation of people conversing. Or possibly, he was enacting how he had experienced his parents talking to him at fond and peaceful moments. It was noticeable how these new explorations into forming a personal relationship were taking place within the context of the continuously developing musical relationship. Session 7 A week later, as he was brought along the corridor to the music room, he sang — before any music had been played — a fragment suggestive in rhythm of Good Morning To Edward, Good Morning. After a few scattered beats on drum and cymbal, he determinedly led the cotherapist to a bench against the wall, climbed on it, then scrambled up into his arms until he was upright, held securely against the cotherapist’s chest, his feet supported by the cotherapist’s left hand. In this position he was held to face the therapist over the cotherapist’s left shoulder. As Edward looked down at the therapist from this height he hummed and chuckled with pleasure. He insisted on being held in this way throughout the session. Every time the cotherapist put him down, he pulled him back to the bench and climbed on him again. He refused any contact with the instruments. He was in an excited controlling mood, and his preoccupation with being held high by the cotherapist made it difficult to find a direction in the session. For most of the session, the cotherapist stood at the treble end of the piano with his back to the therapist, holding Edward to face him over his shoulder; several times adding an experience of movement by dancing a little to the waltz variation of the greeting song. Over the next six minutes, from his elevated position, Edward became impulsively and increasingly vocal: laughing, exclaiming on high tones, shouting tonally, singing short delicate phrases, and calling out variations of his “hello” sound, which he repeated rhythmically. Almost all his sounds were on tones of the music and changed key with it. The therapist attempted to answer his vocalizations and stimulate interaction, but he was so excited and caught up in his impulsiveness that his sounds were scattered and inconsistent. We did achieve a few moments of interaction late in the session: Audio File: Edward—Excerpt 8 (Session 7) [0:01] The cotherapist, holding Edward high, swings and dances to the music. Edward’s wideranging exclamations express a mixture of concern and delight. The therapist plays descending phrases in D flat, and in the pauses makes vocal slides on “hi” and “he.” [0:26] Edward answers softly on Eb' — F' — Db', then initiates “allo” on Bb'— Ab' and repeats it twice antiphonally with the therapist. [0:36] Edward makes a jargon sound like “nyunda.” [0:43] Lyric, dancy music is improvised. The cotherapist, still holding Edward, bobs gently and rhythmically to the music. [0:48] Precisely in the rhythm, Edward makes two high-pitched sounds, Bb" — Gb", tones in the IV chord the therapist is playing. [0:59] He sings a two-note phrase suggestive of “hello,” F'— Eb' and continues singing in twonote phrases, Gb' — F' as the therapist sings “hello” repeatedly in response.

[1:16] The therapist attempts quiet vocal play, without piano. [1:31] Edward calls out his “hello” sound on Bb'— Ab', leading to a brief interaction. Among the sporadic vocalizations that followed, he responded to the therapist singing a phrase on “ah” by imitating and holding the last tone. He squealed repeatedly on high Ab as the cotherapist bounced him in his arms to the music, and in Goodbye Edward he repeated the “E-” of “Edward” and “î” of “bye.” It was a thirteen-and-a-half minute session. Commentary on Session 7 At the beginning of the session, Edward had immediately taken the movement toward personal and physical closeness of the sixth session further into directly controlling the cotherapist to hold him high. This was new behavior in music therapy, and hitherto unknown in the Day-Care Unit. No matter how much we tried to discourage it — we did not see then what significance it had; it appeared to us to be merely some form of manipulation — he insisted on being held high. From this height, his head some inches higher than the cotherapist’s, he had initiated more vocalizations than we had heard before. They were impulsive, and there was considerable variety. Almost all were musically responsive, although few were communicatively directed. Session 8 A week later, he climbed on the cotherapist as soon as he was in the room, and from this height again greeted us exuberantly with repetitions of “awo!” We sang back to him — and this was the principal moment of contact. In the minutes that followed, he made tonal sounds and repeated his “hello” many times. He was in a tensely agitated mood and his sounds were exclamatory. He did not respond to our responding to him, nor to any new phrases that were sung. He wanted to stay held high and became increasingly restless. After about seven minutes, as his climbing appeared to be achieving nothing and distracting him from contact through music, the cotherapist put him down and refused to be climbed on further, despite all Edward’s attempts to do so. He squealed, screamed, leapt, and threw himself about. The therapist played and sang slow, minor, affirmative music for him. His squealing gave way to crying, but crying without its earlier character of protest and acute distress, more expressive of childlike disappointment. He cried-sang sustained low tones in the key. He did not want to go when the session finished and was fretful as he left the room. Going down the corridor he repeatedly cried on low Gb, a tone common to the harmonies then being quietly played. It was a ten-and-a-half minute session. Commentary on Session 8 On studying the recording of the eighth session, we realized that although Edward’s physical behavior had been obsessive and seemingly directionless, his vocal responses had actually advanced. His restlessness had obscured our perception of their significance. He had made sounds new to us — among them a quick, five-note ascending scale passage and some very rhythmic

jargon — and we were impressed by his spontaneous impulses to sing communicatively, even though these attempts were short-lived and haphazard. We decided that if he needed to climb on the cotherapist, for whatever reason, then we would let him climb as he wished and concentrate on working with his vocalizations, responding to them as they came, and in whatever form he gave them. Session 9 Two weeks later. Coming down the corridor as he approached the music room he softly sang single tones in the tonic chords as they were played. He climbed onto the cotherapist immediately; he was quiet and intent. After a few musical sounds he began to repeat his “hellos” antiphonally with the therapist — it was noticeable how gently and calmly he did this. From speaking them in the tonality, he progressed to singing them with the music, then to changing the tones and intervals on which he sang them to follow changes of harmony. He became increasingly animated, at times exuberant, but he remained cooperative throughout. For the first time, he introduced his vocal game into the musical exchange; it became a spontaneous rhythmic vocal interplay that became more melodic as it was repeated and developed. There were more than sixteen minutes of continuously responsive vocalizations; the following excerpts highlight the progress of the session: Audio File: Edward—Excerpt 9 (Session 9) The therapist sings “Good morning.” Edward twice sings a short jargon phrase “woi-o-woi,” then initiates his “hello” sound, repeating it on the 4th and 3rd tones of the key, interresponsively with the therapist. The therapist introduces “hi” into the exchange, but gives it up as Edward continues with “hello.” Audio File: Edward—Excerpt 10 (Session 9) Edward sings “hello” repeatedly to the Hello music, often with the therapist, on the 6th and 5th tones of the key. When the cotherapist dances [0:22] Edward exclaims-sings a melodic phrase along the tones of the tonic chord. He continues singing “Hello.” His singing has a strong melodic quality. Audio File: Edward—Excerpt 11 (Session 9) [0:01] The cotherapist puts him down. Engrossed in repeating “hello,” Edward leads him back to the bench. [0:07] As the cotherapist lifts him, he squeals, sings a descending phrase on five clear tones, followed by an ascending interval, all in the tonality. He then initiates a return to “hello.” Audio File: Edward—Excerpt 12 (Session 9)

As he climbs again he makes two high-pitched squeals on Ab"' precisely in the rhythm in which the cotherapist bounces him, then continues to exclaim in tonal intervals. Audio File: Edward—Excerpt 13 (Session 9) He repeatedly sings “hello” on intervals that follow the melodic-harmonic movement of quiet, lyric music. He sings descending major and minor seconds and minor thirds. His voice is musically expressive, friendly, and gentle. Audio File: Edward—Excerpt 14 (Session 9) Edward sings “hello.” The therapist answers “Hello Edward ...” playing the dominant on the piano and singing the third of the dominant — Edward sings an ascending phrase made up of the 5th, 7th, and 9th of the dominant seventh chord. The therapist responds with a similar phrase in the same rhythm. Sustaining the initiative, Edward leads into vocal play, singing “ee-ee-ee” on ascending tones. The therapist answers, playing and singing, and a give-and-take in 2/4 time develops. Edward adds his “hello” sound to the game. In the mutuality of the play they are equal musical partners, the leading of the game passing from one to the other. Edward’s vocal patterns are tonally defined and melodically responsive to the therapist’s phrases — and vice-versa. Both sing and play in arpeggiated fashion on chords in the tonality. Edward’s chordal fragments are consistently related to the dominant seventh. The interaction quickens: the singing becomes bolder, as the phrases follow each other more rapidly they are shortened to two notes. Everyone laughs. [0:32] Edward brings resolution by restating the “hello” interval in the original tempo. The Hello music is played; he partially joins in singing it. [0:39] The therapist presents Edward’s name as a possibility for vocal exchange; he does not imitate it. [0:46] The therapist reintroduces the three-note give-and-take. The co-therapist offers “Uncle Paul” in the same rhythm for imitation. Edward sings an ascending three note pattern ending on Bb"; the therapist responds and their interaction leads into animated vocal slides. The Hello music is reintroduced. Audio File: Edward—Excerpt 15 (Session 9) [0:03] Edward voices the seventh of the dominant chord. The therapist sings an ascending three-note pattern on “ba”- to see if Edward would imitate the consonant; he does not, but answers with a four-note pattern: triplet-quarter in 2/4. Again, Edward’s vocalizations are along tones harmonically related to the dominant seventh chord. They are more complex, containing as many as four or five different pitches: [0:04] Eb'— Gb' — Bb" — (Eb"). [0:09] Eb'— Gb' — Ab' — C". [0:11] Gb' — Bb'— Db" — F". [0:13] C" — Db" — Eb" — E" — F".

[0:19] Edward reintroduces “hello.” Audio File: Edward—Excerpt 16 (Session 9) [0:01] The therapist sings “Edward” for him to imitate if he will; Edward sings an ascending stepwise, four note pattern F'— Gb' — Ab' — Bb. The therapist repeats “Edward.” Edward responds with an ascending fourth, Eb'— Ab'. The therapist sings “Edward” as an emphatic four-note pattern. Edward obviously listens and his responses are partially imitative. [0:17] The cotherapist, holding Edward, sways in a dancelike way; Edward makes musical sounds of enjoyment including [0:32] F', Bb', and Eb'. Audio File: Edward—Excerpt 17 (Session 9) Imitative play on several vowels. Edward responds sensitively to the therapist’s surprising change of voice quality and harmony on “goodbye”; Edward sings “beebye,” sliding gracefully in a wide tonal contour. They sing antiphonally four times. Some moments of softer singing, without piano, ended the session. As he was returned to the Unit, he sang and chatted in jargon to the cotherapist all along the corridor, continuously imitating phrases and interjecting “allo” and “beebye.” When they reached his child-care worker in the day-care room, he was still intent on exchanging vocal patterns and did not want the cotherapist to leave. To make the parting positive, a game was made of singing “Oh — goodbye!” Edward accurately imitated the rhythm, inflection, and stress of the phrase three times. Including this coda to the session, it was nineteen minutes in length.

Review of Sessions 1 Through 9: The Process of Discovering and Developing Communicativeness The Effect of Musical Order: Stabilization and Objectification Create a Foundation and Medium for Intercommunication In session nine, Edward achieved self-expressive intercommunicative singing in two ways: (1) in sustaining his singing of “hello,” which he did by singing it, both antiphonally with the therapist, and freely with various forms of “hello music,” and (2) in extending the motif of his vocal game into a musically developing rhythmic-melodic exchange. “Allo” or “awo” were exclamations he was now using in the Unit, calling them out as a kind of teasing greeting or to get attention; similarly, the vocal game had become a teasing way of playful encounter. These vocal patterns were usually initiated only on his impulse, and any responses in kind made by the day-care workers were accepted, diverted, or ignored. The effect of this was that he effectively avoided becoming committed to any interaction that was directed externally. Both forms of vocalization had become habitual modes of behavior that had developed little since he first used them in the Unit seven months previously. When Edward expressed these vocalizations interresponsively in the improvisational setting, they became subject to musical organization: to tonal structure, which ordered them in relation to pitch, scale, melody, and harmony; and to rhythmic form and tempo continuity, which stabilized them in the flow and measures of time. This must have imparted a greater intercommunicative-expressive significance to his vocalizations, for they acquired, through the musical forms they took in the musical context into which he directed them, a substantiality that they could not have had as haphazard impulsive utterances. That his sounds became invested in musical order, were structured and carried by it — while being vivified and enhanced by living, responsive musical expression — gave them a reality in musical language for him. Throughout his course of therapy thus far, the language of music had been presented to him, adapted to all his moods, flexibly answering or supporting all his activities. He had come to know music as communicative, alive, and pleasurable. In this ninth session, he found his way into making this language in part his own, and into using it with increasing confidence. His inherent musical sensitivity and intelligence drew him into entrusting his vocal impulses to music, spontaneously and livingly, moment-by-moment, and so to entering into and sustaining intercommunicative singing with the therapist. He was able to go beyond the state of producing only one-way expressions; in this session personal and musical conditions so combined to make it possible for him to participate in sustained two-way communication. He became a successfully active partner in an interactive situation, able, in a medium in which he was finding competence, to spontaneously transcend previous barriers to self-expression. His satisfaction in discovering this was evident in the quality of his singing and in his facial and bodily expressions. He was intent on his participation, and his warm pleasure in the exchanges with the therapists was directly expressed. There was much mutuality of enjoyment. He was happily energetic rather than overexcited, animated rather than restless. Freedom from .

usual behavioral patterns and emotional reactions gave him the possibilities of realizing selfinitiated, responsive expression, and the experience obviously elated him. The developmental significance of the ninth session appeared to stem from (1) the successful experience of intercommunication, and (2) the self-integration he achieved as he combined three important aspects of his personality: his auditory acuity, his inherent musicality, and his strong, personally expressive, vocal impulsiveness. This dual development came about through a process that originated in the imitative, evoked crying-singing of the first session, developed further in the brief vocalizations of the second session, and first involved Edward purposefully in the directed singing-crying of the third session. Vocalizations in sessions four through eight were impetuous but becoming more varied and musically refined. In the interaction of session nine, this process attained a stage of completeness in which he experienced self-integration on a level of perceptive, mobile expression in which he was cognitively and interresponsively active. In sustaining singing and vocal exchanges he could identify himself positively with the unifying of receptive and expressive capacities; he was able to attain and experience communicativeness The Role of Relationship: Acceptance and Dependability in Developing Trust The process of fostering communicativeness in Edward was closely involved with the development of relatedness between us; at each stage the quality and level of our relationship directly influenced the character of his vocal expression. Seen in retrospect, the dynamics of relationship development from session to session trace the progression that underlies his achievement: In his first session he perceived us as threatening, and attempted to reject us and the music therapy situation. Our musical and personal resolve to contain his reaction would have to have communicated to him some feeling of the dependability and purposefulness with which we were approaching him. His tentative acceptance in the second session made possible the intense, unsettled, but coactive singing-crying of the third session. The more relaxed mood that ensued in the fourth and fifth sessions brought the beginning of sharing in movement and instrumental activity. By now, he had sufficient trust in us — and confidence in himself— to be motivated to extend his musical contact into the closeness of an interpersonal relationship. Out of this came his series of approaches to the cotherapist in the sixth session, which led to the climbing on him in the seventh. The tension and restlessness of the eighth session resulted in the confrontation over climbing that evoked a brief return to singing-crying and apparently brought some stability into his relationship with us. It was out of his deepening trust in us and his pleasure in the mutuality of the musical play that he was motivated to communicate to us. This progression of intentionality was then met in session nine with our acceptance of his need to climb on, and be held by, the cotherapist, and a more understanding attitude on our part toward the complex of sensitivities, abilities, behaviors, and reactions that were uniquely his. Thus from both sides, the resolution became possible that opened the way to the new level of personal-vocal interaction.4 Why Edward so purposefully maneuvered the cotherapist into holding him high — a behavior not previously reported — and how this position seemingly contributed to his attainment of intercommunicative singing, are subjects for speculation. Possibly, he needed the kind

of stabilizing support that could come from firm physical contact, or needed to be elevated above the therapists and the piano to feel expressively free. Did being raised to where we were “looking up” to him bring him a primal sense of esteem and well-being, the empowerment of elevation that gave him the courage and confidence to attain interactive singing? Certainly, being held seemed to help contain his overexcitability so that he could focus on singing. How Edward experienced the transformation of his voice into a means of communicating his music intelligence, especially in the vocal play of session nine (CD 1, Excerpts CD 1/14 and 1/15, pp. 38 and 39) is also a matter for consideration. What must it have meant to him to achieve the freedom of volition to use his voice interactively and with self-expressive independence? Formerly, in his crying and screaming, he was accustomed to using his voice as an instrument of defense, a means of warding off encroachments from a feared and largely uncomprehended world of human presence and demand. He also used his voice to signal his pervasive distress and to give sound to the frustrations resulting from his disabilities. Furthermore, when he was in a tantrum his screaming voice became a primal weapon of defensive attack through which he could subdue and eliminate circumstances perceived to be unendurable or threatening. In all these uses of his voice, his attention was focused on his fears, and on his need to protect himself. In contrast, by session nine, his attention had become focused on the music, the therapists, and his pleasure in vocalizing with them. His use of his voice was becoming more healthily extroverted. Through it he could directly project his happiness and eagerness into the creatively responding human environment: he could place his expanding self actively into the sharing, nurturing musicing, and could experience the mutuality of musical intercommunication. This must have brought him experiences of capability and fulfillment, together with a sense of release. It would be surprising if these new experiences did not also result in some awareness of impending challenge, for he had no experience of coping with the freedoms of intercommunication or with its interpersonal dynamics and social implications. In a sense, his autistic defenses, progressively infiltrated by the expanding release of his inherent musicality, had been breached from within. How he would handle the results of his new experiences would have to be practically explored in subsequent sessions. Sessions 10 to 13 Session 10 A week later, he was eager to come to music, tensely excited, and restless in his climbing on the cotherapist. His sounds were exclamatory and abrupt — there was a feeling that he was holding back. Apart from a little laughing and squealing, he was mostly silent in the first minutes; there was hardly any response to familiar music and variations. In the effort to stimulate participation and explore the possibilities of extending his repertoire of speech-like sounds, the therapist presented new words to him: Audio File: Edward—Excerpt 18 (Session 10) The cotherapist is holding Edward in his accustomed position. The therapist briefly sings Good Morning To Edward, Good Morning, then introduces “How are you?” Edward responds

briefly with his “hello” sound, indistinctly formed, and laughter. At one point he imitates the melodic tones of “how are you?” The therapist says-sings “Hi!” Edward imitates directly (without the “h”) three times, then produces short, playful jargon phrases. The cotherapist dances while holding Edward His restlessness continued. His vocalizations included laughter mingled with exclamations, isolated sounds, and his “hello” sound, which he repeated ten times without responding to any of the therapist’s responses. The cotherapist continued to hold Edward high and at times moved him with the music, causing him to squeal. Trying to meet him in his scattered mood and catch his attention, the therapist experimented with a technique of playing and singing in a legato style, freely interspersed with short rhythmic passages: legato to induce listening and calmness, then rhythmic — and often detached — to match and meet the quality of most of his utterances. Whenever possible, the therapist tried to lead his sounds into the legato style: Audio File: Edward—Excerpt 19 (Session 10) [0:01] The therapist sings softly, Edward is partly imitative. Hello music, briefly. [0:24] A change to rhythmic intervallic music, modulating to E major, evokes two lively imitations of a melodic phrase [0:31]. Edward seems to become a little more attentive to the therapists. [0:52] Lyric dancelike music; Edward sounds a short rhythmic pattern. The therapist responds similarly. Edward initiates various sounds, which the therapist imitates. [1:20] While answering a rolled guttural sound, the therapist plays two rapidly repeated, inverted G sharp chords — the top and bottom tones of the right-hand chord are both D#. Edward hums D#. The therapist sings, then plays a rhythmic pattern (triplet and held note) on the interval of a fourth, D# — G#. Edward responds immediately, inverting the interval, G#'— D#". His voice is soft. He becomes rhythmically engaged. His singing is mixed with laughter. [1:39] Their singing touches briefly on Pop Goes the Weasel, but neither takes it up. [1:44] The therapist develops a quiet improvisation in G sharp minor, incorporating the triplet motif on the tones of Edward’s original response, G#'— D#". Edward repeatedly directs short phrases and single tones into the structure of the music, once laughing in the rhythm. As he ceases to respond, the cotherapist dances gently while holding him. The therapist returned to the legato style and once more worked for speech by singing “Edward” and “Edward’s hair” to him. He made no attempt to imitate the words, but a short, playful exchange ensued. He was quiet while the therapist sang and played softly. He then made varied impetuous sounds, among them a sudden loud, perfectly placed and sustained E" in response to an F sharp seventh chord. Another antiphonal singing play developed: Audio File: Edward—Excerpt 20 (Session 10) [0:01] Edward and the therapist exchange sounds, Edward initiates his “hello” sound. The therapist responds, then softly sings “eye.” Edward continues with his “hello” and laughter.

[0:25] Working for speech responses, the therapist introduces “nose,” then persists in repeating it. Edward answers with laughter and sounds that successively more closely approximate “nose.” [0:44] The therapist experiments with a staccato style. No response to “eye.” [1:05] Edward ignores the therapist’s first two offerings of “hair,” but clearly imitates it when it is sung emphatically. [1:10] The therapist returns to “nose.” Edward repeats it thoughtfully. The therapist tries for “hand” and “finger.” Edward, still concentrating on “nose,” repeats it once more. [1:18] The therapist repeats “finger.” Edward answers “ning(e),” then “ninner” — he repeats it excitedly twice more. The therapist continues with “finger,” then returns to “hair” and “nose”; Edward responds with vocal play. He was happy, playful, more relaxed in himself, but physically restless. After more songlike explamations the therapist worked again for speech but without result. However, when “goodbye” was sung he responded with “beebye.” We sang “goodbye” to the Hello music; he joined in twice with “beebyes.” He and the cotherapist sang “goodbye/beebye” all the way back to the Unit. It was a sixteen-and-a-half minute session. Commentary on Session 10 His purely musical responses, particularly to melody, harmony, key change, and dynamics, were still more varied and refined, indicating growth in sensitivity, perception, and vocal skills. He had responded to words in several ways: moving into a word progressively, as in his first response to “nose” (CD 1/12); through evoked imitations, such as to “hair” (CD 1/12); in sustained responses that implied recognition or discovery, as to “hi” (CD 1/11), the second response to “nose,” and the response to “finger” (CD 1/12). Additionally, some words were partially or entirely sung, such as “(h)air,” and “beebye.” Considerable restlessness accompanied these developments. The cotherapist, holding Edward high, coped with his constant wriggling but could do nothing to diminish it. We were concerned with the extent of the restlessness. What was its cause? Did it result from being in a volatile, changing condition, and from the effect of all the sensory stimulations that were directly impinging on a process of change? He was obviously stimulated by the music, by the energy of its repetitions, developments, and new experiences — the quick sensitivity of his responses was evidence of the immediacy of its impact on him. His own musical responses and the therapist’s quick answers were also exciting for him. And it was obvious that he was stimulated by his moments of participation in speech play, by his spontaneous imitations, discoveries, and conscious productions of words. Prone as he was to overexcitability, was this almost continuous stimulation, outer and inner, being reflected in his restlessness? The lively mutuality of the musical play with its call for sustained interaction was new to him. He was finding it pleasurable and inviting, yet he may also have been feeling it as unsettling as it took him onto an unfamiliar plane of intimate communicative contact that he was not as yet ready to take on and cope with, and which threatened the security of the limits he had established to relating behavior. Did an inner tension between growing responsiveness and residual insecurity also underlie his hyperactive state?

Sessions 11 and 12 The combination of restlessness and vocal responsiveness continued. The mood of both sessions was playful and good-humored. He obviously wanted to be there — he cried in disappointment when he was unintentionally kept waiting for the twelfth session — yet his vocalizations were diminishing. It was as if his motivation had shifted in some way and he was no longer able to sustain the level of outgoing freedom he had achieved in session nine. Nonetheless, in these sessions he followed changes of key, and twice showed sensitivity to modulation by anticipating the key the therapist was moving into. There were several brief moments when, spontaneously yet delicately, he seemed to be actually composing as he vocally explored tones. In speech, he imitated “shoe” and put an “f” onto “finger.” At the end of session eleven he sang “goodbye” correctly, then, possibly teasingly, countered our “goodbyes” with repetitions of his “hello.” (Had he perhaps remembered that at the end of the previous session we had sung “goodbye” to the Hello music?) Session 13 He was too tense to be responsive. There were only scattered musical vocalizations, and no speech except an evoked “ow are oo” in answer to “how are you?” He was in no mood to participate. He was neither outgoing nor confident, nor could he be communicative. As letting him climb now appeared to be serving no positive purpose, we discouraged it. Edward was showing a reaction previously observed with children characterized as autistic, or emotionally disturbed: after a build-up in response has led to gains in expressive freedom and to closer relationship, a period of resistiveness seems to become necessary in which there is an avoidance of interresponsive contact. His hyperactivity had increased over the last four sessions. The Transfer of Communicativeness from Music Therapy to Daily Living For a time, Edward also became increasingly hyperactive in the Unit, but with this came new developments in his communications to staff and children. As singing and speech diminished in music therapy, they increased in his daily life situations. One week after the ninth session, it was reported that he had begun to hum the songs used in ring games in the Unit. He imitated words with more sense of their meaning in the context; at times he spoke his jargon “conversationally”: He had approached the senior child-care worker and thoughtfully spoken jargon “words” to her as if wishing to start a conversation. As a result of these developments and a study of the recordings of the ninth and tenth sessions, the speech pathologist decided that Edward could now possibly accept a structured speech learning program. Although he was not overtly cooperative, there was some participation in speech training. Over the following weeks, it became evident that a fundamental change was taking place in his attitude to spoken language. He imitated more sounds and words equally in all the circumstances of his daily life — in speech therapy, in the playrooms, during the afternoon rest

period, and at meal times. He showed an interest in looking through picture books and department store catalogs with his child-care worker and repeating the names of household objects after her. It was at first disconcerting for us as music therapists that the level of communicative exuberance of the ninth and tenth sessions could be neither sustained nor reattained, and at the time, we were at a loss to understand why this should be. But Edward’s unmistakable readiness to extend the scope of his verbal comprehension and expression into all the areas of his daily life held the explanation to this unexpected turn in the process. In the creatively interactive setting of music therapy his inborn sensitivity to music had projected him to a peak of communicative freedom — to the surmounting of a barrier of disability — that involved the awakening and release of a latent capability. It was now evident that he needed time to assimilate this event and its developmental thrust. He needed growth time to equalize his development by spreading his communicative motivation and confidence outward into all the opportunities for verbal contact and sharing the Day-Care Unit presented. He was demonstrating the most positive and healthy outcome we could want to the liberating process we had shared in music therapy. Progress reports from the Unit four months after session nine listed 47 words spoken in this period — his most significant progress being in the development of spontaneous speech: 22 of his words were spoken spontaneously, appropriate to the situations in which he used them, and 13 were spoken communicatively to adults or children. Seven months later, he had used approximately 120 words, including verbs and short phrases; two-thirds of them were spontaneous and appropriate, and most were directly communicative. He was still generally tempestuous and restless and prone to tantrums if upset, but he did not panic as easily. His hyperactivity diminished. Through his child-care worker’s careful handling, he gradually became able to accept learning situations. This was corroborated by his activities in music therapy as we guided him, with some firmness, into using instruments. He worked on the piano, xylophone, drum, and cymbal, in that order of preference. During one session, he spent thirteen minutes at the piano, playing freely, often rhythmically or dramatically in response to the therapist’s playing and singing. On another occasion he became involved in playing the principal notes of a simple, slow goodbye song built on five ascending tones; for a few moments it was actually possible to teach him the notes to play, and after he had almost mastered one repetition, he quietly said “more.” At the age of seven his music therapy sessions were taken over by music therapy interns with whom he continued to develop skills in the rhythmic use of the drum and the cymbal. There was an episode during this period that is illustrative of the unpredictabilities that can accompany work in the area of developing communication skills with children in the autistic spectrum. The speech pathologist, having observed that at times Edward seemed impervious to sounds in the environment, arranged for an audiological evaluation. Physically, his ears showed no abnormalities. But when he sat through the hearing test there were no responses at any frequency or decibel level. Even startlingly loud sounds failed to produce involuntary reactions. The test results indicated total deafness. Finally, the audiologist turned to the speech pathologist and said — the microphone to the booth was open — “Well, I guess we’re through.” Edward stood up and put his coat on.

At nine, his behavior was more stable, and he was able to accept change and unfamiliar circumstances that would formerly have upset him. He was interested in playing with other children. His vocabulary was wide enough to enable him to communicate his needs and often his feelings. He was learning to write single letters. As he no longer needed the special services of the Day-Care Unit for Psychotic Children, Edward was discharged and enrolled in a local school offering a special education program.

Taken from: Nordoff, P., & Robbins, C. (2007). Creative Music Therapy: A Guide to Fostering Clinical Musicianship (Second Edition: Revised and Expanded). Gilsum NH: Barcelona Publishers.

CASE TEN Anna Paul Nordoff Clive Robbins When Anna began music therapy she was eleven years, three months old. She was cerebral palsied and spent much of her day in a wheelchair. She was blind, with vision estimated to be less than one quarter of one percent normal; she had some perception of light and darkness. Her muscular difficulties were first noticed at the age of nine months at which time she began wearing casts for metatarsus adductus. She sat up independently at one year, walked with assistance at three, and walked unaided but supporting herself against a wall at four. At the time we met her she could walk with her father holding her by one arm but became tired after about 300 yards. She was wearing long leg braces with a pelvic band to prevent scissoring and to give stability to her legs. She had a history of language limitations and a speech defect; she spoke her first word at the age of two but there was practically no speech before she was four-and-a-half. At the time music therapy started she could speak fairly understandably at about a 30 month vocabulary level. She was able to answer simple questions appropriately and identify a large number of familiar household objects after handling them. However, she showed an initiatory delay, lability, and unpredictability in using speech. She also produced speech that was described as being autistic in the sense that it had no relationship to the immediate social situation. It was impossible to make any sort of valid evaluation of her mental ability. In terms of the Binet verbal items to which she was able to respond, her functional mental level appeared to be about three years. She was toilet trained “when she wanted to be,” but needed help to adjust her clothing. She could feed herself with large pieces of food that she could handle; otherwise, she required assistance. She was said to be left-handed but able to use her right hand in eating. She was reported to have had one generalized seizure annually, beginning at the age of two. She also suffered from petit mal epilepsy and subnormal thyroid and was receiving medication for the control of these conditions. The diagnosis given was a blind child with cerebellar ataxia. Her progress at the Institute of Logopedics where she was resident had been erratic; some decrease in the initiatory delay and in the amount of inappropriate speech had been noted. Although she was described as outgoing, she was often uncooperative, even stubborn to work with. One therapist commented, “You can work for something and make no gains in six months.”

The impression given by re-evaluation and progress reports was that she had reached a plateau and had settled into a static routine of life. She was not responsive to other children and the general tone of her behavior often seemed to be apathetic. We were asked by the director of the Institute to provide individual therapy to a number of children whose response to their education and rehabilitation programs was limited, and to include visually impaired children among them. On a visit to a classroom containing several such children, we observed Anna sitting in a kind of see-saw rocker with another blind child. She seemed inattentive and her mood was dull. Together with the director and the class teacher, we chose her for therapy; we did not meet her again until her first session the following week. Session 1

The Course of Music Therapy

As Anna was brought into the room we greeted her. She did not answer, nor allow us to remove her coat or protective helmet. The cotherapist wheeled her to a position a few feet from the treble of the piano, placed a snare drum (with the snare removed) to her left, angled it appropriately, placed a lightweight mallet in her left hand, and hand-over-hand demonstrated the drum’s position to her. She handled the mallet exploratively and reversed it.

Anna, at the beginning of her first session. Her mood of resignation — almost boredom — was evident, but her presence also carried qualities of personal strength. Although her multiple disabilities made her so practically dependent on others, her independence of spirit, which would often make her stubborn or perverse to work with, was to manifest boldly in interactive musical activities.

The therapist’s approach and his music were exploratory from the start: he began with unresolved dissonance for stimulation and in an indefinite tonality to leave the situation open for responses to emerge and take direction. As she began to beat, he accompanied her by repeating the top note of the chord, G#, with each beat:

Audio File: Anna—Excerpt 1 (Session 1) Anna beats uncertainly, holding the mallet by the head. The therapist suggests “Turn the stick around.” As the cotherapist helps her do this she says “Good morning” in a musically inflected voice. The therapist repeats her words, then sings the greeting three times on G# — C#' She beats firmly in response in tempo twice, then [0:28] deliberately drops the mallet. Anna Notation Example 1 Exploratively, the cotherapist asks her “Now, who’s going to pick that stick up?” (He wanted to learn more about her — would she be motivated to try picking it up — and would she be able to if she tried?) [0:38] The therapist prioritizes the musical interaction, singing “Good morning” on G# — C# (the cotherapist returns the mallet to her). Anna answers on C#' — F#'. They repeat the exchange; this time she sings C#' — F#' — E'. Continuing to accompany their singing with a major seventh chord on D, the therapist extends the phrase to include her name. In the pauses that follow the repetitions of the greeting phrase, [0:52] she twice declares “I a’ school.” The therapist, not hearing “I a’ school” as “I at school,” sings “I school” on the fifth, F# — C#'. She listens to a repetition then cooperatively answers “I school” [1:13]. She also sings a fifth, but principally on the tones (C#') D'— (A#') A'. Remarkably, she sings the other two tones of the accompanying seventh chord. Anna Notation Example 2 In the pauses that follow the repetitions of the greeting phrase [0:52] she twice declares “I a school.” The therapist not hearing “I a school” as “I at school” somgs “I school” on the fifth, F#–C#’. She also sings a fifth, but principally on the tones (C#) D’—(A#) A’. Remarkably, she sings the other two tone of the accompanying seventh chord. Anna Notation Example 3 [1:26] The cotherapist, wanting the therapist to know that Anna has said “I a’ school,” sings this phrase on an ascending octave C# — C#'. She responds — after listening to the therapist’s repetition of “Good morning to Anna,” — by singing “I a’ school” on an ascending major tenth E'— G#". Anna Notation Example 4 When the therapist replies with an ascending octave F#' — F#" she laughs with pleasure. She sings two more ascending leaps, widening her interval each time.

In exploration, the cotherapist sings a descending phrase; Anna grimaces — possibly with disapproval. The therapist repeats “Good morning to Anna”; she sings an ascending leap on “I school.” Antiphonal play with this phrase ensues. [2:41] The therapist recommences work on drum beating. Anna beats with a mallet in her left hand in a slow-moderate tempo for about eight seconds. He accompanies her using the greeting phrase. She initiates beating again and is immediately influenced by a short ritard in the music. She sings “I school,” leaping up to G#' then again higher in response to the piano alone, singing “school” on a trill that slides down from C#. She beats briefly and becomes quiet, unresponsive to repetitions of “Good morning to Anna, good morning.” When he sings “Hello,” she sings “I a’ school,” then sinks back in the wheelchair, her head bowed. [3:58] He improvises, extending the “Good morning” phrase into a short song form. The therapist improvises in a pentatonic scale. Anna remains silent and still. He interrupts his playing [4:30] with a heavily accented dissonant chord. The second accented chord [4:34] stimulates her to recommence beating. Because she lacks beating skill, and is not certain of the position of the drum, her stick at first hits the rim. He accompanies her, adding emphasis to her beats with syncopation. Commentary on Excerpt 1 /21 This was an unexpected beginning for a child so extensively disabled. Her singing responses showed that she felt the musical freedom of the situation immediately, and was clearly aware of the order in the improvisation as it took form. She immediately perceived the possibility of interresponsiveness in the improvisational situation and used it, waiting for the therapist to finish singing his phrases before singing or speaking her own. The therapist’s approach from the outset had to be explorative for he could have no idea what her abilities might or might not be. He held back from an established tonality or style until her response emerged to give a definite direction for work; his improvisation then took its form from the character of the interaction as it developed. Anna’s first spoken “Good morning,” on a rising and falling phrase, had considerable tonal inflection; from it the therapist took his cue to sing these words to her on an ascending fourth. He kept the statement simple, using the piano only to reinforce in octaves the tones he was singing. When she sang “Good morning” in response, she quickly showed a sense for tonal phrasing by beginning her phrase on the tone with which he had finished his phrase, and singing a fourth, as he had. This was almost certainly an evoked response, but seemed instinctively musical — her phrase answered his and created a short melodic form. He added harmony as she sang, an open-voiced D-major seventh chord played in the lower-middle register. This by-passed any resolution of a consonant chord and kept the situation fluid and open. As he felt the need for supportive stability in the harmony, he continued to use only this chord to support the singing for the next minute and a half. She appeared to find the exchange enjoyable and smiled as she sang the repeat with more confidence, adding the E'. He added her name to the greeting. Her statement: “I a’ school!” (was she reassuring herself in the midst of this change in

her daily routine?) carried tonal inflection again. The therapist had responded “I school” because he had not understood that she meant “I at school.” Out of her intention to sing in answer, she also sang “I school.” She answered his singing of the fifth: F# — C# by singing her own fifth: D — A. It was astounding that she sang the other two tones of the accompanying seventh chord, being played as a harmonic interval in the therapist’s left hand, two octaves lower.1 He developed the “Good morning to Anna” phrase with each repetition (singing with the piano doubling the melody in octaves), basing it on the intervals of a fourth and a fifth for openness and space. As the phrase developed, the quality of the give-and-take in their singing led into the Mixolydian mode on F sharp. The cotherapist’s prompt of “I at school,” sung on an ascending octave — and placed between the therapist’s phrases where Anna had been singing — appeared to be interpreted by her as a signal that free vocal leaps were possible and could be part of our vocal play. The therapist’s octave, following her leap of a tenth, immediately communicated his musical acceptance of her initiative and his encouragement. All these vocal responses, and those that followed, were extraordinary because, as we subsequently learned from her teacher, she had difficulty joining in songs in the classroom. Unable to enunciate the words readily in the rhythmic settings and tempos the songs required, she could not place them satisfyingly on the tones of the melodies and would soon give up trying. But in this improvisational vocal situation, where she was responding to singing and music that was responding to her, she could sing with intelligent purpose. No extraneous verbal demands were being made on her; only the words she had spoken were being sung — and sung in the tempo range in which she had spoken them. In this freedom of singing she spontaneously and self-expressively pitched her voice in a high register, reflecting tones in the Mixolydian mode that was being used. It was so delightful that this child with no experience of free personal mobility should pitch her voice higher and higher in tonal space, laughing and enjoying an experience of vocal flight. Anna Notation Example 5 Her brief beating response to the therapist’s singing “Good morning” early in the session had indicated rhythmic sensitivity and it was to explore this further that he led her attention back to the drum. She began beating at 105 beats per minute (bpm) and slowed to 90 bpm before stopping; he followed her tempo. In the next short spell of beating, she was sensitive to the ritardando he made. None of her beating was sustained. When she stopped, he sang “Good morning” and “Hello” to see if she would either beat to these words or sing them, but she did not respond — she sank back in her wheelchair and became still, her head bowed. This was to happen several times in the early sessions, particularly after periods of active response. She may have been withdrawing briefly, or perhaps having a petit mal seizure. Her quiet stillness commanded respect. Yet whatever the cause of her outer inactivity, the therapist felt the need to maintain the flow of creative experience. She had revealed how alive she could be to music, and the immediacy of her sensitivity to tone. He appealed to her listening — taking her greeting words “Good morning,” which had been the underlying link throughout all our interaction, and continuing in the Mixolydian mode, he improvised to hold

her listening attention. The theme of a Good Morning Song came into form: Anna Notation Example 6 As she remained quiet, the therapist experimentally played in a pentatonic scale, also on F# — possibly the contrast and the new experience would stimulate her. The repetition of the musical shock of a stressed dissonant chord (not in the pentatonic tonality) aroused her; she quickly recognized this as a kind of musical nudge, a call to action, and beat again. [Improvising in pentatonic scales is addressed in Part Five: Developing Musical Resources (p. 471ff.).] During the next five minutes, we continued to encourage Anna to be active, particularly in beating the drum. Having been told that she was left-handed we focused on the use of this hand. To begin with she did not seem to find much meaning in beating, and perhaps the unaccustomed physical effort was difficult, for her responses were scattered and she made few attempts to sustain beating. Most of the periods of beating lasted less than five seconds. The effort of initiating beating produced a first tempo of between 100 and 115 bpm, but she appeared unable or unmotivated to sustain this level of energy and her tempo quickly dropped to about 80 to 90 bpm and she would stop. When she beat with her hand alone, unencumbered by a mallet, she beat passively for about ten seconds each time. Several improvisational techniques were tried to make beating the drum more meaningful for her, but they had limited effect. The therapist then concentrated on repeating rhythmic phrases and accents to give impetus to her beating. Several times she sang “I a’ school,” sometimes at random, sometimes in response to his singing. Her singing lacked the communicative intent she had shown earlier. There were two further periods when she became quiet and still. To add a new element of stimulation the therapist suggested offering her a small cymbal: Audio File: Anna—Excerpt 2 (Session 1) The therapist plays softly while the cymbal is brought. The cotherapist holds out an 11" crash cymbal in front of her; he takes her left hand and briefly guides her beating to demonstrate the cymbal’s sound and position. She waits while he attaches it to the drum stand then [0:20] tries to beat it by herself.She has difficulty in determining its position and managing the beating, but with encouragement she perseveres and succeeds in beating it about twelve times. The therapist first fits his music to her beating, then sets a definite beat in a rhythmic, detached style in the Mixolydian mode. [0:41] She feels to her left, searching for the drum. The cotherapist indicates the position of both instruments by leading her mallet first to the drum, which is slightly to her left, then to the cymbal, directly in front of her left arm. [0:45] She beats independently for 32 seconds, choosing the cymbal and making the effort to maintain a basic beat in the tempo of 105 bpm. The therapist repeats a clear rhythmic statement to provide a secure basis and rhythmic impetus for beating. Toward the end of this beating period, her effort falters and there are a few beats at 70 bpm. After a pause, she beats briefly at 95 bpm.

[1:29] For relaxation, the therapist sings “Good morning to Anna.” She appears to check an impulse to reply “I a’ school” and instead says “I a’ gyassmm.” Having difficulty understanding her word, the cotherapist asks her to repeat it. Instead, obviously understanding his difficulty, she replies with “school,” from which the cotherapist deduces that she has said “I a’ classroom.” [1:54] She confirms this. [2:02] The cotherapist gives her a lightweight mallet and positions the fingers of her left hand into a firm grip on the handle. She beats energetically for 24 seconds. Her tempo starts at 110 bpm and drops to 100 bpm. The therapist continues in the Mixolydian mode, changing the rhythmic pattern to leave rests — beating through regularly placed rests could help emphasize for her the experience of maintaining the continuity of the basic beat. All his playing is detached and forceful. [2:32] When she shakes the stick aimlessly, the cotherapist coaxes her to resume beating. The therapist increases the impelling drive of his music by subdividing the beat into triplets, and then eighth notes. She beats almost continuously for a minute, obviously wanting to use both instruments; she is not discouraged when some beats miss their mark. Her tempos fluctuate between 80 and 110 bpm. The therapist sings and repeats “Good, Anna. Good, Anna. That was good, Anna!” Commentary on Excerpt 1/22 The cymbal’s sound obviously attracted her and stimulated her to make a new physical effort and prolong it. As she repeatedly renewed her impulse to beat, she showed some awareness of the relationship between her beating and the pulse of the music. She also appeared to be developing an awareness of, and enjoying, the active, purposeful rhythmic movement of her body. The vigorous music and rhythmic techniques used to intensify and energize her beating had the effect of dramatizing her effort. Through this, our rhythmic coactivity could begin to be mutually communicative.2 After her exertion she was quiet once more. The therapists sang and chanted, repeating playfully and with rhythmic emphasis words and concepts she had introduced: “Anna came to school, Anna beat the drum, Anna in the classroom was very good.” The therapist sang “I a’ school,” extending “school” with florid embellishments. She and the cotherapist joined in with “I school”; she then said “I going to go”: Audio File: Anna—Excerpt 3 (Session 1) The cotherapist sings in falsetto. “I a’ — I going to go.” Anna speaks with musical inflection. The therapist answers, “You’re going to go — ” and, following the cotherapist’s prompt, extends the thought, “ — to — school!” [0:14] Lively vocal interplay develops: Anna sings a succession of descending slides with the therapist answering imitatively. He encourages her by singing descending slides of his own that take on a florid style. They freely exchange the words “going to go” and

“school.” All her singing is in the tonality. [0:43] The therapist’s melodic phrases are increasing pentatonically formed. Anna laughs with delight at the musical humor they express and [0:52] sings “school” on B, A#', A, and E#' above the staff. [1:03] She sings, “Going to go!” as an affirmative melodic statement on F#'— G#'— F#'— C#'. [1:09] The therapist repeats her phrase and develops it into a song; she responds by holding a high C# from which she makes a descending slide. [1:30] After the fourth phrase the cotherapist inserts “to school” on the tonic F#", intentionally holding “school” and making a slight crescendo as a link inviting a repetition. Anna seems to recognize the musical need of the moment, and initiates the repetition. She improvises the first and third phrases, singing antiphonally with the therapist. After another high tone and a descending glissando, she sinks back in her wheelchair. Commentary on Excerpt 3 She had been in this unfamiliar situation for more than fifteen minutes, involved in totally new experiences with two people she did not know, and was probably feeling the need to get into her familiar daily routine. “I going to go” implied this; her musical sensitivity prompted her to speak these words in the tonality. When her concept “school” was linked to it, the idea was expressed completely for her and she could feel understood. That these concepts were put together melodically in a phrase that ended with an ascending leap on “school” — as she had sung it — engaged her immediately; her descending glissandos directly expressed her recognition and pleasure. The vocal play and humor that ensued must have been liberating and given her the confidence that drew her again into interresponsive singing. From the last tones of the therapist’s florid repetition of “school,” she took the tones with which she made “Going to go!” a clear melodic statement. Musically and expressively, this demanded a melodic answer and led into the improvisation of the song. Anna’s participation in it makes an illuminating study of musical sensitivity. Anna Notation Example 7 After the song, she listened quietly as the therapist improvised, then again declared “Going to go.” As he repeated the song she tried, in a rather weak voice, to sing it with him but gave up the attempt. She was then inactive except for two short bursts of vigorous regular beating. The therapists sang Goodbye! (Playsongs 1) to her. The session had been twenty-two minutes long. Commentary on Session 1 This was a revealing and developmentally significant first session, Anna disclosed important strengths and latent abilities. •

Vocal Spontaneity, Self-expression, and Interresponsiveness. In her singing, Anna

showed a vivid sensitivity to music and the will to use it self-expressively. She had listened actively, attentive to the therapist’s singing and playing, and had placed most of her responses — at first carefully, then impulsively — into the melodic phrase structures as they evolved. The strength of her musical responsiveness and will within such severe conditions of restriction, deficit, and developmental disability was impressive and moving. Her presence was bright and alive. Her pertinence, intelligence, quickness, humor, and confidence all indicated inherent capacities she could normally have little opportunity of using so directly, and hence of developing. • Finding the Basic Beat; and the Purposeful Use of her Left Arm. Her capability for rhythmic expression with her left hand developed progressively during the session. Her natural rhythmic response was drawing her into beating the basic beat, the fundamental component of rhythmic energy and structure in music, and universally the basis of mutuality in music making. At first her use of the instruments was impulsive and discontinuous, her rhythmic responses seeming naturally reflexive rather than intentional. But the conditions necessary for her to begin to develop an awareness of the basic beat and the skill to beat it were there in the reality of the activity, largely through the rhythmic placement of her impulsive responses and the vigor and immediacy of the music improvised to meet them. This first stage in perceptive and physical development leading toward beating the basic beat with conscious intention, is termed the incipient stage — a stage common to many children who are just beginning to discover this experience and skill. By midway through the session, her increasing motivation had extended her ability to sustain a beating effort to almost a minute. In doing this she had begun to experience the basic beat through successfully asserting her will to gain some control over the use of her left arm. Her efforts must have resulted directly in a sense of musical-physical satisfaction in achieving rhythmic bodily expression. She was moving from the incipient stage of discovering the basic beat into the more conscious and controlled stage of actively finding it.3 The tempo range in which she beat most consistently was 80 to 115 bpm, although she had very briefly beaten as fast as 120 and as slowly as 70 bpm. Interestingly, the tempo of her speech was also in a moderate-slow range of 80 to 95 syllables per minute. A rating of Anna’s first session illustrating the use of Scale II. Musical Communicativeness appears as Appendix A. Following on the promise of these initial explorations, she was scheduled for two twenty-minute sessions weekly. Session 2 As Anna was wheeled into the room she recognized her music the moment the therapist began playing and singing. She joined in “I at school” and Going to Go to School. She would not allow her helmet to be removed. The therapist based much of the session on Going to Go to School. When he introduced a variation: I’m going to drum at school, she attempted the word “drum,” pronouncing it “draw.” Later, she enjoyed vocal play on “I drum — at school.” Most of her singing was accurately placed and again, with pleasure and laughter, she sang high tones and descending glissandos. The therapist deliberately left spaces in the music for her to initiate her own improvisations and singing of words. Her singing was more careful, less impulsive than

in the first session, and she did not sing quite as much. She beat the drum for short periods and, as the therapist played her songs and improvised in her tempo range, she joined him in the basic beat several times. Twice, she handed the stick back to the therapists. Her beating was in the same tempo range. She made one vocal response to our singing of Goodbye! Session 3 Now in the second week of therapy, the therapists continued to start with singing. She sang “I school” and “morning” in the Good Morning Song. Again she insisted on keeping her helmet on. To lead her singing further, the therapist began to develop the “Good morning to Anna” phrase, but her interest was turning to the drum: Audio File: Anna—Excerpt 4 (Session 3) The therapist sings “Good morning to Anna.” She reaches out to find the drum, then beats it with the palm of her left hand. She maintains a tempo of 100 bpm, beating in a moderate dynamic to extensions of the “Good morning” phrase. As a ritardando and diminuendo are made, she immediately slows and stops. He returns to singing “I at school”; she sings “school” on the repeat. She became quiet and did not respond to any of her music for singing. When given a mallet and shown the position of the cymbal, she beat it firmly. To support her the therapist first improvised in the pentatonic: Audio File: Anna—Excerpt 5 (Session 3) The therapist plays and sings in a pentatonic scale on F sharp; he fits his music to Anna’s cymbal beats. He moves into a Middle Eastern idiom, also based on F sharp (F# G A# B C#' D' E' F#') (see notation on p. 303ff.). He chants nonverbally to an ostinato to emphasize the flow of the music and draw her along with him. He adapts his playing and chanting to her beating. She concentrates on beating a basic beat; she uses the drum, then cymbal, and then drum again. At her slowest she beats at 70 to 80 bpm. Her intention to sustain beating causes her several times to renew her muscular effort — this happens in impulses that increase her tempo to between 90 and 105 bpm. Commentary on Excerpt 5 Anna’s ability to beat the basic beat directedly continued to develop. As she sustained her beating she progressed from the stage of finding this experience and ability to that of consciously establishing it.4 In this session she achieved this level of awareness and skill with her left hand in her limited tempo range. She was further realizing her inherent sense of rhythm, and bringing it to expression in an increasingly purposeful use of her left arm and hand. The therapist’s use of an energetic improvisation in a Middle Eastern scale arose intuitively

from his wish to create a music that would match and meet the quality of her concentration on the physical effort of beating. This idiom has a character and purposefulness that he felt would suit her temperament; its mood and unfamiliar intervals could also arouse her attention. It is predominantly a dance idiom, music for rhythmic movement — its rhythmic drive and repetitions could be emotionally and physically stimulating for her. Its freedom from the requirements of harmonic progression, and the freedom with which accentuation could be used would reinforce her physical effort. At the same time the Middle Eastern idiom offered the possibility of bringing a new musical world to her dawning experiences of self-discovery and achievement in musical action.5 After the successful basic beating, he returned to her music for singing. She introduced the word “classroom”; as this was sung freely many times, her pronunciation improved. There was humor in this vocal play, and she seemed rather close to us. Her relationship with us thus far had been solely in musical activity. She had not met us in any other circumstance; she did not know our names. The cotherapist felt the time had come for a personal introduction. He said “Anna, give me your hand” and placed her hand in the therapist’s saying “Anna, this is Uncle Paul.” The therapist replied with a variation of the “Good morning to Anna” phrase: “Uncle Paul says good morning.” The cotherapist answered for her: “Anna says good morning —to Uncle Paul, Uncle Paul, Uncle Paul!” —repeating the name several times, and moving her hand strongly in the rhythm of two eighth notes and a quarter note as he made a ritard with a crescendo. She laughed and chanted it emphatically with him. Then he introduced himself on an ascending fifth “ — and Clive.” Smiling, she leaned toward him and patted his hand. We led our introduction into singing “Anna’s in the classroom with Uncle Paul and Clive.” She half-sang “classroom” several times and the therapist wove this word into sentences using words and phrases with which we knew she was familiar. At one point she said “I going to classroom,” pronouncing “classroom” quite clearly. She recommenced beating the drum and held a steady beat to an improvisation. The therapist sang Going to Go to School to her beat, then reintroduced the Middle Eastern idiom. Anna found the cymbal a little to the right of the drum, and used both instruments. Since her beating was going haphazardly from one to the other, we worked to increase her consciousness of them by singing their names as she beat them: Audio File: Anna—Excerpt 6 (Session 3) She beats the drum and cymbal with her left hand. In a Middle Eastern idiom the therapist sings “Anna beats the drum, Anna beats the cymbal,” etc. She half-sings “I a’ classmm.” He responds “Anna’s in the classroom for music!” leading energetically back into the Middle Eastern. She beats the drum and cymbal vigorously. The cotherapist takes her hand and singing “This is the cymbal! This is the drum!” leads her beating to each instrument in turn. Commentary on Excerpt 6 In the working moment, this opportunity presented itself as a way of bringing some rudimentary form into Anna’s basic beating. It could be important for her to know the drum

and cymbal by their names and possibly come to use her left hand with more directedness. We also wanted her to become more purposefully aware of the contrasting timbres of the instruments and to distinguish between their positions in space. For the rest of the session she continued to respond by beating rather than singing, although she joined in singing briefly at the end of Goodbye! Session 4 She arrived passively huddled in her wheelchair, her head down, her eyes closed. The session began in a warm, gentle mood: Audio File: Anna—Excerpt 7 (Session 4) The therapist sings “Good morning to Anna.” She opens her eyes, smiles, and sings her name. After a repetition of “Good morning,” she sings a new idea: “Tick a’ school” ([drum] stick at school). The therapist explores her singing; she briefly participates in singing “school” to different harmonies. She does not respond to direct encouragement but says “Anna go to school.” As he sings a “You are going to school,” variation of Going to Go to School, she responds at the ends of the phrases. [1:33] She introduces “classroom”; some play on “classroom” develops. When the therapist attempts to improve her pronunciation of “room” she responds strongly with “oomm.” ([2:18] the cotherapist whistles quietly in the harmony.) In the gentle antiphonal play Anna carefully constructs a sentence: she says, “I draw [drum],” then, after the therapist’s response, completes her statement with “at school.” The vocal play is relaxed and gentle. Commentary on Excerpt 7 There was a quiet, friendly ambivalence about Anna this morning. In her singing she clearly asked for the stick and later for the drum, yet the question hung in the air: was she suggesting that she be taken to school? However, when the therapist sang her words “Anna go to school” back to her, she responded immediately by singing. She seemed to be needing time and repetitions of the familiar materials to re-enter the world of musical interactivity we were offering her. We repeated greeting her individually and personally in the Good Morning Song as we had in the previous session. She listened and responded as we sang to each of us in turn — the rhythm of “Uncle Paul” amused her — then joined in with some animation as the cotherapist took her hand and sang his greeting. She was still unwilling to have her helmet removed. When we resumed the structured work on the drum and cymbal, she could just begin to turn her beating from one to the other as we sang their names. The cymbal attached to the drum stand was proving to be too small and too close to the drum for this work so we replaced it with an independently mounted, 16”

Zildjian thin crash cymbal, placed in front of her, a foot or so from the drum. The cotherapist led her left hand to it and we continued work on her use of the two instruments. At times her beating of the instruments followed our singing, at times we followed her. She was obviously intrigued with the stronger sound of the larger cymbal. Later, the therapist introduced a variation of Going to Go to School: Audio File: Anna—Excerpt 8 (Session 4) The therapist plays and sings Anna will go to school. She listens through the first phrase, determines the position of the drum during the second phrase, appears to say “music,” then carefully beats the basic beat through the third phrase. He adjusts his playing to her; her response gives the impression that she is listening intently and the melodic line is directly influencing her beating. Her tempo is mostly between 80 and 100 bpm. He holds back the final resolution, impelling her to sing. Antiphonal vocal play on “school” ensues. Commentary on Excerpt 8 Her careful beating to the third phrase was evidence that she was beginning to connect her left-hand basic beating skill with her memory — her mental image — of the song. After the vocal play we began to explore her use of her right arm. The cotherapist moved the large cymbal to her right, put a lightweight mallet in her right hand, and encouraged her to beat. She found the mallet difficult to hold and beat the cymbal intermittently. The therapist sang and played in a pentatonic scale to support her. In between her short periods of beating, she freely answered his singing, and her gains in vocal control were noticeable. Experimentally, we developed a simple song-game with some hand-over-hand guidance of beating the drum with the left hand then the cymbal with the right — with the intention of beginning to extend her differentiation of the instruments to an increased awareness of her arms. During the ten minutes of work with the two instruments, the cotherapist guided and supported her closely. Goodbye! concluded the session, she sang the word “goodbye” twice. Review of Sessions 1–4 Anna’s sessions were now taking a form. A structure was evolving in which she and the therapist could work freely; we began with singing, alternated song with drum and cymbal beating, then ended with song. The repertoire of music created through our interaction in these first sessions had become the basis for, and substance of, much of the ongoing work. The song materials had mostly originated in her singing responses and the therapist’s extensions of them: the “Good morning to Anna” and “I at school” phrases, the Good Morning Song, and Going to Go to School. These were obviously living firmly in her memory; she appeared to be identifying with them and responding confidently to them. Goodbye! which did not arise from her spontaneous singing, but was a precomposed song introduced to bring a meaningful sense of closure to the sessions, was also beginning to become part of the vocal repertoire.

The idioms in which the therapist was improvising to motivate and support her use of the drum and cymbal were mainly the pentatonic, for its tonal freshness and energy, and the Middle Eastern, for its mood, purposefulness, and drive. Both idioms had the advantage of being new to her and without extrinsic associations, hence there was the greater likelihood that she would directly associate them with fulfilling experiences of self-discovery and growing capability. This music would then be directly carrying associations for her that were intrinsic to the therapy process.. The explorations of these first four sessions were indicating these goals: •

Vocal: To continue to encourage her singing, both for musical purposes and for its possible effects on the development and use of speech. Musical and speech goals combined practically at this stage because most of her singing consisted of words, and when she introduced a new statement it was usually either sung, or inflected in the tonality. Our intent was to continue to foster the qualities and aspects of response she had already manifested: spontaneity, attentive listening, accuracy of pitch placement, melodic and harmonic perceptiveness, rhythmic certainty, quickness and freedom of response, confidence, and creativity, focusing when appropriate on aspects more directly relevant to speech: voice quality, communicative intent, expressive variety, memory, conceptualization, expressive independence, vocabulary, pronunciation.

•

Instrumental: To encourage her to use the drum and cymbal in order to lead her into realizing whatever latent rhythmic capabilities she possessed, and so into establishing, through her active participation, as much as possible of a range of new musical and physical experiences and skills. Because her bodily means of rhythmic expression was limited to her arms, this could possibly be of unique importance to her and lead to a new appreciation of body image — an active and positive sense of herself in her body. Progress in this direction had already begun with the left hand. The instrumental work with Anna would therefore be practically aimed at continuing to address a variety of goals:  extend her rhythmic skills  deepen her overall involvement in music and musical activity  increase her bodily awareness and muscular control to bring her into experiences of rhythmic movement and so into finding enjoyment and confidence in using her body  bring her capacity for musical concentration into fuller physical expression  link a sense of physical achievement to her musical satisfaction  bring a range of expressive capability into her arm(s) through developing control of tempo and dynamics  lead her into a close musicing relationship with the therapist

We recognized that work in these areas would continue to be both explorative and adaptable; processes of development would need to be monitored closely to recognize and enhance new skills as they appeared. The documentation of vocal and rhythmic responses through the analysis of the session recordings would be necessary to provide the clinical

foundation for ongoing improvisational practice.6 Session 5 We were now in the third week of therapy. The session began in a quiet and friendly mood that was expressed in the Good Morning Song and playful vocal exchanges on “school” and “classroom.” As she beat the drum and small cymbal with her left hand, she became increasingly energetic. Then her responses became confused, scattered, and somewhat evasive; she beat for only short periods and sang sporadically. The therapist tried to meet her activities, answer them, and extend them, but it became impossible to engage her purposefully. About halfway through the session, in an attempt to find and give a direction to the work, he reintroduced the Middle Eastern idiom, this time in a thoughtful, more melodic style in the middle and lower register: Audio File: Anna—Excerpt 9 (Session 5) The therapist sings “.. music.. “ Anna half-sings “.. a’ school.” The therapist responds “Music in school, for Anna in school.” He begins to improvise in a Middle Eastern idiom. Anna Notation Example 8

Anna listens, then initiates chanting rhythmically. After some seconds she firmly sets a slower tempo, which the therapist follows. Her style of chanting suits the music. She is briefly silent, then leads the improvisation back to a faster tempo. When she stops chanting, she tugs at the strap of her helmet, indicating that she wants it taken off; the cotherapist removes it [not audible on the recording]. Commentary on Excerpt 9 This was a remarkable response, her chanting fitted the Middle Eastern style the therapist was using and echoed the chanting he had done in the third session when he was supporting her concentration on achieving basic beating. In that session, she had been at her most active yet — for more than three and a half minutes — in response to invigorating Middle Eastern music. He had not used this idiom in the fourth session because he had concentrated on encouraging her singing, and had used her songs and the pentatonic for her drum and cymbal beating. Now, seven days after first experiencing successful basic beating to the Middle Eastern idiom, she heard it again, and immediately took it up and chanted her memory of the style of this music and her feeling for its quality. She also asserted her presence firmly in setting the tempo she wanted. That she indicated after her chanting her readiness to have her helmet removed, communicated the sense of confidence she gained from being active in a Middle Eastern idiom, and how much at home she felt in it. Because of her blindness, her auditory environment was

immensely important to her, a reality that critically calls into question the effect of the use of musical idioms in music therapy with visually impaired children. In some way, the Middle Eastern idiom, first improvised to support her will to participate physically in music, had taken on an identity factor in her relationship to all the events of our interactivity and intercommunication. As long as she kept her helmet on she was always ready to leave, not yet fully sure of the situation, neither totally trusting us nor even the natural forcefulness of her own responses. But with the removal of the helmet by her own choice, she was committing herself more completely to the adventures of active musical participation with us. The helmet came off early in all subsequent sessions. Toward the end of the fifth session, after working with her songs and on her left-hand beating, we again gave her the large cymbal for her right hand. This time, raising her arm high, she beat with big impetuous movements. Her determination to beat over-reached her ability to control her movements and her sense of the cymbal’s position. It was necessary for the cotherapist to hold the cymbal by the stand and move it quickly to intercept her impulses to beat and protect her from hitting her hand on the cymbal’s edge or on the thumbscrew that fastened it to the stand. She seemed to be bursting with an urge to be active — to the extent that she was disregarding her own safety. At one point she made an explosive, gesture with her whole body that was expressive of impatience and frustration. After this, her cymbal beating became somewhat calmer. The session ended, as usual, with Goodbye! Audio File: Anna—Excerpt 10 (Session 5) Anna comes to the end of a spell of beating the large cymbal with her right hand. The therapists sing Goodbye! Anna listens, then responds to the deliberate pauses and carefully sings much of the song. Commentary on Excerpt 10 Her response to this song had been gradually increasing each session. At the end of the second session she had sung “bye” on the final “goodbye”; in the third, “an’ goodbye”; in the fourth, the final “goodbye” both times. Now, at the end of the fifth session, the pauses induced her to sing “goodbye” and the complete last phrase. This was the first time in therapy that she sustained her singing of a precomposed song — in contrast to free vocalization — with care and confidence. The song was in a slow tempo and its simple words had expressive meaning for her in the context. Although the melody as written finishes on the fifth, Anna chose to close the song more conventionally by singing the tonic. We were struck that she sang “Oh thank thee and goodbye!” She did not come from a Quaker family; why then her spontaneous use of the second person familiar pronoun? She could be familiar with “thee” only from attendances at religious services: was she associating aspects of her experience in music therapy with the seriousness, closeness, and mood of reverence she felt during religious observances? Session 6

Anna sang immediately as the session began. The therapist worked to get her to speak or sing the words “music room.” We wanted her to know the room in which we made music together by its correct name. These words were new and difficult for her, and her reluctance to attempt them showed in her playful stubbornness. She was also still adjusting to the fact that the session was taking place in a classroom in the school building she knew — and at the time when she normally she would be in school — yet we were giving the room a different name. Audio File: Anna—Excerpt 11 (Session 6) Anna half-sings “I a’ classoom.” The therapist repeats this, then sings “Anna’s in the music room.” She replies “I a’ classoom.” He continues singing “Anna’s in the music room.” She counters this with “I a’ classoom” several times before attempting “I at music room.” After a little free singing on “school,” she half-sang: “I go to school, I draw” — asking for the drum. We placed it to her left, and to a Middle Eastern improvisation she firmly beat the basic beat. Then the cotherapist beat the cymbal to remind her that it was there, and to her right. He once more told her that the drum was for her left hand and the cymbal for her right. Again, the cymbal captured her attention. She was more sure of its position and height, of how to use the mallet and measure her strength. She could beat it for only short periods but her beating was firm and gaining control: Audio File: Anna—Excerpt 12 (Session 6) Anna beats the drum strongly and steadily with her left hand at 85 bpm. The therapist plays in a Middle Eastern scale. When she pauses, he increases his tempo to 105 bpm. The cotherapist briefly beats the large cymbal [0:22] with the improvisation to bring her attention to it. He then takes her hands [0:29] and leads them to the instruments, telling her that the left is for the drum and the right for the cymbal. At [0:35] she concentrates on beating the cymbal. To give more support to her beating effort, the therapist plays in the middle and lower registers. The tempo of Anna’s cymbal beating varies between 90 and 110 bpm as she repeatedly renews her effort to beat it with her right hand. She is obviously keenly involved in extending her basic beating skill to her right hand. Acknowledging her achievement, the therapist improvises on “That was very good Anna: that was very good!” We began to structure her use of the two instruments, freely alternating “Anna can beat the drum!” and “Anna can beat the cymbal!” with the cotherapist occasionally guiding her hands. This was a development of the differentiation between drum and cymbal on which we had worked with her left arm in the third and fourth sessions — but now with the larger purpose of encouraging her awareness and purposeful use of both arms. She focused intently on her use of the instruments. Halfway through the session she took the control of her right-hand beating further: She was beating the cymbal well to an improvisation when the therapist introduced her name and sang it repeatedly as a two-beat pattern. In the rests between the repetitions she concentrated on beating the rhythm of her name, and succeeded twice. She then reverted to basic beating. The music led into Going to Go to School:

Audio File: Anna—Excerpt 13 (Session 6) The therapist plays Going to Go to School without singing it. She beats the cymbal with her right hand, responding sensitively to the phrase structure. Four times, her beating starts in tempo and on the beat. She finishes precisely on the last note of the accompaniment. [0:39] She listens as the therapist plays the “Good morning to Anna” phrase and as he starts the Good Morning Song. She beats the cymbal with the song, again beginning in tempo and on the beat. [1:29] The cotherapist encourages her to sing the song; then both therapists urge her on. She begins tentatively. [1:53] She sings the Good Morning Song assertively, and initiates beating the cymbal as she sings, firmly timing her beating with how she phrases her singing. The therapist fits his playing to her beating. Commentary on Excerpt 13 These were two significant developments: (1) She actively connected her right-hand beating skill with Going to Go to School — as she had her left hand in the fourth session — and with the Good Morning Song, and (2) for the first time she attempted to integrate singing and beating, and was able to achieve this. Her total concentration and the sheer effort of will through which she mastered this coordination were deeply impressive. It was noticeable in this session that her right hand, which she used less than her left in daily life, was becoming equally free in musical-rhythmic expression. Moreover, she worked with sustained concentration for seventeen minutes; there was no withdrawing into quietness, no sign of fatigue. Session 7 In this session, Anna’s beating skills continued to advance. After we had all spoken and sung our greetings, we asked her where the drum and cymbal were. She knew where to reach for them. She beat the cymbal confidently for about a minute, then felt again for the drum and, as the therapist improvised lightly in a Middle Eastern idiom, used both instruments briefly. For five beats she achieved a coordinated alternation of her hands, the left on the drum, the right on the cymbal. Anna Notation Example 9 She beat the cymbal softly for some moments longer and then said “Anna go to music,” offering us the important word “music,” that she had been led into attempting to say for the first time in the previous session. He pronunciation was indistinct and at the time we did not understand what she had said. Thinking that she had said “knit” we sang this back to her. Her mood seemed confused, and she was listless and withdrawn. When we asked her to continue

beating she quietly chanted “No,” and then “No more drum.” The therapist picked up on her ambivalent mood by singing teasingly “No, no, no — yes, yes, yes — ” repeating and varying this idea until she beat the cymbal briefly again. But she was unwilling to continue with the drum and cymbal, and intentionally dropped the mallets to the floor. We made a game of her resistiveness, singing, to the melody of Going to Go to School, “Anna has dropped the sticks!” and “Clive has picked up the sticks!” She was drawn into singing with us and for several minutes we played and sang a stick-dropping game. She kept the game going by repeatedly asking “One more!” As we worked to regain her cooperation and restore her confidence, she became less scattered and evasive. The therapist accepted Anna’s need to divert our interactivity away from drum and cymbal beating into the stick-dropping game and provided the music for it. However, he also had the intuitive urge to bring to her the stimulation of a particular kind of energetic tonal brilliance, and several times in the session began lively treble improvisations. After she had sung “Clive has picked up the sticks!” with particular care he responded to the playfulness of the situation and launched into a bright, invigorating improvisation. With both hands in the treble, he played a succession of rapid descending scale passages, glissandos and trills over an ostinato of pentatonic intervals. This produced a ringing shimmer of tonal energy. He sang her name on high melodic phrases; the cotherapist added his falsetto and played the cymbal softly. The impact of this music seemed to energize her and lift her out of her state of indecision. When we paused she demanded, “One more!” With encouragement, she sang these words, then shouted them assertively. The therapist took the energy of our interaction directly into an improvisation in a Middle Eastern idiom in the middle and lower registers. Its warm sonority was in distinct contrast to the tonal brilliance of the preceding treble improvisation; its stable thematic character seemed to focus her and give her musical direction. When she began to beat the cymbal; her beating was stronger and steadier. She beat the drum with her left hand, equally vigorously, and began to use the two instruments freely. Then she actively directed the coordination of her hands in alternate beating. Again, her face showed intense concentration. Audio File: Anna—Excerpt 14 (Session 7) The therapists sing “Anna can beat the drum!” and “Anna can beat the cymbal!” She follows, beating freely on the instruments. She coordinates left and right arms in beating single beats alternately on drum and cymbal at 92 bpm. She maintains this for 9 seconds. She pauses, then recommences beating alternately for 7 more seconds — therapist moves into the Middle Eastern idiom. The therapists celebrate her achievement. Her effort was impressive and we did not pursue alternate beating further in this session. In the singing that followed she showed an eagerness to sing “music room,” and her pronunciation of “music” improved. She reintroduced the stick-dropping game and intently worked on singing the new words “Anna has dropped the sticks,” and “Clive has picked up the sticks.” In Goodbye! she was singing “bye” as “byeeeee.” When the therapist asked her (through demonstration) not to sing it that way but correctly, she carefully and accurately imitated his singing. She was becoming musically teachable.

Commentary on Session 7 In this session Anna again demonstrated how deeply committed she was to all the activities that were developing. Her keen involvement in acquiring and mastering new means of musical self-expression was forcing aside the constraints imposed by developmental disabilities. She was obviously finding a needed fulfillment in asserting herself in expressing her presence through the skills she was acquiring. Early in the session she had briefly shown an impulse to coordinate her arms in alternate beating. This had appeared spontaneously and signaled that a natural process of balanced bilateral bodily response to music was surfacing. While this would be the logical next step in the course of Anna’s therapy, its new emergence seemed to disorient her at first. For some minutes she seemed to be in a state of confusion, her statement “no more drum” expressed her holding-back hesitation. She was ambivalent, charged with an impetuous will to freedom of self-expression, yet not knowing what to do next. The therapist answered her ambivalence by teasingly singing on “yes” and “no.” Her dropping of the sticks was a direct form of resistiveness, which we decided to treat playfully as a means of communication. That we made a singing game of it transformed her resistiveness into vocal participation — and also communicated to her our acceptance and active support. The therapist’s penetrating stimulation of a vigorous improvisation in the treble then seemed to refresh her and remotivate her to use the drum and cymbal. As she did this to a forceful, supportive improvisation in a Middle Eastern scale, she was able to assimilate her impulse to beat alternately — and then even to reinitiate it, sustaining it for a total of sixteen seconds. The deepening of her overall musical involvement appeared to be releasing a latent developmental necessity. Moving both arms alternately in rhythmic coordination was a new pattern of motor action for her — a fundamental operation of her body she had never before had the opportunity to experience.7 Complete Review of Audio Files for Session 7 Note: At this point, the reader has the option of reviewing the comlete audio file of session 7 and follow the full index below, or to proceed directly to session 8. Audio File: Anna—Excerpt 15 (Session 7 complete) In this index, the main characteristics of Anna’s drum and cymbal beating are noted and tempos are timed. All the numbers in the text of the index refer to tempos in beats per minute. Abbreviations are used: cym (cymbal), LH (left hand), RH (right hand), imp (improvisation), ME (Middle Eastern), HOH (hand-over-hand), BB (basic beat), RP (rhythmic pattern), NV (nonverbally). The therapists are identified by the initials P (Paul Nordoff) and C (Clive Robbins); Anna’s name is not abbreviated to avoid confusion with the indefinite article. Song titles are also abbreviated: GTGTS (Going To Go To School), GMS (Good Morning Song), and GBS (Goodbye Song). 0:00 0:10

P sings the Good Morning phrase to her. GMS sung by P and C.

0:21 0:24 0:26 0:34 0:38 0:59 1:16 1:43 2:05 2:10 2:27 2:31 2:46 3:02 3:17 3:21 3:40 4:00 4:05 4:13 4:27 4:31 4:41

5:08 5:15 5:24 5:33 5:36 5:48 5:54 6:03

Anna joins in on “morning.” P stops singing to greet her with “Hello” — then asks her to say “Good morning to Uncle Paul.” She taps his hand and says “Good morning” softly. C prompts her to say “Uncle Paul.” She does. P sings the GMS — she partially joins in. Anna “I a school” on a high tone — P responds similarly, with free singing. GTGTS — P & C sing. Anna taps quietly on wheelchair — P includes “music room” in the song. Anna twice says/sing “I a classroom” — P repeats this and adds “Anna’s in the music room.” P asks “Where is the drum, Anna?” — Anna reaches out with LH and finds it. We both ask her “Where is the cymbal?” — she reaches with RH and finds it. C beats the cymbal once to motivate her attention. Anna beats the cymbal. C beats the drum HOH with A’s LH. — we briefly work on “Anna can beat the drum” and “Anna can beat the cymbal.” Anna beats cymbal. P sings on “la.” P moves into ME through dissonant cords (do they possibly suggest alternation?). Anna reaches out to left and right, determines the positions of the drum and cymbal then beats — and [3:29] for five beats, independently achieves alternating left and right arms on drum and cymbal. Her tempo centers on 95 bpm (see notation p. 73). P chants briefly, Anna pauses, then enters beating the cymbal rather softly in the slower tempo. C repositioning her hands for more beating on both instruments. Anna offers the words “Anna go to music.” Her voice is indistinct, C misunderstands and asks, “You’re going to knit?” P takes up C’s misunderstanding and sings this phrase. We ask her if this is right. 4:20 P sings on “la.” (She beats on her leg?) P “That’s not the drum.” C tries HOH to motivate her to beat the drum. Anna repeats “no” twice in a chanting voice. P begins to chant on “la” in ME. Anna says/sings “No more drum!” P responds to Anna’s ambivalent state of mind by chanting “No, no, no, yes, yes, yes, and alternating “no” and “yes.” He continues in a ME scale. C joins in. P extends the idea, “No Anna, yes Anna, no Anna, yes Anna, no Anna, yes Anna, no, no, yes.” Anna begins to play the cymbal, but seems to lose her orientation to its position. C tries guiding her verbally, “A little more in front of you.” Anna beats briefly. P begins a ME improve in the treble, playing 2 against 3. C beats drum. Anna deliberately drops her sticks. P sings, “Anna’s dropped the sticks.” 3 times, more melodic each time. Anna quite firmly “One more!” P sings “Anna has dropped the sticks” to the melody of GTGTS. Anna joins in the singing, her voice has a kind of gleeful, intent quality, and gets

6:26 6:48 6:53 7:03 7:11 7:15 7:21 7:29 7:44 8:01 8:13 8:20 8:36 9:17

9:50 10:05 10:26 10:38 10:41 10:55

stronger. P and C use repetition and pauses to entice and support her participation. She pitches her last “sticks” high, P sings with her — and as she holds her tone (6 seconds) she brings it down with his descending melismatic line. C picks up the sticks and sings “Clive has picked them up,” but Anna seems to want the word “sticks” and sings it (prompting C?). He responds and sings, “Clive has picked up the sticks.” Anna sings “sticks” after the end of the musical phrase. P repeats “the sticks” playfully and begins a lively somewhat pentatonic improvisation that becomes syncopated. C on cym. Anna interrupts the improvisation with “One more” wanting the stick-dropping game. We repeat it. P sings “sticks” on a descending melismatic melodic line. C continues leading the game, encouraging Anna to sing. She does. A responds to P’s descending melismatic melodic line with her own melismatic singing of “sticks.” C again asks Anna to sing, P accompanies and participates in the game, but is eager to resume and develop the stimulating high pitched improvisation he has in mind. A's singing is gaining in control and clarity. C asks her again to sing about Clive picking up the sticks. She does w/ prompting. As she sings “sticks” P plays a vivid affirmation, then takes off on a lively, stimulating improvisation with a ringing bell-like character — it is made up of trills, turns, and rapid scale passages. P repeatedly sings her name and “Anna can beat the cymbal.” C sings in falsetto, Anna seems to be surprised and intrigued by the music. She smiles with pleasure at what she is hearing. Cymbal beating by C. The improvisation continues with P singing her name. P brings the improvisation to a waiting ending. After a moment of silence Anna says “One more.”1 C encourages her to sing this. P sings “Anna wants one more,” to lead her. She sings this, then loudly calls it out. There is a brief exuberant play with “One more!” 9:48 P launches into a driving ME imp. C on cym fairly softly. Anna firm, strong RH cymbal beating begins impetuously at around 100 bpm, then slows to 80. P chants with the imp and rhythmically repeats her name. Anna firm LH drum beating, it feels controlled and with sustained purpose, 75 bpm slowing to 70 bpm. P tries to speed up her beating but she stays where she is. Her drum beating becomes indecisive and intermittent for 14 seconds; the music is softer. P, still in ME, singing, “Anna can beat the drum” A's LH drum beating resumes with a feeling of purpose at 88 bpm. It could be that Anna is calling for the treble improvisation to continue.

11:01 She makes a pronounced ritard to 55 bpm — P slows with her. 11:09 Anna RH cymbal beating, 92 bpm, P sings, “Anna can beat the cymbal.”

11:16 Anna LH 3 firm drum beats in the same tempo of 92 bpm. 11:19 Anna starts alternating right and left hands on drum and cymbal at 92 bpm. P changes his singing to “cymbal, drum, cymbal, drum. . .” She sustains her intention. 11:27 She pauses. 11:34 Anna resumes alternate beating at 90 bpm. 11:40 We sing and chant to celebrate her achievement and communicate our understanding of what she has achieved. She concludes the improvisation beating the cymbal firmly. 12:03 P quietly sings “Anna is in the music room,” she joins in and with direct encouragement sings the entire phrase. She makes a concentrated effort. We congratulate her. 12:29 Anna sings the phrase again. 12:37 P improvises a short “Good Girl!” idea. 12:44 P leads into GTGTS, Anna starts to join in but then remembers the stick dropping game. She says “one more,” and drops first one stick and then the other. 12:59 P changes to “Anna has dropped the sticks,” and Anna sings “stick” where it belongs and adds a playful little lift, a kind of grace note at the end. 13:08 Repeat, again she is enjoying using her voice playfully. 13:17 “Clive has picked up the sticks.” P puts the mood of relaxed playfulness into a musical vignette. 13:33 C invites her play the game one more time. “One more?” She drops the sticks. Play with the idea continues. 13:55 Anna enjoys using her voice with strength and freedom — she holds “sticks” for 11 seconds. 14:17 She sings/speaks “Clive has picked up the sticks.” This may be some of her clearest speech yet. 14:31 P improvises a “That was very good Anna” idea. C joins in. 14:52 She claps on C’s hand as we extend the idea. The idea is very lively and she goes with the accel we make. 15:20 Anna initiates her own playful vocal idea that contains “music room.” 15:36 P plays a playful, gentle melodic idea. C and Anna listen. 16:12 GBS. She joins in freely, more in the spirit of the song than in its structure. On repeat P sings “Oh thank thee and goodbye” as Anna had. 16:50 She does begin to sing the last note on the fifth, as she has heard it sung, then slides down to the tonic. 17:01 P works on Anna’s “Good byeee,” and she sings close to “Good baah.” 17:23 Recording ends. There followed a little conversation in which the therapist asked her if she liked her music with us. She answered “yes.” We helped get her coat and helmet on, and the staff helper wheeled her out of the room. A rating of Anna’s seventh session illustrating the use of Scale I. Child/Therapist Relationship in Coactive Musical Experience appears in Appendix B.

Anna sings her Good Morning Song as she arrives for the eighth session.

Session 8 Soon after beginning beating she beat alternately again, entirely on her own initiative, clearly demonstrating that the ability to coordinate her arms in alternately beating the basic beat had become newly established in her repertoire of musical skills. Audio File: Anna—Excerpt 16 (Session 8) Anna beats the cymbal briefly, then the drum. As the therapist moves out of triple time into the duple time of the Middle Eastern idiom, she begins to beat the instruments alternately. She beats the drum briefly, then beats alternately with large arm movements; therapists sing “Cymbal, drum, cymbal, drum!” to her beating. The cotherapist asks, “What do you want this morning?” Anna replies “Fun!” Commentary on Excerpt 16 She had progressively brought both arms independently into directed musical activity and now she had coordinated them. In her wide beating movements in space, in the alternate emphasis of left and right — drumbeat and cymbal crash — she must have felt a new satisfaction in the physical completeness of her involvement, in the balanced symmetry of her

body’s rhythmic activity. That she effected this development herself made it all the more satisfying and joyful for her — made it “Fun!” In these sessions in which she was achieving this coordination, a quality of independence with a definite element of contrariness was appearing in her choice of words for singing. For example, after she had said “Fun,” she went on to say “I going to school”; as this song was sung she deliberately sang “Good morning” instead (on tones in the harmony), and tried to continue singing this against him until she was drawn into singing “school” on a high note. She did not beat alternately again in this session. Her subsequent beating was listless; she seemed tired. It must have demanded a considerable effort to realize this new coordination of her arms. When we attempted to get her to beat the rhythmic pattern of her name again, she was not interested and said “No.” The therapist introduced the “No — Yes” idea of the previous session. She took it up immediately. Audio File: Anna—Excerpt 17 (Session 8) [0:01] Anna says, “No.” The therapist and cotherapist sing, “Yes, yes, yes, yes, no, Anna, no, Anna, yes, yes, yes.” (She deliberately drops her stick.) As she repeatedly half-sings, “No, no, no,” the therapist replies, “Yes, yes, yes,” accompanying both her singing and his responses, so giving their exchange rhythmic-harmonic form. [0:53] The therapist sings a short, “No, no, no, and yes, yes, yes, Anna can say —” refrain. She listens, then [1:01] makes a well-timed and well-placed entrance, singing, “No, no, no.” The repartee continues playfully. Anna laughs. The therapist, cotherapist, and Anna take their “contest” into a crescendoaccelerando. The therapist sings, “Yes!” operatically. Anna answers, “No, no, no,” on a high note. After another half a minute of vocal play and laughter, she called out an emphatic, “Yes!” Commentary on Excerpt 17 Again, we were able to transform her resistiveness into vocal interactivity. This was childlike vocal playfulness — repartee in its most primal form. She took up the rhythm of three beats and a rest and based her free and elaborate vocal responses on it, using her voice pertly and expressively. Although she kept her independence and most times sang her own tones in the scale, she sensitively sang with — and even appeared to anticipate — the harmonies of the improvisational accompaniment. Session 9 In this session the game of “No-Yes” repartee went further. She used more vitality and spoke assertively. Audio File: Anna—Excerpt 18 (Session 9)

As the therapists sing, “Anna’s in the classroom, beating the cymbal, beating the drum!” Anna half-sings, then says, “I a’ class-oom.” The therapist responds, ”Yes, yes, yes.” The cotherapist initiates the “No-Yes” game. She starts with “Yes, yes, yes,” and the therapists with “No, no, no.” When the therapist changes to “Yes, yes, yes,” she pauses and replies “No, no, no.” Session 10 The repartee advanced still further and was based on other words that had been important in her singing: “music room,” “classroom,” and “school.” She was perceptive and quick. Audio File: Anna—Excerpt 19 (Session 10) The therapist presents a playful variation on “Good morning.” Anna joins in the fun; closely attentive, she beats the drum with the palm of her left hand. The therapist leads into “Anna is in the music room.” She states, “I a’ class-mm.” A “music room/classroom” repartee results. The therapist changes to “classroom” — she counters with “school.” He returns to “music room” — she returns to “classroom.” When he sings “school,” she laughs as she repeats it. Commentary on Excerpt 19 She was showing both wit and intelligence. She knew that the three words belonged together, and played with them cleverly. She also recognized that when the therapist sang “school,” she had no choice left in this group of words to counter it with, and so had to repeat it after him. After the repartee she reached for the cymbal but found the treble end of the piano instead and began to tap the top key. She was wheeled closer to the keyboard; she played freely and rhythmically; the therapist accompanied her. Then he took her finger and with it played the melody of one of her songs and included in it the word “piano.” This word amused her as she tried to sing it. When she was returned to her place between the drum and cymbal she listened to a new song being developed: Audio File: Anna—Excerpt 20 (Session 10) Anna beats on most of the first beats of the measures of To Make Some Music and a repetition of it — she is holding both sticks in her right hand. The therapist: “Very good, Anna!” Anna, “One more!” The cotherapist takes one of the sticks from her right hand and puts it in her left. The song is repeated and she attempts to fit her alternate beating to it. The therapist begins the next repeat with a long fermata on “To ——” (taking cotherapist by surprise); his descending octave slide from the dominant invites her cymbal crash on the first beat of the measure. She tries again to beat alternately — and finishes the song with her own fermata.

Commentary on Excerpt 20 Her beating of the first beats of the three-four measures took considerable control and concentration. In the second playing of the song he made short pauses before the first beats (mini-fermatas), holding them back so that, as they coincided with her beats, she could experience in her beating the essential rhythmic accentuation of music in three-four time. In the third and fourth playings of the song she must have felt a discrepancy between her alternate beating (as movement in duple time) and the rhythm of the song. Her beating was disturbed by this, but she continued, seeming several times to be trying to adapt her beating to the song. Notwithstanding this difficulty, she could respond perceptively to the fermata and quickly initiate one of her own. As the song was repeated she ceased being disturbed by its three-four character, and beat alternately to it, letting the accented beats fall to her left and right hands in turn. At this stage in the development of her newly coordinated alternate beating skill, we did not consider that there was any immediate need to intervene in her beating to try to adapt it to the structure of music in three-four time. Working with her perception of the song’s phrase structure and her use of the fermata was of more immediate importance. The fermata was a way of bringing a dramatizing element into basic beating, and was directly attainable to her as an expressive skill; she was quick to recognize its effect. We went on to incorporate it into a song-game developed for her to enjoy using the cymbal and drum more selectively. Audio File: Anna—Excerpt 21 (Session 10) The therapists sing, “Anna’s in the music room beating the cymbal, Anna’s in the music room beating the drum!” With a little teaching she beats the basic beat vigorously on the cymbal throughout until the word “drum,” when she beats with a big swing of her left arm on the drum, emphasizing the word with both a fermata and a strong accent. The fermata became an important component for her in all the sessions that followed. Session 11 In the middle of the session, the therapist began to sing her name in a Middle Eastern style with a fermata on the first syllable. She quickly understood this and sang her name antiphonally with him repeatedly — in the mood and on the scale tones — singing the fermata and using the cymbal to emphasize the second syllable. With deliberation and control, she repeatedly combined her singing and the cymbal beat. Anna Notation Example 10 At the end of the session she wanted to beat alternately to Goodbye! It took her many attempts to find its very slow tempo of 44 bpm. With intense concentration she gained control of her beating in this tempo and beat the basic beat carefully and evenly throughout one

repetition of the song. Anna was now achieving a unity of self-expressive capability in her musical participation. Within the context of the work she could direct the use of both her arms successfully and was beginning, freely and expressively, to relate her singing to her beating. Our repertoire of song, singing, and instrumental activities was now continually widening. Each new skill she acquired she used repeatedly and freely in the sessions, often progressively extending a skill or combining one skill with another in what was unmistakably an ongoing dual exploration of musical activity and her own capabilities. The basic form of the sessions as it had developed by the fourth session remained, but as a flexible framework within which we interacted with considerable mobility, Anna often taking the leadership in the development of our work together.

From the twelfth session onward she insisted on being out of the wheelchair for all her musical work. The strength she used in her alternate beating is clearly evident. She sings as she beats, her pleasure shown in her face turned toward the cymbal. The photographs illustrate well the dimension of self-expressive spatial freedom that this way of musicing came to carry for her. Sessions 11 through 19 In the following nine sessions, which took us to the Holiday Season, she wanted to press her mastery further; she worked to widen her activities and put ever more of herself into musical expression. She was no longer content to work from the wheelchair; from session twelve onward she would undo the retaining strap and attempt to stand, indicating that she wanted to be helped to a chair (see photographs). She sang and spoke words with increasingly expressive ease. Her participation in repartee showed more freedom and inventiveness in the rhythmic variation and intonation of her responses. Audio File: Anna—Excerpt 22 (Session 12)

“No — Yes” repartee with freer variation of rhythm and intonation. She consistently increased her control of drum and cymbal beating. She raised the tempo of her alternate beating to 115 bpm and then wanted to beat alternately as quickly and as slowly as she could to contrasting fast and slow repetitions of the beating songs. Audio File: Anna—Excerpt 23 (Session 13) Contrasts of tempo in alternate beating (50–100 bpm) to “Anna’s in the Music Room.” Her next step was to follow and lead accelerandos and ritardandos, within her tempo range. It became possible for the therapist to work with her beating for short periods with less structured music; he could use more freely varied improvisations to mobilize her attentiveness and beating ability. It was clearly evident that Anna was becoming ever more musically perceptive, and that she was increasingly confident in initiating original responses to experiences as they arose in the mobile openness of the working situation. In session thirteen the therapist was improvising in a pentatonic idiom when she surprised us by beginning to sing To Make Some Music. This song had a pentatonic melody, although it had never been played in the context of purely pentatonic harmonization. She had heard it only with a distinctly diatonic F sharp Major accompaniment. On this occasion she apparently felt — that it, spontaneously musically perceived — the tonal affinity between the music she was hearing and the melody in her memory. She listened, then taking his playing as an accompaniment, chose her moment to begin singing, accurately in the scale and sensitively in the structure. Audio File: Anna—Excerpt 24 (Session 13) The therapist plays quietly in the pentatonic, Anna appears to treat his playing as an introduction — she listens through four phrases, then makes a good entrance to sing To Make Some Music. She corrects her pronunciation of “music.” The therapist adapts his playing to her singing. As the last note approaches she prepares to hit the cymbal — she misses at her first attempt, then succeeds. A new form of vocal play evolved in session sixteen out of “Good morning” and “Goodbye.” As it developed, the therapist sang “Good — ” repeatedly while Anna responded, “ — morning,” “ — bye,” “ — night,” freely and humorously. Audio File: Anna—Excerpt 25 (Session 16) Vocal play on “Good — ,” “ — morning,” “ — bye,” and “ — night.” Occasionally she made great efforts to enunciate words of songs clearly, correcting herself entirely of her own volition to get them right. She sang what was a new word for her, “beautiful.” She also became interested in beating the cymbal softly, and in session fifteen discovered a way of changing its timbre. The therapist was accompanying her soft cymbal beating with quiet pentatonic music in the treble when she felt for the rim of the cymbal with her right hand and held it while beating with a small mallet in her left. The damped cymbal

made a brief metallic sound, reminiscent of an instrument in a Javanese gamelan. She quickly learned that he would play softly, with no sustained tones, using no pedal, when she held the cymbal, and play louder, more sustained music when she released it. At some time in each session, on her own initiative, she would carefully lead the therapist by alternating from one way of beating the cymbal to the other to take us into contrasts of dynamics, timbre, and musical intensity. Audio File: Anna—Excerpt 26 (Session 17)

In response to a change in the dynamics and texture of a pentatonic improvisation, she damps the cymbal with her right hand while beating steadily with her left. This is the look of intense concentration we saw on her face whenever she took a new step in development — we saw it, for example, when she was finding the experience of the basic beat in the third session, when she beat to her songs in the fifth, and when she was coordinating her arms in the seventh and eighth sessions.

The therapist works with Anna’s beating using pentatonic improvisations. She damps the cymbal with her right hand while beating it with her left. He plays in a light, detached style, mostly supporting her, but occasionally trying to lead her into a faster tempo. From time to time she releases the cymbal and beats firmly; he responds with more forceful playing. She leads throughout. She coordinated her singing and alternate beating at the slow tempo (40 bpm) of Goodbye! and concluded it with a fermata.

Session 18 Anna’s expressive skills took another step forward as she effected a dramatic tempo change in her beating from fast to slow by making a fermata with her voice. Audio File: Anna—Excerpt 27 (Session 18) Anna beats the cymbal and then beats alternately on drum and cymbal. She sings as she beats to the Good Morning Song. She beats slowly, then, following the therapist’s lead, quickly. She initiates a change back to a slow tempo by making a fermata with her voice: She sings, “Good — ,” slides from it with the “m” of “morning” to a lower pitch, and places her cymbal softly and accurately on the beat. She maintains the slow tempo assertively, beating alternately with her singing. She and the therapist make a crescendo together. During these weeks the director of the Institute reported that Anna was carrying the effects of her developments and activities in music therapy over into other activities. In the classroom her behavior changed radically from passivity to liveliness; she required more attention and responded to it. Her teacher shared her enthusiasm with us. While she was at home for the Holiday Season, her mother, a pathologist, wrote to Anna’s teacher: We are so happy to see Anna so happy and with a certain self-assurance about her — much of it, I’m sure, can be attributed to her beginning ease of repartee, so much that she does not hesitate to correct us if we misinterpret her. Anyhow, she is happy and I am amazed as well as very appreciative of your work and all your colleagues. Incidentally, her fingering at the piano is quite impressive. Her horizons are certainly expanding. In addition to the family she is beginning to respond to neighbors, young and old, and she is quite fond of Jeanna’s new dog, Fallah. After the Christmas vacation she had another eight sessions. We worked to make her beating skills finer and more flexible. Her responsiveness to dynamics increased, and she began to beat simple rhythmic patterns with some consistency. Her beating became more adaptable in following freely varying music. She also worked at the piano. She wanted to stand to play the piano and to beat the drum, which she did with minimal assistance. Her singing gained in skill and confidence; she was quicker at picking up new songs and sang melodies with longer verbal phrases. Her speech was often more distinct. In the spring, after running for seven months, the project concluded. That summer, a progress report from the Institute stated: Anna now uses spontaneous speech in the speech training room and can express wishes, or relate incidents in short phrases to the instructor .... [Her] cooperation is very good.... She talks a great deal and her speech is becoming more intelligible. She picks up new words and puts words together. She makes continual progress in her special education class ... [she] is well aware of what the other children are doing and is much more accepting of them. Generally speaking, Anna seems to show a great deal more openness and willingness to accept instruction.

Transferring Anna’s Course of Music Therapy to the Institute’s Resident Music Therapist In the last months of the project a speech therapist at the Institute who was also an amateur musician had observed sessions with many children and had received some in-service training to prepare him to continue the music therapy program. When he began, so many new children were scheduled for music therapy that he could not take Anna until the summer of the following year. After his first session with her he wrote to us: “It is as if the last session with her was last week. She has remembered all her songs and all her beating skills, despite the lapse of sixteen months.” He developed a program for her that combined speech therapy and music therapy. This treatment apparently had considerable success. He began the sessions by working freely. Anna made up songs in a give-and-take with him and was active in creating and telling stories, using instruments for characters, and building the dramatic content verbally with musical support. He also taught her new songs, which she was quick to learn. After these free activities, he led the subject matter into more formal speech therapy, but continued to use music intermittently when required. After one year of therapy he reported: A lesson with Anna which begins with music instead of direct questions and direct work for propositional speech is a hundred percent more successful. It is always after music that we get our best response. Progress continues to be good in speech and excellent in music. Her general progress continued. In her special education class her teacher reported that she had begun to enjoy the presence of other children, was reaching out to touch them, and participating with pleasure in group games. The following January — she was now fourteen and a half years old — her father wrote us: Anna’s range of conversation and her initiative in starting a conversation have increased considerably. She has poise and charm, her multiple defects notwithstanding. We enjoy her visits home.

Appendix A

SCALE II MUSICAL COMMUNICATIVENESS RATING FORM Child: Anna Therapist:

DOB: PN/CR

Date:

Rater:

CR

Session: 1

Rating Date: 7/23/06

MODES OF ACTIVITY Body Instrumental Vocal Movement

LEVELS OF COMMUNICATIVENESS (7) Musical intelligence and skills freely functioning and competently, personably communicable. Enthusiasm for musical creativity. (6) Participating communicative responsiveness firmly established. Growing musical self-confidence. Independence in using rhythmic, melodic, or expressive components. (5) Sustaining of directed response impulses setting up musical communication. Musical motivation appearing. Involvement increasing. (4) Musical awareness awakening. Intermittent musical perception and intentionally manifesting.

2 x xxxx 2 x xxxx

(3) Evoked responses (ii): more sustained and musically related.

x

(2) Evoked responses fragmentary, fleeting.

x

(i):

(1) No musically communicative responses

Rating Totals

1 xxx

1

3 xx xxxx xxxx

3

1 xxx

3

2

1 Nonactive 1 xxx

Appendix B

SCALE II MUSICAL COMMUNICATIVENESS RATING FORM Child: Anna Therapist:

DOB: PN/CR

Date:

Rater:

CR

Session: 7

Rating Date: 7/12/06

MODES OF ACTIVITY Body Instrumental Vocal Movement

LEVELS OF COMMUNICATIVENESS (7) Musical intelligence and skills freely functioning and competently, personably communicable. Enthusiasm for musical creativity. (6) Participating communicative responsiveness firmly established. Growing musical self-confidence. Independence in using rhythmic, melodic, or expressive components. (5) Sustaining of directed response impulses setting up musical communication. Musical motivation appearing. Involvement increasing. (4) Musical awareness awakening. Intermittent musical perception and intentionally manifesting.

1/2 xx

Rating Totals

1/2

1 1/2 xx xxxx

4 x xxxx xxxx xxxx

1/2 xx

6

1 1/2 xxx xxx

1 xx xx

1/2 xx

3

2

(3) Evoked responses (ii): more sustained and musically related. (2) Evoked responses fragmentary, fleeting.

(i):

(1) No musically communicative responses

1/2 Nonactive 1/2 xx

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

CASE ELEVEN Preverbal Communication through Music to Overcome a Child’s Language Disorder Amelia Oldfield Abstract This case describes two years of group and individual music therapy for a five-year old boy with a language disorder. A wide variety of music therapy techniques are used, all aimed at motivating Jamie to communicate, either nonverbally or verbally. Background Information Jamie is the only child of very caring and capable parents. As a young child, he appeared somewhat smaller and slower than other children in his age group, and eye contact was often difficult. His mother reports that, as a baby, he did not babble at all, and used very few other nonverbal means of communication, such as pointing. He was always a very quiet child, and only occasionally and inconsistently used words. At two and a half, Jamie found mixing with other children very difficult, and would often appear to be in a world of his own. However, he did not present any major behaviour problems and was able to play by himself. At this stage, the pediatrician reassured his parents that Jamie’s development was not necessarily abnormal. Nevertheless, both his parents and other professionals involved continued to be concerned. Jamie’s health visitor wrote a report at this time describing him as: “rather worrying in a not altogether definable way.” When Jamie was three, he was assessed by a clinical psychologist who suggested that, although his overall intelligence was within the normal range, there were great discrepancies in his skills. He had high scores for manipulative skills, such as putting puzzles together, and marked problems with both comprehension and expressive language. Jamie’s hearing was also tested at this stage as he seemed both oversensitive to some sounds and oblivious to others. It was found to be within the normal range. Jamie was then referred to the Child Development Centre where he began having regular sessions with the speech therapist. He also started attending a small play therapy group of four children. This is a structured group run by a clinical psychologist where the emphasis is on encouraging social integration. She reports that, over a period of a year, Jamie took part in more group activities and managed to overcome some of his fears and obsessions. He became more able to tolerate the screaming of another child in the group, for example, which he had been terrified of at first.

When Jamie was four, he was assessed by the local specialist consultant in child psychiatry. He suggested that, although Jamie’s language was very restricted, he was showing signs of imagination. In spite of his difficulties, Jamie seemed to be developing an understanding of the meaning of words; therefore, there seemed to be potential for the development of abstract thought. The psychiatrist felt that Jamie’s social problems and occasional disturbed behaviour were the result of his great difficulties in understanding social practices. Thus, he diagnosed Jamie as having a specific language disorder. In his opinion, there was no evidence of autism or an autistic like disorder. The term “language disorder” generally describes an atypical pattern of language acquisition and development. Unlike children whose language may be delayed but nevertheless following a normal pattern of acquisition, children with language disorders have both a delayed and deviant pattern of development (Webster & McConnell, 1987). Deviancy or disruption may occur in any or all aspects of speech and language: context, form or use; or as a result of a distorted interaction between them (Bloom & Lahey, 1978). Jamie had difficulties in all these aspects of language development, and particularly in the area of language use. This affected his ability to establish social relationships and to relate to the world around him. A speech therapy report written a couple of months later agreed with this diagnosis. The speech therapist explained that Jamie had difficulties processing sentences in order to comply with a task. Although he responded to everyday instructions, he was reacting more to the context and the routine than to the actual meaning of the instruction. Jamie could say quite long sentences, but had difficulties learning when to use these sentences appropriately. He was mainly silent and only made occasional, spontaneous, self-generated comments. From the age of four to the present, Jamie has been attending a small language unit for eight children with language disorders. The children in this class receive very specialised schooling, and the main focus of the work is on improving their language difficulties. The class is based in an ordinary school, and the children are integrated into other “normal” classes at times, as well as working together as a group at other times. Both the teacher from the unit and Jamie’s parents are still unsure about Jamie’s diagnosis, and suspect that he might have some autistic tendencies. At five, Jamie was referred to me at the Child Development Centre by his language unit teacher. She had noticed that Jamie seemed to respond to words in songs more easily than spoken words. She hoped that I might devise some exercises for both her and Jamie’s parents to use with him to improve his speech. Music Therapy Assessment I saw Jamie for three consecutive weekly, half hour music therapy assessment sessions. The purpose of these sessions was: (1) to determine whether music therapy would be a useful way of helping Jamie, and if so to roughly outline what kind of direction this treatment might take; (2) to see whether he responded to me in a different way through music and thus to shed new light on some of his difficulties; and (3) to suggest ways in which both his teacher and his parents could use music with him. Jamie presented as a small, attractive looking boy with a serious and often puzzled expression. He had no difficulties separating from his mother, and showed no anxiety about

coming into the music therapy room with me. He seemed to understand simple requests or comments such as: “Here is a chair for you, Jamie” or “Shall we finish this now?” He was able to point to me and to choose an instrument for me on request. He could listen to my playing and also play himself and was good at taking turns with me. He made very few verbal contributions or vocalisations, but at one point suddenly and surprisingly, made an appropriate comment about an instrument, saying in a very clear voice, “There’s a ball inside.” Jamie particularly enjoyed activities where we teased one another, or where he could “control” me by, for example, making me jump when he played the drum. At these times, he would look straight at me and have a beautiful mischievous smile. Jamie seemed pleased to listen to the music and the songs I improvised on the piano and the clarinet. He anticipated the ends of harmonic phrases by looking up at the appropriate moment, and showed that he knew and recognised a number of songs by occasionally filling in words when I left a gap. For example, I would sing: “London bridge is falling....,” and Jamie would say: “Down!” Sometimes he would sing the words at the correct pitch to fit in with the song. Jamie enjoyed playing the instruments, and would spontaneously explore various ways of playing them in a creative way. For example: he seemed to experiment with the different sounds the drumstick made on various parts of the drum, and played the cabasa in a number of ways, stroking and rattling the beads as well as shaking the whole instrument. Jamie generally seemed to prefer the quieter instruments. He did not appear particularly frightened of loud sounds, but would blink slightly anxiously when they occurred. With a little encouragement, he could join in and enjoy both quiet and loud improvisations. He was able to follow dynamic changes when we improvised together, but had more difficulty following rhythmic changes. He appeared to be able to play in a regular pulse for short periods, but the pulse was hesitant and gave his playing a slightly tentative feeling. Jamie found it difficult to move freely or spontaneously to music. His physical reactions were slow, and he needed encouragement to do things such as march or jump to the music. Jamie seemed to be developing a positive relationship with me. He was at ease playing the musical instruments, and was able to both listen to and contribute musical ideas during our improvisations. I felt he would benefit from a situation where he could communicate with an adult without having either to understand spoken language or use words himself. The areas I thought we could work on were: increasing his motivation to communicate with another person; providing an opportunity for Jamie to vocalise freely and spontaneously; increasing Jamie’s confidence and enabling him to speed up his reactions so they were more spontaneous. I therefore recommended that he should have weekly individual music therapy treatment for at least six months. Jamie appeared to be more spontaneous in his communication with me during our sessions than he was with other adults. This was probably because far less speech was necessary in my sessions than in other situations. The fact that he was more at ease in this non verbal situation seemed to confirm the diagnosis of language disorder. After reading Jamie’s notes, I had expected him to be more sensitive to loud sounds and was surprised when he did not seem to mind hitting the drum very loudly. On reflection, however, it became clear that it was unexpected and unexplained loud noises that particularly troubled Jamie, and not loud sounds that he knew were about to occur or sounds which he himself produced or controlled.

I did not think that it would be beneficial to give Jamie’s parents or his teacher structured musical exercises to improve his speech. I felt the priority was to help Jamie feel at ease with a non verbal means of communication, so that he would eventually become more spontaneous in his efforts to communicate. I also thought that Jamie should be encouraged to enjoy making sounds and vocalising without the pressure of using the correct word or structure. Jamie had never babbled or experimented with sounds as a baby, and I thought that he needed to discover the fun of producing sounds. I therefore suggested that both his parents and his teacher should encourage Jamie to vocalise in any way, and that they should try to engage him in playful vocal dialogues. I also suggested they do “toddler” like rhymes such as “Incy Wincy Spider” or “Round and Round the Garden” with him, so that Jamie could laugh at them with an adult, and learn to enjoy communicating in a simple way. Treatment Process Phase One: Introductory Group Work Unfortunately, I did not have any spaces available to see Jamie for individual music therapy sessions immediately, and he was therefore put on a waiting list. As it happened, however, I had already arranged to see the group of children in the language unit that Jamie attended for a a twelve week period, starting four weeks after I had finished the assessment on Jamie. I was, therefore, able to observe and work with Jamie in a group setting before I started to work with him individually. The group sessions occurred once a week, lasted approximately forty minutes and went on for one school term (twelve weeks). Both the teacher and the welfare assistant took part, and I reviewed our work with the teacher every week, directly after the session. All eight children in the group were diagnosed as having language disorders. Jamie, however, was shyer and more withdrawn than the other children. The group sessions had two or three specific aims for each child. These were determined jointly by the teaching staff and myself after a couple of “exploratory” sessions. Generally, the goals were: to provide a different setting for the teaching staff to observe the children’s strengths and difficulties, and to give the teaching staff ideas of musical activities to use in the classroom. Given my large case load, this is one of the only ways I can provide some input to a large number of children. The musical material and the activities used in the group would vary from week to week, and was largely determined by the aims for individual children. Although suggestions for activities for the following week’s session might be made when we reviewed our sessions, I would always remain flexible and would usually choose activities on the spur of the moment, based on the children’s reactions and moods on any particular day. Nevertheless, I would always start off with a familiar greeting song and end with a “good bye” activity. Throughout the group I would often alternate between activities which involved the group as a whole and activities which involved one or two children playing on their own. An example of a general group activity would be: the whole group plays together on various percussion instruments led by improvised music I play on the piano. When the piano stops the children all move around and exchange instruments. Playing starts again when the piano begins. An example of an activity involving two children would be: two children sit back to back in the middle of the circle,

each with a different instrument, and are asked to have a musical conversation. The rest of the group is encouraged to listen. I would also try to alternate between activities where the children were actively involved in playing instruments, singing or dancing, and activities which required concentrated listening without so much active involvement. After observing Jamie within the group for two sessions it became clear that he was much more withdrawn in this setting than he had been with me on a one to one basis. We therefore decided that individual aims for Jamie would be: to help him concentrate and listen to instructions; to encourage him to communicate in any way with either adults or children; and to encourage him to make eye contact and to make any vocal sounds. During the first five sessions, Jamie seemed to understand some but by no means all the instructions, and was able to take part in a few activities only. He seemed to enjoy choosing and playing instruments, but was unable to pass an instrument to another child. He did not understand the games involving drama where we pretended to put a tambourine to sleep, for example, and he needed help whenever any of the activities involved moving around the room. He made little eye contact, and only used a few sporadic single words. He often appeared to be in a world of his own, and made no efforts to communicate with either the children or the adults in the group. During the sixth session, there was a marked change in Jamie. He suddenly appeared more at ease, smiling happily and looking straight at me when I played the clarinet. He was able to contribute some vocal noises to a song where all the children were suggesting different sounds, and even gave his instrument to another child when this was suggested to him. From this session onwards, Jamie continued to progress well. He learned how to “conduct” by pointing to other children and adults. He would listen to instructions better, and he began to take part in even quite complicated activities. He started using more words, both on request and spontaneously. Both Jamie’s teacher and I were pleased with Jamie’s progress within the group, however we felt that he would benefit even more from individual sessions. Phase Two: Individual Sessions Two weeks after the group finished, a space became available, and I started to see Jamie for regular weekly individual music therapy sessions. Although he had made some progress during the group sessions, the aims remained the same: to increase communication, eye contact, vocalization, and spontaneity. As Jamie’s use of words had improved, I continued to keep a record of both spontaneous speech and the speech he used to answer direct questions. Nevertheless, I still did not want Jamie to feel that this was the focus of our sessions, or that I was putting pressure on him to talk. The individual sessions lasted half an hour, and were held at the same time and in the same room every week. After each session, I would briefly discuss with Jamie’s mother how he was progressing. Like the group sessions I would start and end each session with familiar “hello” and “good bye” activities. In between, sessions would vary from week to week depending on Jamie’s mood, on what had happened the previous week, and in what particular areas I felt I should be helping Jamie. In general, I would spend some time encouraging him to choose instruments or activities, and then attempt to follow and support his playing; at other times, I

would make suggestions myself. For example, I might suggest that we take turns playing the glockenspiel, and pass each other the stick when our turn was finished; or I might encourage Jamie to play three different instruments that would make me jump, wave my arms or shake my head depending on which instrument he played; or I might suggest that we have a “noise” dialogue on the kazoos. I would always try to give each of our activities a structure with a clear ending. I would prepare Jamie for each ending by saying “One more turn each,” or “Try to find a way to finish this off.” Jamie was at ease with me straight away, and was delighted with the familiar “hello” song on the guitar. This led to a sung “noise” dialogue accompanied by shared guitar strumming. Jamie initiated vocal sounds such as “Hey” with great delight, and would then laugh happily. He gradually added “funny” faces to these noises, particularly when I encouraged him by mirroring and extending his contributions. Jamie was clearly excited and pleased with these humorous exchanges, and I was able to keep them mischievous and creative rather than just silly. These vocal dialogues immediately followed my greeting to him, and became a regular part of our sessions. Sometimes Jamie would respond immediately, and at other times it seemed to take him a little time to relax and allow himself to enjoy this basic form of communication. Over the first six months of treatment, Jamie continued to become more spontaneous in any familiar activities that we shared. However, he would revert to a blank, puzzled expression whenever I introduced anything new. I, therefore, made a conscious effort not to allow the sessions to become too stereotyped and, while always keeping some familiarity, tried to vary the way we played together, always introducing at least one new idea every week, As Jamie became more able to make his own choices and contributions, he started to use more single words or two word phrases, both spontaneously and in answer to direct questions. In a conducting game, Jamie gradually managed to give me more and more complicated instructions, such as “Play the drum and the cymbal loudly.” Nevertheless, his speech was still far from normal, and at times he would be unable to say something as simple as “Goodbye, Amelia” or tell me which day of the week he came for music therapy. Jamie still found it difficult to move quickly or spontaneously. However, he started to enjoy and understand imaginative games where I pretended to fall asleep on the piano, or I hid from him in the room. At these times he could react quite fast to “Wake me up!” or “Find me!” Jamie continued to enjoy experimenting with various ways of playing the instruments, and seemed to become more sensitive to various tone colours. He began to listen much more carefully to the sounds he produced. His sense of rhythm also improved. He would enjoy improvising on the piano and quickly became able to pick out tunes such as “Ba-Ba Black Sheep,” “Happy Birthday To You” and “Puff the Magic Dragon.” As he apparently wanted to learn more tunes, and enjoyed playing the piano, I arranged for him to start piano lessons with a teacher who had an interest in children with special needs. This also meant that there could be a clear separation between my work and more formal piano teaching. As Jamie gradually became more spontaneous in his contributions, he also developed some slightly obsessive behaviours, such as repeating a tune fragment again and again, or insisting on holding the drumstick in a certain way. Nevertheless, he could be distracted from these obsessions relatively easily. As time went on, these rituals seemed to die away, and were replaced by ordinary “toddler like” naughtiness and rebelliousness. The only slightly strange

behaviour that did occasionally creep back was that of Jamie “telling off” his right hand for misbehaving. By the end of six months of individual music therapy sessions, Jamie had made great progress, and the aims set out at the beginning of our work together had been achieved. Progress had also been noticed at school, and at home Jamie’s parents were delighted with his greater willingness and ability to communicate. However, they were also finding him a great deal naughtier and less easy to manage. I therefore decided that, as I had developed such a good rapport with Jamie, I would continue to see him for another four months with a view to helping both Jamie and his parents to cope with these new “naughty” behaviours. I also thought that his communication skills could be further improved. Phase Three: A Slightly New Direction Aims for the last four months of treatment were: to diminish silly behaviours such as screaming or deliberately throwing objects; to encourage longer spontaneous and creative dialogues with me (nonverbal and verbal); and to help Jamie to answer questions appropriately (and not let him divert me from this). When dealing with Jamie’s “naughty” behaviours, I felt it was important to explain what I thought about these behaviours, and why I was responding in a particular way. I told him that we would work out ways of stopping his naughty behaviours together. At times, I would smile at him, and tell him in a “teasing” way that I thought he was trying to be naughty. At other times, I would suggest to him that it was easier to opt out of an activity and be naughty, than to continue our work. When he threw an object, I would take his hand and physically help him to pick it up again, saying that it was important for us both to make the naughty behaviour “better.” Occasionally he would get “stuck” when asked to do something and say “I can’t.” In this case I would either help him physically (and comment that I was giving him a “helping hand”), or I would say that perhaps what I had asked Jamie to do was too difficult. This approach seemed to work well. He remained mischievous but became more accepting of direction, and would allow himself to be diverted from whatever was causing a problem more easily. During the last few sessions, Jamie sometimes became “moody,” and on one occasion, he cried when he did not have time to play an instrument he had wanted to play. He seemed relieved to be told that there was nothing wrong with being sad and crying. During the last four months, Jamie continued to make progress in his communication skills. By the end of my time with him he was able to hold ordinary conversations with me. He would initiate a conversation and ask appropriate questions. However, he would still sometimes need encouragement to answer questions. Overall, the progress he made during that year was remarkable. From a quiet often mouse-like child, he had become a vocal, boisterous child, often full of mischief and fun. Discussion and Conclusions

In the first instance, the musical instruments and our music-making interested Jamie, and motivated him to be actively involved with me. This enabled me to start building up a relationship with him which was initially based on shared enjoyment of the music and the musical activities. Jamie was able to maintain this positive relationship with me because I used very little speech in our assessment sessions. He could, therefore, relax and simply enjoy being with me. We were playing music together and communicating through sound, but very few specific words needed to be said or understood. It was the use of music as a means of communication which was essential at this point, and this could only have been achieved through music therapy. For the first few group sessions, Jamie again became very shy and withdrawn. This was probably because far more speech was necessary in this situation to understand what was going on and what was expected of him. However, he was able to maintain an interest in the group because of his fascination for music. The familiar structure of the sessions gradually reassured him, and gave him the confidence he needed to take part with the other children and make his own contributions. When I started working with Jamie individually, the familiar framework of a “hello” and “good bye” activity reassured him, and allowed him to start work with me straight away. In fact, it became clear that Jamie relied too heavily on familiar and predictable activities, and I had to start introducing “surprises” so that he did not become entirely dependent on this familiarity. One of the most important things that we worked on throughout Jamie’s individual sessions was vocalisation. As Jamie had never babbled as a baby, I felt that he needed to discover what fun it could be producing sounds and experimenting with different vocal noises. It is interesting to note that it was during these vocal exchanges that Jamie first started using his face in an expressive way, wrinkling his nose and making “funny” faces. This ability to encourage a child to have vocal sung dialogues which can be varied and made interesting through musical improvisation is unique to the music therapist. Another important aspect of our work was the fact that I was able to put Jamie “in control” by encouraging him, for example, to conduct my playing. I think this was helpful in building up Jamie’s confidence, as his language difficulties often made him feel confused and “out of control.” Slowly, and almost in spite of himself, Jamie discovered that it was not only easy to communicate with an adult, but that it could be fun and therefore worth the effort. This was my main aim with Jamie but it happened so gradually that I only realised how much progress he had made when I looked back at how little he had initially contributed. Finally, it is interesting to note that as Jamie’s abilities to communicate improved, he developed new “naughty” behaviours. The approach that I used to help him with these behaviours was based on explaining my actions very carefully, and making use of his new found language and comprehension skills. At this stage, I was also able to put more pressure on Jamie and be more demanding, something I would have avoided doing in the earlier stages. I think it was my relationship with Jamie which was crucial at this point, rather than the special skills that I have as a music therapist. Nevertheless, I had developed this relationship through our musicmaking, so it was important for me to continue and complete our work together. When I recently telephoned Jamie’s family one evening to find out whether they would be happy for me to write this case study, I heard a familiar voice in the background: “I don’t

want to go to bed!” Certainly, this is a well-known and unwelcome communication for any parent to receive from a child, but in this instance, I could not help feeling moved. I was reminded of the amount of progress Jamie had made since I first saw him two years previously, when he had hardly been able to use speech to communicate in any way at all. Although I generally enjoy my work as a music therapist, I do sometimes wonder whether I am really achieving results, and whether the children could equally well be helped through means such as special teaching or play therapy. Cases like Jamie make up for the times when progress seems to be very slow or nonexistent, and help to maintain my belief that music therapy is a truly unique and invaluable form of treatment. References Bloom, L., & Lahey, M. (1978). Language Development and Language Disorders. New York: John Wiley and Sons. Webster, A., &McConnell. C. (1987). Children with Speech and Language Disorders. London: Cassel.

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

CASE TWELVE Self-Communications in Creative Music Therapy Carol M. Robbins Clive Robbins Abstract This case describes Creative Music Therapy with Lyndal, a nine-year old Australian girl with multiple handicaps. Through individual and group work aimed at developing her musical expressivity and interresponsiveness, Lyndal was able to find and set free the “music child” within her. The effects of this release of potential on various aspects of self are described. Introduction In answering a question, one communicates one’s self. This simple aphorism of Sufi thought (Corbin, 1969) captures the very essence of creative music therapy. Every time the therapist creates a musical idea, or offers a musical phrase, it is an invitation for the child to respond—a question for the child to answer; in repeating the child’s motif, or extending the child’s phrase, or complementing the child’s timbre, or in leading the child into another tempo or dynamic range, the therapist is in effect posing musical questions; and the child—in responding spontaneously to the music, the therapist, and the situation—is continuously communicating his or her self, and the state of the self. In doing this the child also communicates the individuality of that self—the inner directive will, its capability to assert or express itself or communicate its potentials as they manifest, and its inherent proclivities. So that in the child’s response we experience together with the self, the being-within-the-self. And it is in the being-within-the-self that the potential for creative development lies. In creative music therapy, the child’s self is developed from within—using inner resources—the most important of which is the “music child.” The “music child” is that part of the inner self in every child “which responds to musical experience, finds it meaningful and engaging, remembers music, and enjoys some form of musical experience” (Nordoff & Robbins, 1977, p. 1). This individualized musicality is inborn in every child, regardless of handicap, and reflects a universal sensitivity to music and its various elements. In order for the “music child” to function, the child must be open to experiencing himself, others and the world around him; for it is through these experiences that receptive, cognitive and expressive capabilities are

developed. Thus, it is the “music child” that answers the questions posed by music, and in so doing, communicates the self. When the child is disabled or handicapped in some way, the music child is encased within what we call the “condition child.” The condition child denotes the child as it has come to be, through the number of years it has been living with a neurological deficiency or a physiological condition, with some form of handicapping condition. A child’s personality develops in response to the life experience he or she can assimilate. Very often this development is limited, partialized, deformed, and incomplete—the child’s potential for development has not been released—a state represented symbolically in Figure 1 by an uneven, irregular form.

Figure 1. The Condition Child The condition child is obviously a self, the self that the child has been able to develop, or the present state of the child’s self. Then we find that in music therapy we can reach the inherent, inborn musicality, which is so fundamental to human nature. We begin to reach the music child, Figure 2.

Figure 2. The Music Child

First, the therapist becomes aware of an inner growth of awareness. Perceptibly, if all goes well in the early sessions, the child’s personality develops a new nucleus of selfhood which is formed in (or by) musical experience, through musical communication, through the beginnings of musical activity. This musical-personal nucleus then is nurtured, encouraged, challenged, supported, answered by the therapist and begins to take the individuality beyond the previous limits of its function, beyond the behavior barrier of the condition child.

Figure 3. The Old Self and New Self In the growing child-therapist inter-activity and inter-relationship the personality expands, a “new self is formed, and the former condition child becomes the “old self.” (See Figure 3 for symbolic representations). If a therapist is working with a child who is deeply neurotic, emotionally disturbed, or with what might be called a strong emotional overlay, you find that the old self remains, to some extent. Therapy then can lie in resolving the conflicts between the old and the new selves. The child is still going to be self-protective–an old mode of conduct–until it outgrows this need and old modes of life, reactions, habits or other limiting behaviors are replaced by new perceptions, a new sense of self, a new confidence in living. Method We would like to illustrate this process with excerpts from a course of creative music therapy with Lyndal, an Australian child. We worked with Lyndal over a period of four and a half years, in both individual and group sessions. The individual sessions centered on interactive improvisation, and the group sessions involved Lyndal in a musical drama. Creative music therapy involves two therapists working as a team, one at the piano and the other directly with the child or group. In individual work, musical improvisation is the predominant means of interaction with the child—it is the way that contact is established with the “music child:” ...the therapist will find the essence of music as therapy to lie in his improvisational creation of music as a language of communication between him and an individual child.

The “words” of this language are the components of music at his disposal, its expressive content is carried by his use of them. In the clinical situation he becomes the centre of musical responsiveness himself; the music his fingers draw from the instrument arises from his impressions of the child: facial expression, glance, posture, behaviour, condition—all express that presence his music will reflect and go out to meet. The flexibility of his playing searches out the region of contact for that child, creates the emotional substances of the contact and sets the musical ground for interactivity. The timing of his playing—its tempo, its rhythms and pauses—attentively follows, leads and follows the child’s activity (Nordoff & Robbins, 1971, pp. 143-144). In group work, the predominant means of accessing the “music child” is through learning, performing, and responding to specially composed songs, instrumental pieces, and musical dramas, and to the developmental content of such compositions. Background Information We first met Lyndal in September, 1984; she was then nine years old, and had just become resident at “Warrah,” a Rudolf Steiner special school in Australia where we were working and living. She was brain injured, mildly micro cephalic, hypertonic, and with some unsteadiness of gait. She was moderately mentally handicapped and emotionally unstable. Her behavior was fearful, stereotypic and, possibly because of frustration and confusion, selfinjurious. She reacted adversely to loud or unexpected sounds: dogs barking, sirens, car horns, doors slamming, and so forth. Even radio and television at normal listening levels provoked screaming tantrums and a self-injurious reaction in which she would repeatedly strike her forehead against a wall or other firm object. Beneath her bangs there was often a large contusion. She was a much loved child, but life at home for her parents and two brothers was constrained and muted. She had quite a bit of usable speech and could make her wishes known; she often repeated phrases continuously and inappropriately, apparently in the wish to make conversation. Lyndal had attended a state school for some years and had made some progress, although she remained on the sidelines in many school activities because she was so fearful, self-protective and behaviorally unpredictable. Treatment Process Don’t Play the Piano! Lyndal began weekly individual music therapy sessions shortly after being admitted to “Warrah”. Very quickly her responses revealed a dichotomy, a split. She always came eagerly to the music room, she possessed considerable inherent sensitivity to music and enjoyed it immensely. She liked to sing—preferably something she could imitate—and had a good sense of pitch. She was also sensitive to rhythmic patterns and the melodic rhythms. But in beating

the drum to piano and vocal improvisation she showed an instability that was linked to a disabling lack of self-control and confidence. Audio Files: Lyndal Excerpts—1 and 2 At the drum she was over-vulnerable to musical stimulation and to the excitation of her own physical activity—and her beating always tended to break away into disorder. There was evidence that a drive to beat freely and strongly lived within her, but her reactions suggested that she was frightened of the power of her own impulsive energy and was repressing it. Whenever the music or her beating seemed on the verge of becoming too vigorous she would call out “Don’t play the piano!” or interject “See you later!”, her way of escaping the situation. She also developed a real anxiety about the large 16-inch cymbal, and it had to go out of sight behind the piano. Gradually, in these sessions her responses took on some stability and it was apparent that—within limits she determined—she was beginning to place some trust in us and in herself, active in music. Audio Files: Lyndal Excerpts—3, 4, and 5 Lyndal Takes a Role After four sessions we temporarily suspended her individual therapy as rehearsals for a school play required schedule changes. We began working with the 35 children in the school on The Children’s Christmas Play (Nordoff & Robbins, 1970). The girl who was to have played Mary became ill and we asked Lyndal to take the part. When her parents were told they were pessimistic: “We hope Lyndal doesn’t spoil your play” was their concern. I assured them that this play was for the children, and that if it was necessary for Clive to be beside her throughout the entire performance it would be perfectly fine. In the rehearsals she was initially scattered and giggly; she behaved well but did not seem to have any idea what it was all about. When the Angel brought Mary the doll that was the Christ Child, Lyndal took it carelessly with a complete lack of feeling, sometimes holding it upside down. The turning point came in one rehearsal when, as the Angel approached Lyndal, seated in the stable, to present the baby, Clive made a big stretch upward with both hands, “Lyndal,” he said, “reach up to Heaven where it’s coming from!” The drama of the moment caught her, she imitated him—immediately attentive to the gesture—took the baby with much more awareness and held it as one would hold a child. We practiced this several times. Later that day, while Clive was walking outside, his and Lyndal’s paths happened to cross and she came toward him raising her arms high in the same receiving gesture, smiling with pleasure and satisfaction. After this she became serious about the play and seemed to feel her role in it. The play was performed to an applauding audience. Lyndal played her role securely, joined in singing the chorus parts, and sat attentively and quietly while other children acted out their roles. As the play approaches its ending, there is a rhythmic-speech chorus that builds to a climax on the words, “Hail King! Blessed is He! Joy! Joy! Joy!” These words are supported by strong chords on the piano, and as everyone bursts into the final chorus of “Christmas Bells,”

the hand cymbals enter with repeating dramatic crashes. We did not realize at the time the impression the experience must have made on Lyndal; the mood of this Handelian finale was one of celebration: bells were given out and more and more children rang them to build up the crescendo—through all of this loud, vigorous music, the hand cymbals and the large cymbal on the stand added to the jubilation. Bells and both cymbals finished with a sustained fortissimo tremolo. Lyndal showed no distress whatsoever at the very high dynamic level the music reached. Lyndal’s parents were deeply happy with their daughter’s achievements. We received a Christmas card from them with the simple message: “Thank you for having faith in Lyndal.” Am I Going To Play The Cymbal? Quite early in the New Year, before school began and her individual therapy resumed, she would ask us whenever we met: “Am I going to play the cymbal today?” If we asked her in return: “Well, are you?” She would reply, softly but firmly, and perhaps a little wistfully: “No.” It was obvious that the cymbal attracted her, obsessed her to a degree: to have had the freedom to let go and strike it forcefully with strength to produce a glorious crash, full of overtones and shimmer, would have been very important to this constrained child. The attainment of this freedom became one of the goals in our work with her. Lyndal resumed individual therapy, and had one session weekly, lasting on an average 15-20 minutes. Her fifth session begins in a way that typifies her response at this time: she comes running in with a bright eagerness, happily sings her greeting song, loses control the moment she starts beating the drum, then, as the therapist accompanies her disorder, calls out “Stop!” and becomes anxious. In this and the following session, Clive and I take our cue directly from her; we work to engage her perception of structure in music to stabilize her activity, develop her vocal and rhythmic skills, and build her confidence. Concurrently, we also gently lead her further into the area of freer beating where she becomes disordered; we want to explore her ability to acquire control over her reactions—and, at the same time, we work to familiarize her with this up surging of emotional and physical energy in herself in the hope that she can come to enjoy using it self-expressively. We intuitively sense that in this deeper, eruptive region of reaction and disorder lies the source of Lyndal’s self-injurious behavior, and that it could be therapeutic to engage this energy through improvisation and bring it into musical expression. Lyndal’s ambivalence continues, she is both drawn to the instrumental work and apprehensive of it. Carefully, she is led into using a very small cymbal (less than 6 inches in diameter) mounted on the cymbal stand. The trusting relationship develops as she requests activities and is secure in alternate moments in which we lead her into widening her areas of experience. She is always eager to show what she knows she can do—and at the same time very directly lets us know when she has had enough of a challenging activity. Gradually, a repertoire of shared music builds up and progressive connections are established, for example, the phrase she originally used as a means of self-protection, “See you later,” becomes transformed into a much enjoyed song in tango rhythm (Figure 4).

In tapping the melodic rhythm to this song on the drum, Lyndal spontaneously uses the small cymbal to punctuate the phrases. This results in warm approval from us and cheers of self-congratulation from Lyndal.

Figure 4. Musical Excerpt 1 Audio Files: Lyndal Excerpts—6, 7, 8, 9, and 10 As a contrast in instrumental timbre, Lyndal plays resonator bells and is sensitive to the gentleness and lyric tonal quality of the music that is made with them: “Can You Sing To The Sun?” (Nordoff & Robbins, 1962). It is clear that in music her emotional life is being reached and engaged with an immediacy not possible in other areas of experience. Her powers of concentration are also being exercised by the clearly structured objectives of much of the work. Audio File: Lyndal—Excerpt 11

As the sessions proceed, her overall sphere of experience steadily deepens and widens, her attentiveness to rhythmic structure becomes more precise, and her ability to sustain focused work improves. Audio Files: Lyndal—Excerpt 12, 13, and 14 In the eighth session a medium-sized cymbal replaces the small one and through a quiet improvisation, she is eased into playing it. Later, she is intrigued by the Phrygian mode and is able to sustain a short but controlled crescendo on timpani. When she does need to step aside from such a challenging activity she does it adroitly: using a beguiling tone of voice she diverts the therapists into a less threatening alternative, “Now! Carol, Clive, can we beat on the resonator bells?”–showing a more accomplished, healthier form of self-protection. Audio File: Lyndal—Excerpt 15 Although ambivalence shadowed her advances and each step forward was usually followed by nervous uncertainty, progress continued. Her confidence was steadily increasing, and this was fundamentally due to the nourishment her musicality was absorbing from the sessions. Her inborn musicality was such an important part of her personality that it was at the root of her personality development. Audio File: Lyndal Excerpt 16 By the tenth session, Lyndal is smiling and confident playing the medium-sized cymbal. She plays it carefully yet in a relaxed manner. She is responding with trust, as we encourage her to sing freely as she beats to dramatic music. In the fifteenth session, it is clear that much more was coming out by way of freedom and assertiveness. The work in this session sometimes sounds like a child making lots of noise, but it is Lyndal—a nine-year-old who always felt apprehensive, kept herself in, always suppressed, and always constrained, except when she banged her head on a wall in utter fear and frustration—now releasing this energy openly through the joy of music. How she needs a situation in which her feelings are accepted, enhanced and made communicative and selfexpressive! In this session, Lyndal beats to forceful, serious music over a range of tempo. Audio File: Lyndal Excerpt 17 As she beats she raises her voice, and holds high tones. Then, to music in a Spanish idiom, she uses the cymbal with the same strength with which she is singing. Although she beats strongly, she moderates the cymbal’s power by using it rather slowly, such as by beating on the first beats of measures (Figure 5). At no time in the session does she shrink from the intense coactivity.

Figure 5. Musical Excerpt 2 Free At Last We had visitors observing the sixteenth session, and Lyndal seemed to have decided from the very first moment and maybe because they were there, that this was the day to really let go. The session quickly built up to a high level of intensity and the dramatic discharge of energy overwhelmed the visitors. They were taken totally by surprise and sat in stunned immobility. Later they admitted that they were actually frightened by the power of the music and by Lyndal’s unrestrained singing and use of the drum and cymbal-so much so that they failed to see her rapturous beam of joy as she achieved the catharsis she had been seeking. The excerpt below shows the very vigorous compelling fortissimo music that was called for by Lyndal’s forceful beating. I attempt to sing in a way that totally projects my energy into the room. Lyndal sings out freely as she is borne along by the drive of the penetrating rhythms and dissonances of the piano. At 160 beats per minute she can hardly control her beating. Our music-making together has an intensity that borders on the maniacal, yet it has purpose and direction. When I sing short dramatic phrases, Lyndal begins to use the cymbal—first to punctuate them, then accent them (Figure 6).

Figure 6. Musical Excerpt 3 Audio File: Lyndal—Excerpt 18 As the improvisation rises to a climax, Lyndal’s cymbal beating becomes continuous. She sustains a crescendo for over a minute, much of the time beating as hard and as fast as she can. Her tempo attains 260 beats per minute. The room rings with cymbal crashes, overtones, piano, and voices. Who would not love to do that, to be that free, that unrestrained, that unconventional, that unlimited by the norms of behavior! And add to this dynamic of experience what it must mean for Lyndal! Of course, our visitors were in a state of shock; they had no way of knowing what was going on. They knew nothing about Lyndal or where she was coming from, and this was unlike any experience they had had. Where would they have heard music like this unless in a very dramatic or adventurous film, or possibly an opera? As the vigorous improvisation comes to a close, Lyndal calls out: “Now sing!” She sits beside me at the piano and joins in singing phrases antiphonally. I lead her into a world of music in total contrast to the preceding rhythmic percussion: the improvisation is in a moderately slow 3/4 and the experience is lyric and thoughtful; melody and harmony predominate (Figure 7). Audio File: Lyndal—Excerpt 19

Figure 7. Musical Excerpt 4 Lyndal is utterly attentive, she sings the melodic phrases accurately while responding to their rhythms on a drum with her hands. She anticipates repetitions of rhythmic structure and sensitively follows a ritardando and diminuendo. Then she asks for a reed horn and blows rhythmic patterns antiphonally with me. The session closes with Lyndal singing her good-bye song very freely, and bidding goodbye to the stunned, perplexed visitors. Audio File: Lyndal—Excerpt 20 After this session, Lyndal’s parents reported that there was an immediate effect on her tolerance of “family” sound levels; she was no longer upset by louder or unexpected noises—all sounds at home could go up to normal levels. Reports from the school and residents at “Warrah” also indicated that the head-banging was diminishing and that the contusion on her forehead was healing. It was absolutely necessary to generate this dramatic intensity of music-making to enable Lyndal to achieve her “break through.” If one considers all of the great dramas, whether in theater or opera, they are essentially concerned with emotional disturbance and the conflict and pain this brings about—and perhaps the struggle toward resolution. So it can be in music therapy with emotionally disturbed children—they too can be in highly dramatic situations and making what for them are enormous steps. Such happenings are not little events! An achievement like this is a world-changing event! And it is wonderful that the power of music can support such developments—it nourishes the inner growth of these children. Stage Two After a transitional period in which Lyndal consolidated her new gains and confidence, we entered what was in effect “stage two” of music therapy with her. By this time, she sings

and uses a variety of drums; the cymbal work now includes the two large cymbals in use in the regular group work. In the 30th session, Lyndal’s wish to use a large cymbal freely is well illustrated when she raises both mallets high above her head in time for the last note of a melodic phrase— apparently about to beat with great strength. Instead, she brings her arms down slowly with utter caution, makes contact with the cymbal gently and leaves the mallets resting on it to damp the sound. Despite her caution, her use of the instruments develops steadily: her tempo range is widening, her control is improving, and her movements are larger and smoother. She has acquired some poise and is becoming noticeably more graceful. Clive and I work directly for greater physical freedom—for with Lyndal, physical freedom promotes emotional freedom. There is a noticeable air of confidence about her that sustains a positive level of working relationship with us. She participates, willingly, in music and songs developed to widen her circle of experience. During these sessions, Clive begins to raise both cymbals high to extend her reachingbeating movements. Her technique of cymbal playing, in which the beater simultaneously strikes and damps the instrument, is defeated by Clive playfully withdrawing the cymbal as she strikes it, so leaving its tone sounding freely. She sees the humor in what he is doing and goes along with it. Impulses to beat the large cymbal firmly progressively break through. In her 40th session, seated at the piano beside me, Lyndal participates in a creatively free vocal exploration that takes her up to the G above the staff. As she sings she often plays the piano freely, with an appropriate musical style. She is relaxed, smiling, confident, obviously enjoying the vocal competence she is discovering and the mutuality she shares in singing with us. In these last weeks of our work with her she uses the cymbal proficiently, with decision, and no hesitancy whatsoever. She successfully masters a challenging part on a metallophone in the Shaker Waltz, (Pinson, 1988), and works hard to sing The Prayer of the Little Ducks (Nordoff, 1983), which she then performs as a solo before the whole school—a new and important achievement for her. Discussion and Conclusion Lyndal’s general development showed a rounded maturation: she had become quite a self-confident adolescent; she could hold conversations, could function better at home, and had become the leader of her class at school. She had released and realized much of her potential. We experienced this at first hand on a visit to Australia in 1990, when we were asked to make a television videotape with her. After not seeing her for fourteen months, we found in our warm-up session that all her music was still alive within her. As she was filmed the following day in a twenty-five minute demonstration, she was radiant! It was so moving! She is such a self-possessed young lady now, and greets people with confidence. We have truly seen her changing in her personality, in herself, the self that she presents to other people, the self that she lives with. She now verbalizes her concerns and frustrations, and the self-injurious behavior has completely disappeared.

All through this work she has lived in a very supportive environment at “Warrah.” This study of Lyndal shows well the effect of central focused therapy, supported by several peripheral contributing therapies. What growth occurred in music would be taken up and developed in the environment; conversely, the security and courage she gained from the environment would play over into the music sessions—a very beneficial cycle of events. In conclusion, let us look again at this concept of the “music child” present, not only in Lyndal, but in all children. If the “music child” is capable of changing the personality and changing it permanently—and of releasing developmental potentials to give the unfolding personality such a positive sense of identity—from where does it get the power to do this, to be a self-creating force within the self? In answer, we reintroduce a concept we considered earlier, one that will complete this working model: the “being within the self.” We can term this the “being child,” and find that it is contained within the music child (Figure 8).

Figure 8. The “Being Child” Within The “Music Child” As the child develops, the “old self disappears or dissolves, its remnants transformed and absorbed into the “new self.” This process can be described in terms of the four major psychological orientations: behavioral, psychodynamic, humanistic, and transpersonal. Quite often, as was evident in the work with the outer expressions of Lyndal, we are, to quite an extent, working behaviorally—we all must, of necessity, work with behavior. As you work to resolve, within developing children, the tensions that lie between the old self and the new self, you are also working psychodynamically, either on a practical level, where children’s musical activities themselves symbolize inner needs or drives, or with clients who can articulate their inner lives verbally, in more traditional ways. In the centre of the diagram, in the region of being, music therapy is directly involved in self-actualization—which is the core of the humanistic force in psychology. Self-actualization in this context is also transpersonal insofar as we are, through creative music therapy, calling beings into existence that have not existed before. There has been the potential but it has not been actualized into existence before. This may appear to be over-reaching, or presumptuous, but we are all working with the inner lives of children—and we are working for their futures, for every year of their lives to

come. We are working to bring basic, fundamental changes to human beings. We are working at considerable depth, much greater depths than often we understand. This viewpoint is part of the humility we should have in taking this art of music into therapy—because of all that’s there in the music itself: music as it has been handed on to us through the whole of human evolution, through all that the great composers have evolved in their explorations of form, melody, harmony, rhythm and expression, through all that lives in the music we have inherited from all the folk of the earth.

Figure 9. Orientations of the Self As music therapists we have this glorious task, involving two glorious arts: the art of evolving a human personality out of itself through another art which enables us to communicate with all the dynamics that are potential there. One runs out of concepts and words eventually, in trying to put what music therapy is into words.

Glossary Hypertonic: Having excessive muscular tension. Micro-cephalic: Having an abnormally small skull. Moderately Mentally Handicapped: Generally denoting a person testing in an IQ range of 35-49. Stereotypic: Having fixed, repetitive patterns of speech and behavior. Acknowledgement The authors would like to thank the New Zealand Society for Music Therapy for its permission to revise and reprint this case study, which was originally published in the Society’s Annual Journal (1990). References Corbin, H. (1969). Creative Imagination in the Sufism of Ibn Arabi. Translated by R. Manheim. London: Routledge and Kegan Paul. Nordoff P. (1983). Some Prayers from the Ark. Bryn Mawr, PA: Theodore Presser. Nordoff, P. & Robbins, C. (1962). The First Book of Children’s Play songs. Bryn Mawr, PA: Theodore Presser. Nordoff P., & Robbins C. (1970). The Children’s Christmas Play. Bryn Mawr, PA: Theodore Presser. Nordoff, P., & Robbins, C. (1971). Therapy in Music for Handicapped Children. New York: St. Martin’s Press. Nordoff P., & Robbins C. (1977). Creative Music Therapy. New York: John Day Co. Pinson, J. (1988). Mallet Magic. Denton, TX: Home Church School Resources.

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

CASE THIRTEEN Creative Music Therapy in Bringing Order, Change and Communicativeness to the Life of a Brain-Injured Adolescent Clive E. Robbins Carol M. Robbins Abstract Two therapists work as a team, using improvised music to engage Hilary, an acting-out adolescent girl with brain injury. Through the creative process, Hilary learns to channel her natural impulses into musical expression and interaction. As this occurs, she is able to bring order, change, and communicativeness into other aspects of her life. Introduction Music is, above all, a means for bringing about changes: changes of mood, changes in relationship, changes of attitude, changes in attentiveness. One has only to consider how, in a lively, enthusiastic group sing-along, songs in various moods directly influence the participation of the singers. As an agent for the transmission of energy, stimulation, joy, warmth—and order—music is unique. In contrast to the melodic-conceptual experience of singing, consider moving to music, as, for example, responding to the compelling impact of tribal African drumming. How physically animating the beat and polyrhythm’s are! How the timbres of the drums speak the rhythms directly into our bodies! And yet how directional such drumming is, what purpose it has! How it communicates the power of the body’s need to move rhythmically! In considering the kinds of changes that we work to bring about in a client in therapy, it is important to realize that sometimes our wish to bring about a particular change can be misplaced. We can only change what is inherent in the functional possibilities of the organism— to the extent that these make changes possible. Should the damage or the disturbance be extensive, such changes as may be achievable must lie within these possibilities. However, we must not underestimate what changes could become possible through a creative approach, especially when the explorative nature of music therapy based on improvisation discloses areas of ability and sensitivity which would otherwise remain undiscovered. The all-important area, in which we can bring about change, is personality development. Here we can, through music, often bypass some of the organically-based dysfunctions that hinder competent functioning in life. This is where improvised music can play such a vital role in treatment. In working interactively with a client, a therapist can improvise ways around the barriers, around the difficulties, to reach the living sensitivities, and then work into the problem

areas, where creative work has the possibility of releasing potentials for resolution and development. Let us consider the act of creation, or creativity, which is so intrinsic to the level of clinical musicianship we are considering. Those who consume music passively tend to think of creativity as something ephemeral, arbitrary, perhaps haphazard and undependable, and lacking in substantial reality. But a glance at the world of music will quickly demonstrate that the products of creativity are anything but insubstantial. Every piece of music that is important to us—that we are swept along by, enjoy in a particular personal way—has been created. Before it existed, it was inconceivable. But some musician, or group of musicians, has a musical idea, and then begins the process of creation. It might last three minutes, it might last three years, but through this process an experience is realized that becomes part of the very fabric of life. Recognize that once all the music we respond to did not exist, and then through countless acts of musical creation, came into existence. And from being nothing before, now it exists. Realize how firmly it stands in our consciousness: how we carry it around with us, what a vehicle it is for us to share in, what strength it has in our emotional lives, our mental lives, our spiritual lives. It is extraordinary! The rich musical furniture of our lives, everything from folk music to film music, Scott Joplin to Bartok, all has come into being through this process of creation. The potential impact of musical creativity transfers directly into the processes of music therapy. When a therapist works individually with a client through improvisation, he or she will be called upon to create, or adapt, in response to clinical situations, themes with which that individual comes to identify positively. These themes then become sources of nourishment for individuation, express much of the content of the client-therapist relationship, and provide significant opportunities for interaction and intercommunication. Such music, generated spontaneously in response to clinical events and needs, becomes uniquely substantial to the person in therapy. Method This clinical narrative provides an illustration of “Creative Music Therapy,” an approach originally developed for handicapped children in 1959 by Paul Nordoff and Clive Robbins (1977). In its individual application, the approach involves two therapists working as a team with a single child, with improvisation as the focus of the creative therapy process. One therapist improvises at the piano, creating music to engage the child in a therapeutic experience, while the other works directly with the child, helping him or her to respond, either instrumentally or vocally, to the improvised music and to the clinical intentions of the therapist at the piano. The therapists work as partners with clearly defined and equal roles and responsibilities. Each session involves creating an individualized musical repertoire for the child—one that capitalizes on the child’s innate musicality and reflects the child’s unique personality. This musical repertoire is created by the therapist cumulatively, session by session, motif by motif, line by line. Several basic concepts are involved. First and foremost, the therapist improvises music which accepts and meets the child’s emotional state, while also matching, accompanying, and enhancing how the child is expressing it. It is important for the therapist to respond to the child from moment to moment, often

supporting every musical response the child makes, no matter how fleeting or incipient, and musically seizing upon every opportunity to explore its expressive possibilities. The therapist works to evoke either a vocal or instrumental response, depending on the natural propensities of the child. As the child formulates each response, the therapist creates musical situations and activities that encourage the child to further develop the response—to gain some measure of mastery over the music. In doing so, the therapist motivates the child to acquire musical skills needed to participate more fully. Through improvisation, the therapist is constantly “sounding out” the character and extent of the child’s responsiveness, and stimulating, answering, or stabilizing the child’s activities as clinically appropriate. With the acquisition of each skill, the child is musically guided to discover new expressive options and choices that the skill has made possible. In the process of discovering musical possibilities and gaining musical skills, the therapist also engages the child in communicative dialogues, thereby showing the many ways that the child can relate his/her musical expression to that of another person. The child, increasingly confident in personal musical expression, learns how to be inter-responsive. It is essential to the practice of this approach that each session be fully documented with the aid of an audio or video recording, thus ensuring continuity of clinical technique and a clear perception of all phenomena pertinent to the child’s response process. This gives essential clinical guidance for subsequent sessions. Any improvised music that has been important is transcribed so that it can return as an ongoing theme in therapy. We would like to illustrate creative music therapy by describing our work with a 16year-old girl at Inala, a Rudolf Steiner special school in Sydney, Australia. (“Inala” is an Aboriginal word for “peace”). To know this young lady, and the severity of her disabilities, is to realize that the only way you can do anything for her—apart from entertain her and perhaps lighten her mood—the only way you might bring about a significant change is through improvisation. This means a leap into the unknown from the first moment of the first session, to find out what responses music can stimulate—and then support to foster and advance communication. How will a therapist achieve musical interaction with her? She is a multihandicapped person—it quickly became evident that how she manifested in music was symptomatic of her condition. Background Information We want to introduce Hilary not as a “case study” but as a human being who is following a path. And we, as her therapists, are about to find and take a new path with her. We cannot know where the bends will be, where that path will lead us. When working with improvisation, working creatively, there is no recipe—as that would remove the spontaneity, the livingness, the creativity, and the wonderful unexpected moments of unfolding and discovery. When we first began working with her, we did ask for case material, but inquired only about relevant medical problems, such as severe epilepsy. We wanted to meet her as she would be in music with us—to form and work freely from our own uninfluenced perceptions. Once our independent clinical assessment was made, that would be the time to study her case material.

Hilary was born in 1966. She was very much a wanted child as a long series of miscarriages and misfortunes preceded her birth. Pregnancy was difficult, birth was induced, and delivery was instrumental. Though difficult to diagnose with any certainty in infancy, it was later to be evident that Hilary had sustained brain damage. There were early breathing problems. Abnormality was noted at 15 months, and all the developmental milestones were late. She did not develop speech. There were some physical disabilities: she had poor balance and was unsteady on her feet, walking in little shuffling steps a good deal of the time. She was frightened of heights and stairs. Generally, she was placid but overreacted to loud noises. When she was three, she began to react adversely toward other children and became withdrawn for long periods. She first attended Inala School as a day student. As she got older, her behavior problems worsened with tantrums and the pulling of other children’s hair. At six her parents requested that she become resident at the school. Her behavior problems continued. When Hilary was 16, her future became uncertain. She was uncooperative, stubborn, and disruptive in the classroom. Her behavior was threatening to prevent her admittance to the Activity Therapy Centre (a sheltered workshop for moderately to profoundly disabled adolescents and adults) and she faced the real possibility of institutionalization. At this time we were asked to take her in the hope that music therapy could effect a positive change. Once weekly sessions were scheduled. We will describe the first four sessions in some detail, because this is where the major changes began to take place. Treatment Process First Session Hilary comes willingly to her first session, but is very tense; Carol repeats a “Good Morning Hilary” phrase to her, trying to put her more at ease. I notice her fingers trembling, and when I give her drumsticks, there are short bursts of fast, tense beating, most of it around 260 beats per minute (bpm). On the cymbal she beats forcefully at 190-220 bpm, drowning out the music that Carol is improvising to meet her. As part of the exploration, I sit Hilary on the piano bench. She touches the piano keys twice then attacks Carol, grabbing her hair, pulling her head down. Carol goes with the pull, singing gently while undoing Hilary’s grip. Hilary then grabs at Carol’s skirt and knees. She is strong. She yells once as we try to calm her. I return her to her chair, near the piano but not close to it. She listens quietly as music is played and sung to her. Her agitation diminishes over the next several minutes and she is calm when taken back to her classroom. We noted in detail all aspects of Hilary’s reaction and response. Most of the music had been improvised to meet her disturbed state, but because this did not recur (she never attacked Carol again) and the music was not appropriate to the coactivity that subsequently developed, it was not used again. However, the melodic phrase with which Carol greeted her at the beginning of the session did become part of her repertoire, becoming extended in later sessions. It was in a Mixolydian mode (Figure 1):

Figure 1. Musical Excerpt 1 Second Session Hilary is noticeably happy to come to the session with me. She still shows much tension, but I also see a spark of anticipation. I bring her to the drum as in the first session and again she beats in a fast, driven tempo, 200-260 beats per minute (bpm). She is aware of Carol’s improvising, and her beating becomes responsive to the music at times, as when she stops beating at the ends of phrases. It appears that Hilary gains support from the music, she beats more confidently when the music is stronger-and often stops when the music is soft. She is obviously intent on having Carol make music for and with her. She makes a sound of pleasure when Carol begins to sing. We perceive her sensitivity. Experimentally, I place a large timpani before her. At first, to encourage her listening, Carol plays gently using arrieggiated chords. Hilary impresses us with her self-restraint as she holds back her beating to this soft music. After a minute or so Carol introduces vigorous, forceful music to release Hilary into free strong beating. She needs to do this and seizes the opportunity immediately, beating the timpani energetically in the tempo of Carol’s bass octaves at 200 bpm. (See middle of Figure 2). As Carol brings the vigorous music to a close and returns to softer music, Hilary finishes her beating with a flourish which contains a clear, rapid triplet. It seems to originate unconsciously, but it tells us that rhythmic ability is latent within her. She is keen to continue and chuckles as she beats. Late in the session she spontaneously beats to soft music at 200 bpm and follows a ritardando to 170 bpm. In an improvised “Goodbye song” her beating shows her sensitivity to dynamics. She smiles a number of times.

After the session ends, I escort her to the girl’s toilet and, while waiting outside, I hear her screaming. Questions leap into my mind: Why, after such a promising session? Was she

Figure 2. Musical Excerpt 2 angry that she had to leave the music room? Could it be that in the improvised music and in beating with it, Hilary had experienced a special kind of release and freedom that carried over into this letting go of some of her feelings? The kind of liveliness of contact that she felt in the

music was definitely unattainable in her daily life—where else in the normal circle of her life could she be this activated-even though she was in a fine school? She must have found the session stimulating and satisfying; perhaps then, the screaming arose as a way of readjusting to the norm. It occurred to me that there was something quite positive about Hilary finding a private place to scream! In a little while she returned quietly to the classroom. Further insight can be gained from studying Hilary’s way of making music against the background of a comprehensive examination of the clinical and experiential significance of tempo and dynamics. Figure 3 presents a “Tempo-Dynamics Schema” derived from studying the responses of over 200 variously handicapped children in improvisational individual music therapy (Nordoff & Robbins, 1977, p. 158-159). When a fast tempo is determined pathologically by the present condition of the child, one finds that it originates in nervousness, tenseness, hyperactivity, over excitation, obsessiveness, or in resistiveness, in which the child is “running away” to avoid contact through the music with the therapist. For the improvisational therapist, these reactions are much more vividly real than the words can convey: there is a directness and clarity of emotional communication when the therapist is creating music with the child. There is an immediacy of understanding if one follows and lives in the child’s sounds moment to moment. In contrast to the pathology driven fastness is a fast tempo which originates in normal musical experience. The normal range of fast tempos can bring activation and alertness, buoyancy, and a host of qualities that can open up musical enjoyments such as joyfulness, gaiety, playfulness, happy excitement, and fervor. It is interesting to note how all of the pathological states associated with fast tempos are self-isolating, whereas the normal musical experiences of fast tempos bring sharing and uniting with others. When seen in this way, the schema provides a map of musical terrains that can guide the therapist in bringing about change. Through the give-and-take of improvisation, changes in tempo can bring the condition that is on the pathological side over, as this is possible, into the area of normal musical experience: to take what the child is driven to do, and through putting music to it, make it a shared experience in which new, more satisfying emotional experiences can be generated. The dynamics of music can be used in the same way. When a drum or any instrument is beaten loudly, and when this originates in a pathological state of being, one hears aggression, frustration or anger; or as so often observed in emotionally disturbed children, adolescents, and adults, the sounds reflect a lack of impulse control, emotional-motor discharge, nonresponsive assertiveness, and the resistiveness of “shutting the other person out.” In contrast, the loud dynamic in normal musical experience conveys animation and eagerness, exuberance, assertive freedom-all very positive qualities-confidence, and climactic fulfillment. The universal significance of musical tempo and dynamic is nicely illustrated by the true story of an African drummer from Zambia. Whenever he became burdened with a certain emotional disturbance, he would get up in the night, awaken his two wives (both of whom were competent drummers), and then work through his disturbance rhythmically. The drumming allowed him to discharge his emotional tensions with the empathic support of his musicianly wives, who alternately followed and led him through various modes of rhythmic experience: from fast to slow and back, and from loud to soft and back. In terms of the schema, the man needed an emotional-motor discharge, in which he could assert himself and determine

his own course of action, while still being supported by others beating with him. This shared release helped his drumming to become expressive and communicative. He could somehow “objectify” his feelings and their transformations—and therein be healed. TEMPO AND DYNAMIC SCHEMA IN CREATIVE MUSIC THERAPY Pathologically Determined

Normal Musical Experience FAST TEMPOS

SLOW TEMPOS

LOUD TEMPOS

SOFT DYNAMICS

Figure 3. Tempo-Dynamics Schema In Hilary’s first session, her loud cymbal beating had the character of aggression, even anger. In the second session, she moved into loud drum beating, which seemed to come more from frustration. But as Carol took it up with minor, purposeful music, you could hear animation and eagerness coming to expression in her beating. Already a change was beginning.

Third Session Hilary is eager and excited as she enters, but inhibited at first, unable to respond freely. When I give her the drumsticks, they tremble rapidly in the air. Her initial beating comes about as she tentatively brings the trembling drumsticks into contact with the drum—it is soft and fast, 360 bpm. It suggests tenseness possibly compounded with fear. Carol plays to match and meet her mood, and when she begins to sing, Hilary makes a sound of pleasure—in the same key. After much encouragement, Hilary begins to beat with a little more intention at 285 bpm. Carol carefully improvises to support her, and Hilary’s beating becomes sustained. Her face relaxes. A lightness and delicacy emerge in the shared music. Hilary’s tempo comes down to 250 bpm. When Hilary has found her confidence and Carol feels she is in secure contact with her, she improvises a song to bring in the experience of a slower beat (Figure 4). The song is in waltz time and begins at 90 bpm: “Let’s play a song, Hilary’s song, Let’s play a song, together. Hilary can play a slow song, together, together, together.”

Figure 4. Musical Excerpt 3

As the song is repeated Hilary beats the cymbal rapidly several times. Her beating impulses seem to begin in double tempo, two beats to Carol’s one, but then quicken into cymbal tremolos. To give her an experience of beating in a slower tempo, Carol asks me to guide her, and adapts the song to include my name. I take Hilary’s left hand and beat with it to the song, now at 75 bpm; she makes an exclamation of pleasure. When I release her hand she accelerates until she is beating at 300 bpm—subdividing the beat exactly by four. Hilary feels the pulse of the music, and is drawn to unite with it. Yet within her is tenseness that she can only discharge in fast tempi. But also within her are musical sensitivity and a sense of rhythm which, in a way we do not yet fully understand, somehow take over and order her “discharge” beating by bringing it into a 4:1 relationship with the slow tempo. She does not do this consciously by deciding: “Now I will beat four beats to one.” Something much more primal takes place: as the internal pressure accelerates her beating toward the rapidity it needs for discharge, her hearing, musical feeling, and sense of rhythm bring about this concurrence, in this example through beating sixteenth notes. This ordering must happen at a subconscious level, but once it has happened she is able to hear and feel the concurrence, and so feel the release of the discharge within the secure pulse of the music. Carol’s earlier improvising in the tempo of her fast beating must have given her a personal feeling of being accepted-while, at the same time, “making musical sense” of her need to beat fast. This imparting of musical meaning to the fast beating would have already contributed to the awakening of her musicality and so, to some extent, have prepared the ground for the beating of multiples of the basic beat. This now becomes part of her way of responding, it is just beginning; she will go on to do more of it. As the session continues, I take her left arm again and beat to the song at 80 bpm; Hilary joins in with her right arm, beating in the same tempo. Clearly this is her beating impulse. I am only guiding. Again she enjoys the movement together and laughs. I let her arm go free and very steadily she accelerates to exactly two to the beat, stays with this for some moments, and then accelerates further. At the piano, Carol goes with the accelerated beating until a ritardando seems musically inevitable: as if it is the right segue into a repeat of the song. Hilary stops immediately—the ritardando heightens her awareness of the music. She waits as Carol’s momentum unwinds to a natural conclusion, then recommences “a tempo,” beating with the song at 85 bpm. She stays in the tempo to the end. Hilary’s control in the accelerando was remarkable! She was not letting herself simply “run away.” When the music paused she stopped and waited until it continued. An inner control is beginning to show. The session draws to a close with the “Goodbye Song,” after which I experimentally invite Hilary to sing—something we have never heard her do. As I sing freely, Hilary laughs in a musical voice. Fourth Session Hilary is very keen to come to music, and enters the room stamping her feet in excitement and humming with pleasure. Carol sings “Good morning” to her–this time

introducing considerable rubato-Hilary watches and listens with total attention; the rubato brings the element of suspense into the song and she smiles as she receives the greeting. It is so important in therapy to get out of a metronomic beat whenever it no longer serves its purpose—that of keeping the music or the music-makers together. Certainly a metronomic or fixed beat is absolutely necessary whenever rhythmic regularity is required or, for example, in group singing, when everyone has to know where they are in the music in order to stay together, similarly in movement to music. But the moment an improviser or performer brings in a pause, a fermata, or a ritardando, an expressive element is introduced. This arouses keener listening—one listens not because the music takes place on a predictable beat, but because a melodic statement is being made in its own time. The melody or musical statement does not have to move for any other reason than that the musician wants it that way. It is not driven by a beat, and this makes one much more attentive to it. This can add a living sense of immediacy to a song, especially when you are singing 1Q a child. Thus, there are times in therapy when you need the predictability of the beat, and times when it is important to get away from it. As the session continues, Hilary starts to beat confidently in tempo with the song, 120 bpm, and then accelerates with impressive and steady control to 265 bpm. Carol accelerates all the way with her. Hilary seems to be bridging something in her. She made this measured accelerando from the tempo of Carol’s music, in which she began because she is musically sensitive to the fast beating which she still needs to do. What inner process is involved in this? This is the second time Hilary has presented this kind of response: she did not jump from one tempo to the other, but accelerated gradually across a range of tempos. She was linking her response to the music we were presenting with what she needed to do out of her state of self. She was connecting and integrating. There was something moderating at work—she was filling in a gap between sense impression and the tenseness and energy that comes to expression in fast beating. Often, in this kind of work, it happens that a therapist has an intuition. At this moment, Carol decided not to go with Hilary’s fast beating, but to hold a constant tempo and see what would happen. As Carol sets a tempo of 75 bpm, Hilary immediately beats multiples of the beat: 3:1 (225 bpm); a sequence follows in which she changes quickly from 3:1 to 2:1 and back to 3:1. When Carol sings and the tension of the music increases, Hilary’s beating goes up to 4:1 (300 bpm):

Figure 5. Musical Excerpt 4 She stops, waits, recommences at 4:1, then drops to 3:1. She pauses again when Carol makes a diminuendo; as the dynamic is increased she beats again at 3:1. Carol now plays with her fast beating. This happens over a fifty-second period. Carol decides to go further into structure by introducing an eight measure phrase in 3/4, in G minor, ending with a clear cadence (Figure 5). We had heard Hilary stop beating many times at the ends of phrases—can we now use this perception deliberately in a short piece of rhythmic structure as a basis for work together? Carol plays this phrase, stopping on the tonic and raising her hands off the keyboard in a clear visual signal to stimulate Hilary’s control; Hilary beats in the tempo, 165 bpm, and stops five beats after Carol. To a repeat, she stops three beats after Carol. The third time she beats faster than the tempo and stops about two beats early-she looks cheekily at Carol as if to say “I made you stop this time!” We all laugh. The fourth time she again beats fast and deliberately continues long after the therapist has stopped, laughing in a spirit of devilment. The fifth time, she “overheats” by about six beats. Later in the session when we come back to this activity, Hilary picks up the tempo more surely and responds attentively. This time Carol plays the phrase, and Hilary beats in tempo, 160 bpm, adding only two beats beyond the phrase. To a repetition, she beats three beats beyond the stop. The therapist takes this principle of coactivity into “Hilary’s Song.” Hilary beats at 3:1 to the slow tempo. She stops one beat after the end of each of the first two phrases. She stops before the end of the next phrase, out of her keenness to participate, for she is watching Carol closely.

Figure 6. Musical Excerpt 5 As the song leads into a climax Hilary beats vigorously; Carol accompanies her fast beating with the accompaniment while singing the song. Although she is animated, Hilary stops precisely at the end of the next phrase. Carol then begins the next phrase in a soft dynamic, Hilary beats quietly. The phrase is short but she is concentrating and stops exactly again. She laughs with recognition at the musical humor in what they are doing. She sustains her attentiveness. I then stand behind Hilary and, holding her arms, guide her in beating at 55 bpm. She enjoys the assertiveness of the slow tempo and the accompanying music. As she beats, I move my hands up her arm until she is beating alone but can feel the support of my hands resting on her shoulders. She begins an extremely well controlled accelerando that reaches 125 bpm and holds it for eight measures. Her tempo then gradually rises to 210 bpm, where it stays for over 30 seconds. Throughout the accelerando she watches Carol keenly, obviously aware that they are making this musical adventure together–and enjoying the freedom of being a co-creator. The accelerando is led to its climax at 300 bpm, then Carol and I take her back to slow beating at 70 bpm. As Carol begins the “Goodbye Song” Hilary joins in the singing. She does not have the language or the vocal control but the quality of her commitment is unmistakable. She sings through the first two phrases; her voice is soft and breathy but she sustains her tones and some are on pitch. It was in this session that Hilary began to consolidate her involvement and abilities in music: she brought more control to bear on her urge to accelerate into faster beating; the compulsion to beat fast was becoming increasingly ordered by the rhythmic responsiveness of

her multiple beating; she was gaining the control required to beat in a soft dynamic; slow and moderate tempos were coming into her tempo range; and she could participate closely with the therapist in a recognized goal in rhythmic structure. As music was now such a uniquely important area of activity, experience and relationship for her, consolidation in musical participation would mean, in an intimately real sense, consolidation of self. It is not surprising that with this positive feeling of her own self, and her living pleasure in the music, Hilary should spontaneously attempt to sing–and sing a song to which she felt attached. Subsequent Sessions This brief singing apparently brought Hilary to the limit of her abilities. She did not sing again in music therapy until her 30th session, and then not until two years later, although vocal expressions of pleasure were numerous. Her individual sessions, averaging about 17 minutes in length, continued on a weekly basis. On the afternoons of the days she had her individual sessions, she, together with several older girls, sat in on a group activity with a class of eight to 10-year-olds. These sessions brought her much enjoyment. She was included in greeting songs, and sometimes taken round to greet the children. She was gentle with them, and they were unafraid of her. While watching and listening to the singing games she could be seen hugging herself with pleasure.

Figure 7. Musical Excerpt 6 She was an ebullient “dancer” but, being unsteady on her feet, needed support. Even so, she could overwhelm her partner with the vigor of her movements. At this time, she also became an enthusiastic member of an adolescent music group. Most of the effects of music therapy became evident in her school and hostel life by the twelfth session. She was lighter in mood, happier, more amenable and receptive. She seemed fulfilled, more complete as a person. It was noticed that she walked more purposefully. The aggressive behavior almost completely stopped, and only reappeared when she was unusually stressed or upset. Later it ceased entirely. Her teacher, an older woman with considerable experience with the handicapped, was outspoken about the positive changes in Hilary since beginning music therapy. Her individual work continued to be essentially rhythmic. Her slowest tempo came down to 75 bpm, which made a wider range of musical experience possible. She spent about half her sessions at the piano, playing single tones in each hand with Carol’s supportive, responsive improvisations. She reached a stage of freedom in her playing which, to anyone who knew her line of progress in music, would be recognized as being creative. We continued taking her over the next two years as the staff of the school felt that her individual sessions were especially important to her. A year later, when she moved to the Activity Therapy Center, her sessions were reinstated for some months to support her during the transition. Altogether she had 55 sessions of individual therapy. She went on to join a music group of adults from the Activity Therapy Centre. Acknowledgement The authors would like to thank the Australian Music Therapy Association for its permission to revise and reprint this case study, which was originally published in its proceedings of Thirteenth National Conference of the AMTA (1988). Reference Nordoff, P & Robbins, C. (1977). Creative Music Therapy. New York: John Day.

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

CASE FOURTEEN The Use of Piano Improvisation in Developing Interaction and Participation in a Blind Boy with Behavioral Disturbances Helen Shoemark Abstract This case describes music therapy in a school setting with Brian, an eight-year-old boy who was referred to music therapy because of an excellent sense of rhythm and the need to develop relationships which encouraged interaction and participation. The goal in his Individual Education Program (IEP) was to develop piano skills and the interactive behaviors necessary to do so. The method used was piano improvisation, based on the principles of “Creative Music Therapy” (Nordoff & Robbins, 1977) and the classroom philosophy of “Gentle Teaching” (McGee, et al., 1987). Through music therapy, Brian developed several basic music skills, learned to spontaneously interact and participate with the therapist in making music, and increased his participation in classroom activities. Introduction This case study took place in a residential education facility for children with multiple disabilities. The philosophy of the school embraces Individualized Education Programs (IEPs) for each student. Music therapy is well established, employing two part-time music therapists at the time of this study to serve 54 students. The music therapists work to accomplish aims of the IEP within a team approach. The main areas addressed in music therapy are communication and self-awareness. Background Information Brian comes from a family of three children, two girls and Brian (the youngest). Upon admission to the school, Brian was 6 years old, and during the course of this study, he turned eight. The family lived in a country town, while Brian was in residential care at the school. He returned home during school vacation periods. Brian had attended the school for approximately 18 months at the commencement of this program. Brian was born by normal birth at 27 weeks gestation. During the first few weeks after birth, he had persistent and severe bouts of apnoea (cessation or suspension of breathing) and brachycardia (slowness of the heartbeat), and was treated for prolonged periods with ventilation. The large doses of oxygen induced retrolental fibroplasia, which in Brian’s case,

manifested as detached retinas. As a result, Brian had no useful vision or light perception. His hearing tested as normal. Brian also evidenced seizures from the time of birth and has been taking Tegratol to control them. At six years of age Brian’s pediatrician noted head-banging, no speech, apart from clicking of tongue, rubbing of eyes with fists and continual crying at home. Upon admission to the school that year (and for many months thereafter), Brian presented as a developmentally delayed child, with the same characteristics observed when he was six years old. His behavior also included vocal chanting which was often wailing in nature. The phrase was usually four to six notes, with certain phrases being used often and others occurring only occasionally. He would persist with this wailing for periods of up to 45-minutes, and it was usually intensified if a caregiver tried to redirect him. Thus, it was used as a form of communication to remove caregivers and to avoid engagement in activity (Donnellan, et al., 1985). The only positive interaction in which he would engage was cuddling with staff during lunch times. This was deemed inappropriate for a boy of seven, and was halted. During the first 18 months at school, Brian participated in group music sessions with his class (four other students). He showed obvious enthusiasm for musical instruments, playing any that he could find. He displayed a sense of rhythm, beating in a regulated fashion for as long as allowed. He enjoyed songs and was able to accurately produce the melody and lyrics of several lines and/or line endings from songs in his repertoire. He would not tolerate playing or singing with anyone else. He used no verbal communication. He was unable to cope with turn-taking, withdrawing into eye-poking and tongue-clicking for much of the session when not engaged. Rationale for Method At the beginning of the school year, Brian had been placed with a new teacher and new class. The teacher advocated that a “gentle teaching” approach be taken, as outlined by McGee et al (1987). Its basic goal is to teach bonding through three interactional stances: (1) That the care-giver’s presence signals safety and security; (2) That the caregiver’s words and contacts (e.g. looks, smiles, embraces, touch etc.) are inherently rewarding; and (3) That participation yields reward. This shift in philosophical orientation required agreement from all those working with Brian’s class, along with additional training. Brian’s behavior showed that he had little trust for those around him, and yet he desperately needed positive input, as demonstrated by the acceptance of hugging in the playground. The classroom teacher encouraged all those working with Brian to adhere to the central concept of gentle teaching: that bonding is the center of all future complex human development, and punishment results in submission, “the antithesis of bonding” (McGee, et al., 1987, p. 19). Staff were to create an environment of proactive rather than reactive teaching; using activities which would offer reward for participation and interaction. To this effect, music was considered to be a primary tool. Brian did not use speech and language to communicate, whereas rhythm and melody (as evidenced in his chanting) already existed as avenues for self-expression and communication. In the classroom, Brian had produced on a drum the commonly known rhythm pattern: “ta...ti-ti..ta–ta.......ta–ta!” He expressed great delight (jumping and laughing) when the pattern was correctly completed by the teacher, and subsequently, the music therapist. His

enjoyment of this participation with another person, and his sense of rhythm indicated that music may be a starting point for developing an equitable and rewarding relationship, in line with the “gentle teaching” approach. Given his need for involvement in positive relationships, and his interest in rhythm, it was agreed that the music therapy program could focus on interaction and participation through his already established uses of rhythm and melody. The long-term goal specified for the IEP was to employ a range of basic piano techniques in musical improvisation with the music therapist. Specific short term objectives were designed to move Brian through a gradual sequence from passive acceptance of the music therapist’s participation to more active initiation of musical interaction with her. They were: (1) To accept the music therapist’s touch and manipulation of his hands when teaching Brian playing techniques; (2) To co-actively work with the music therapist to develop techniques, using some effort to move responsively with the therapist; (3) To co-operatively work with the music therapist to develop techniques, by anticipating movements and using equal efforts; (4)To independently achieve techniques after modeling without the need for physical contact; (5) To initiate techniques without being presented a model (i.e., without mention or example); (6) To respond to the music therapist’s techniques with reflective techniques, by mirroring, extending, and contrasting what is presented by the therapist. Treatment Process Brian’s music therapy program can be divided into three main periods: the initial period (February through April); the exploration period (May through August); and the control period (September through November). Initial Period In the initial period, Brian received two sessions per week in the classroom, with another child participating. The sessions were scheduled for 30 minutes early in the day to maximize energy levels; however, sometimes the sessions were shortened due to the short concentration span of the two children. These classroom sessions provided a period of observation and rapport development. Each session was devoted to introducing songs that would be used later as formats for teaching communication and social skills as well as rhythmic improvization skills on the drum. In the improvisation work during the initial period, Brian and the therapist both played the same small, tunable drum. This was done to give Brian equal opportunities for creativity and participation. The therapist responded to any patterns initiated by Brian with imitation or playing the patterns simultaneously. Brian’s patterns usually consisted of straight quarter/eighth note patterns or combinations of dotted and straight notes. They were generally of four quarter beats’ duration. The therapist would also initiate patterns, and Brian would immediately try to copy them. He was usually successful with straight, dotted and triplet rhythms. During these improvisation exercises, Brian was relaxed (smiling, at-ease posture) and attended the activity for periods of approximately 10 minutes. He used open-handed and closed-handed beating, scratching with finger-nails and rubbing with open-hand. He accepted

the therapist’s presence, and participation in turn-taking, but he did not enjoy playing simultaneously. It became obvious in the period from February through March that Brian would benefit more from individual work in a place other than the classroom. His rhythmic interplay with the therapist was beginning to be an important part of each session, and this needed to be extended and explored; however, Brian was often distracted by other activity in the classroom. It was, therefore, decided to remove Brian to the music room for individual sessions. This allowed the entire session to focus on his music-making, and provided the isolation to encourage full concentration. Exploration Period As sessions were transferred to the music room, the possibility of using the piano was introduced. Since Brian had enjoyed playing the piano with the therapist while in the classroom, it was hoped that the piano could be utilized within the individual setting to extend the scope of his improvizations beyond rhythm to include melody, and greater texture and dynamics. Sessions were held twice weekly? Beginning with this period of therapy, improvisation was used as the primary modality, based in principle on the Creative Music Therapy model of Nordoff and Robbins (1977). As described in Bruscia (1987), each session involves three phases which occur spontaneously as the client’s responses dictate. They are: (1) Meeting the child musically, (2) Evoking musical responses, and (3) Developing musical skills, expressive freedom and interresponsiveness. The author had successfully used this model with similar children on earlier occasions. The main approach taken in relating to Brian during this period consisted of: introducing new techniques for him to learn through modeling and co-operative practice; and playing in an alternating rather than simultaneous fashion. When placed at the piano, Brian demonstrated enthusiasm in creating sounds, and craved to discover new ways to approach the keyboard. Several piano techniques were introduced, along with variations of them in speed, volume, and register. The techniques were: Tone Clusters: Brian would produce these either with closed fist or open hand or full arm placed at a right angle to the keyboard. He would also slide from black to white keys. Fingers: Brian would play two or three fingers together, or isolated fingers on black and white notes. Glissandi: Brian would slide his fingers or hands across the keys in ascending or descending motions. Trills: Brian would alternate quickly between the two index fingers or between wholehand clusters. Brian listened closely as each new technique was introduced, and immediately made attempts to copy the sound. Generally, he was unable to learn new techniques simply by listening, but required demonstration or physical intervention by the therapist. Since Brian was reluctant to accept physical intervention at the beginning, the learning of techniques had to be approached in stages, as described earlier. Each technique was introduced to offer a new type of sound, while also offering a new hand shape and tactile sensation. Brian had spontaneously offered the closed-hand cluster, and

this remained his “home-base” sound. When he felt insecure with a new sound or technique offered by the therapist, he would return to the cluster. Similarly, when he was angry, upset, or frustrated, he would play the closed-hand cluster continually, until the intensity of the emotion was dissipated. It most often appeared at the beginning of a session, when he was coming straight from the play-ground to the music room. Brian was still overwhelmed by the playground because he did not have the skills of orientation and communication he needed to play with the other children. He was often frustrated, and sometimes upset. The therapist would offer Brian the piano, and he would “attack” it with the clusters. The second technique which Brian thoroughly internalized was the glissando. The therapist introduced this to Brian as a contrast to the clusters. It took him several sessions (over a period of approximately six weeks) to master the glissando. As the therapist moved her contact finger over the keys, she held Brian’s hand behind her’s with her thumb, thus exposing him to the action without the responsibility for producing the actual sound. For approximately four sessions, he needed modeling first and then co-operative work before he would achieve it independently. After this he would use the glissando to express happiness. He would often play a series of glissandi after the clusters, almost to indicate a finale to the expression of frustration. Rather than developing new or more advanced hand actions, the next technique was aimed at further delineation of the keyboard. Brian was exposed to the black notes as distinct from the white notes, using open hand and arm clusters. The arm clusters often brought giggles and smiles. Brian discovered sliding down from black to white notes, and thereby demonstrated his understanding of their spatial relationship. The use of isolated fingers to play isolated notes originated with the use of the children’s nursery song “Hey-Di-Ho.” It had been sung in the playground when the music therapist was pushing Brian on the swing. In the session it was used as a familiar activity to close the session. Brian would sing, while the therapist played it on the piano. As the second period of therapy progressed, and Brian would sometimes arrive happy, he would request “Hey-Di-Ho” to open the session. He made the request by singing the first line. Then as the therapist played, Brian began to search out the notes, an octave above. The therapist put Brian’s hand over her’s, grasping his index finger with her thumb and third finger, directing it to the notes of the melody. This offered Brian the contact with the correct keys and the spatial interval between the keys in sequence, while receiving total support for the rhythm and continuity of the melody. Brian was thrilled, smiling and requesting it verbally with “More?”. Brian did not achieve independence in playing “Hey-Di-Ho,” but this was not a priority. After playing the song a few times, Brian would sometimes initiate independent exploration of other notes on the keyboard. If the therapist played a single note he would seek out the note an octave higher, and match it, then move by tone or semitone either side to hear the contrast. He could sometimes happily settle on a note one tone apart. The final technique to be introduced was the trill. This was introduced incidentally, as ornamentation of “Hey-Di-Ho.” Brian’s excited response encouraged the therapist to introduce it to him as a technique. The fine manipulation of two fingers on one hand to produce a trill was overcome by using the index fingers from each hand. This was introduced in the same way as use of isolated fingers, with the therapist holding the index fingers within her own fingers. Brian learned this within two sessions, initiating extensions of it independently. He used random intervals for the index finger trills, and then incorporated them into his cluster playing.

At this point, playing clusters became part of his happy repertoire too. He began to utilize speed in the trills. He began slowly, building speed as he continued. The control of this aspect gave him immense pleasure. The therapist also demonstrated the use of decreasing speed, and he incorporated this to produce lengthy passages of accelerating and decelerating cluster glissandi. In the latter part of the exploration period, Brian began to arrive in a happy state on a consistent basis. This was due to increased communication and play skills for the playground. His increase in confidence was attributed to the “gentle teaching” approach and the acknowledged role of music within it. His exploration of the piano took on an independent nature, not requiring modeling, and initiating techniques he had learned. Brian accepted the therapist playing piano with him for periods of about our quarter-note beats at a time. The therapist’s improvisation during these brief periods was usually restricted to a rhythmic underlay to support Brian’s material, occasionally extended to reflect Brian’s material such as the clusters. This step into simultaneous playing saw the shift into the third period of the program. Control Period This was a period when Brian worked to bring all of his piano techniques under greater control—so that he could produce them as he wanted, and in any combination. He accepted the therapist’s participation, often halting to listen and then rejoining her with the same sound or a contrast. Brian had the tendency to increase volume as he became more engrossed in his playing. The therapist had until this point controlled that by offering a different technique, thus evoking a halt in Brian’s playing, and then often matching the reduced volume and playing style. During the control period, Brian would still increase volume but would also respond to a diminished volume in the same playing style by the therapist, displaying greater cognitive control over his playing. The therapist controlled the volume of his playing only when it was considered that the forceful playing was withdrawing Brian into a self-stimulating situation. Brian enjoyed the contrast of high and low notes. He played clusters in the bass region, using his whole body weight in an almost jumping style, and would glissandi up and down the length of the keyboard allowing the therapist to complete the glissando where his reach ended. Late in this period, Brian enjoyed the simultaneous participation of the therapist. He was able to sustain his playing and listen to the shifts in the therapist’s playing; responding sometimes with an answer, and at other times choosing to sustain his own material. He would initiate a “theme,” and then either return to it for security, or insist on the therapist’s recognition of his leadership capacity. His signature themes were the clusters and the glissandi (which never ceased to make him giggle). Brian arrived upset for only one session in this period. He furiously bashed clusters and glissandi for ten minutes, and as the intensity of the anger subsided, the closed-hand clusters opened into flat-hand clusters. The fingers finally began to search out the notes of “Hey-Di-Ho,” as Brian sang the lyrics. The therapist supported this with an approximate bass line (Brian’s melody was not accurate) until Brian moved away to more general improvising, and the relationship became an equal one.

Evaluation Evaluation was conducted through observation by the therapist. Notes were taken with regard to aims being addressed, and the therapist’s participation. By the end of his music therapy program, Brian had achieved all of the IEP aims and maintained all of the skills he had developed. Brian accepted the therapist’s manipulation of his hands in late July. He skipped working co-actively, moving directly to a co-operative mode for late-July and August. In early September (just before the school vacation), he began producing techniques after modeling and initiating techniques without any modeling. In late October, Brian began to respond to the therapist’s techniques with reflective techniques. The development of a relationship involving interaction and participation through rhythm and melody (the underlying ‘gentle teaching’ aim) was established when Brian first accepted the therapist’s manipulation of his hands to achieve a technique. From this point, it was strengthened and deepened by the participation in the music. Discussion and Conclusions The three core phases of a Nordoff-Robbins session: meeting the child musically, evoking musical response, and developing musical skills, formed the ideal basis for Brian’s therapy. The musical interaction this approach fosters, echoes the bonding that the ‘gentle teaching’ method so explicitly details for working with children with special needs. The emphasis was modified to meet the educational constraints of IEPs, with much time being spent on actually developing musical skills. Nonetheless, the philosophical stance of meeting the child musically and evoking responses was ever present in the therapist’s manner. The music therapy program provided Brian with an intensive period of success on a biweekly basis. This success in interaction and participation served to help raise his self-esteem. Evidence of the carry-over in self-esteem came from his classroom teacher’s reports that his mood was consistently happy on returning from music therapy (singing to himself, moving through space confidently), and he had become quite co-operative in following instructions. The music therapy sessions helped him to work more efficiently and comfortably within the more difficult environment of the classroom. After this program, the therapist left the facility. The ensuing music therapist continued the individual music therapy program with Brian. After a another school year, his musical accomplishments culminated in a high-powered and complex drum improvisation with the therapist, which he performed at the school Christmas concert to a rapturous audience of nearly 200 people! References Bruscia, K. (1987). Improvisational Models of Music Therapy. Springfield: Charles C. Thomas. Donnellan, A., Mirenda, P., Mesaros, R., & Fassbender, L. (1985). Analyzing the communicative functions of aberrant behavior. Journal of the Association of Persons with Severe Handicaps, 9(3), 201-212.

McGee, J., Menolascino, F., Hobbs, D., Menousek, P. (1987). A non-aversive approach to helping persons with mental retardation. New York: Human Sciences Press Inc. Nordoff, P. & Robbins, C. (1977). Creative Music Therapy. New York: The John Day Company.

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

CASE FIFTEEN Being Beverley: Music Therapy with a Troubled Eight-Year-Old Girl Helen M. Tyler Abstract This case study follows the music therapy process of Beverley, an eight-year-old girl diagnosed with moderate learning difficulties. She had been referred to music therapy because of her aggressive and disturbed behavior at school which was preventing her from learning and fulfilling her potential. The weekly music therapy session became a place where Beverley could explore her feelings in a safe, nonjudgmental environment through fantasy play and musical improvisation. Understanding Beverley’s outward play as a representation of her inner world enabled the therapist to survive her potentially overwhelming attacks and to find the real child behind the “acting out” behavior. This in turn helped Beverley develop some insight into her difficulties and enabled her to lead a more fulfilled life, emotionally, socially, and intellectually. Introduction It is a well-established fact that children’s development and learning are affected by pressures such as family conflict, financial strains, illness, or the loss of a parent through separation, divorce, death, or imprisonment. In the final pages of “Good Wives,” written in the 1860s, Louisa M. Alcott’s character, Jo March, expresses her dream of opening a school in the large family home, Plumfield, for “poor little forlorn lads who hadn’t any mothers.” When challenged by her family that a school for poor children would not be profitable, she replies: Rich people’s children often need care and comfort, as well as poor. I’ve seen unfortunate little creatures left to servants, or backward ones pushed forward, when it’s real cruelty. Some are naughty through mismanagement or neglect, and some lose their mothers. Besides, the best have to get through the hobbledehoy age, and that’s the very time they need most kindness and patience (Alcott, 1994, p. 338). The issues which Alcott tackles through the pupils of Plumfield are astonishingly wideranging, including overeating, running away, bullying, theft, fighting, murder, and imprisonment, but each episode comes back to the overriding need for a child to have someone reliable to “feed, nurse, pet, and scold them” (1994, p. 337). Today, we might translate this in terms of the need for emotional and physical nurturing, unconditional acceptance, containment, and boundaries. Dickens, too, expressed his concern for society’s neglected children through literature, in the stories of Oliver Twist, Nicholas Nickleby, and David Copperfield. The Victorian philanthropist, Thomas Barnardo, put all his missionary zeal into the rescue, care, and

education of destitute children through the founding of his “Dr. Barnardo’s Homes.” Although moral and spiritual teaching was a priority, Barnardo’s vision went beyond this: Little cottages should arise; each of them presided over by its own “Mother”.... The girls should be of all ages, from the baby of a few months or weeks to the growing girls, some of whom would be nearly out of their teens. There, family life and family love might be reproduced and gentle modest ways would be made possible... under the influences of godly women (Wagner, 1979, p.80). There are echoes of Alcott and Barnardo in Docker-Drysdale’s account of the setting up of the Mulberry Bush School for emotionally disturbed children in 1948. She writes: Therapy in child care is concerned with the content of the total life situation in the place, including waking and sleeping, eating and drinking, working and playing, and so on (Docker-Drysdale, 1993, p. 57). In the same post-war period Axline was drawing up her principles of nondirective play therapy to address the emotional needs of difficult children and so free their minds to work and develop to their full potential. A teacher whose mind is beset with anxieties, fears and frustrations cannot do a satisfactory teaching job. A child whose emotional life is in conflict and turmoil is not a satisfactory pupil (Axline, 1989, p. 133). The link between emotional difficulties and learning was also acknowledged by Nordoff and Robbins, who recognized that music therapy addressed more than simply musical needs. In a rationale for their pioneering work in the special education department of Philadelphia they wrote: It is the music therapists’ role to supplement the educational and classroom activities of the teacher with a programme aimed at providing special experiences that have central psychological significance for the children, and which can be therapeutic for their whole development. The strengthening of ego-function, the liberation from emotional restrictions and the alleviation of behavioural problems all make for happier, more fulfilled children who can participate more fully in their school life and derive greater benefit from it (Nordoff & Robbins, 1992, p. 139). Winnicott, in his dual role of pediatrician and psychoanalyst, saw the child as part of its family and society. His case studies of work with children reveal his concern for the child within the context of home, family, and the wider world while his theory of play expresses many of the principles that he drew from his analytic work with both children and adults. It is play that is the universal and that belongs to health: playing facilitates growth and therefore health; playing leads into group relationships; playing can be a form of communication in psychotherapy; and, lastly, psycho-analysis has been

developed as a highly specialised form of playing in the service of communication with oneself and others (Winnicott, 1999, p. 41). Like psychoanalysis, the music therapy session provides a place for a child to play, in every sense of the word, and a safe, accepting environment in which to explore “communication with oneself and others.” The framework of the therapy gives the security and consistency of time and place, while the shared language of musical improvisation offers a medium for expressing unsounded feelings and thoughts. In this chapter I hope to show how the “highly specialised form of playing” which takes place in the music therapy room can make a significant difference even to children like Beverley, facing the most intractable of life situations. Background Information Beverley was referred to the Nordoff-Robbins Music Therapy Centre in London by her school--an inner-city primary school for children with moderate learning difficulties and behavioral problems. The school was in an area of social deprivation with poor housing and a high crime rate. All the background information that I had about her came from her class teacher, Peter. I did not ever meet Beverley’s mother, but Peter visited her to explain about the music therapy program and to obtain consent for Beverley to attend. This was necessary as her mother also had learning difficulties and could not complete the usual consent form without help. As a child, she too had been a pupil at the school Beverley now attended, but was described by Peter as being “not as bright” as her daughter. Beverley’s father did not live with the family, and at the time of the therapy was, in fact, in prison. There were two other children in the family and the mother had recently had two pregnancies, which ended in miscarriages. Home life was said to be chaotic, with various boyfriends coming and going. Because of the instability of the family there were concerns for the children’s safety, and social services were monitoring their well-being. Beverley’s grandmother lived nearby and was able to help out when things were difficult by having Beverley to stay. This provided a safety net. The unpredictability of Beverley’s life showed in her appearance when she arrived for her Monday morning music therapy session. Sometimes she looked unkempt, grubby, and neglected while on other occasions she was smartly dressed with new clothes. Treatment Peter had referred Beverley initially because of poor peer relationships and aggressive outbursts in school. He felt that she had ability, but was not achieving as well as she could in class because of her emotional difficulties. She came with three other girls from her class for group music therapy where the aim was to encourage positive relationships, cooperation, and sharing through musical activities. However, although she was obviously motivated to take part in the music-making, Beverley found it impossible to share the instruments or the attention of the therapists with the other children. She would become distressed, claiming that the others were “picking on her” and would rush out of the room. As her presence became increasingly disruptive and detrimental to the progress of the rest of the group, her group therapists suggested that she should transfer to individual therapy. This was agreed, and after a planned

ending with the group, Beverley began therapy with me on a one-to-one basis, work which was to last two years. Early Sessions — Preacher and Pop Singer Beverley made the change from group to individual therapy willingly and seemed delighted to have all the instruments to herself. The room contained a piano, side drum, bongos, a cymbal, a metallophone, wind chimes, and a selection of small percussion instruments. My first impression of Beverley was of a graceful, well-coordinated girl with a great deal of physical energy. She was rarely quiet or still, restlessly moving around the room, often dancing and singing into an imaginary microphone. Her speech was muddled and unclear, with a lack of grammatical structure, and her tendency to change from one topic to another added to the sense of confusion. In the early sessions, she played the percussion and I accompanied her on the piano. Her musical tendency was to “run away” from me, so that if I matched her playing precisely, she would invariably change tempo or meter. She also sang, revealing a flexible and wide ranging voice, which was generally so loud that it drowned out my accompaniment. She often interrupted the music suddenly, saying it was time to go, or rushing out to the toilet, finding it hard to stay in the room for the full half-hour. Her lack of containment was apparent, as was her need to control our interactions and the environment. Each week she would rearrange the instruments and the furniture in the room, often putting them behind the piano so that I could not look at her directly when she was playing. As Beverley settled into the new relationship, she began to use the sessions to act out a variety of scenes which mixed fantasy with reality. They were usually highly dramatic with a sense of energy and excitement. I would accompany her singing, acting, and dancing wherever possible, but she was quite controlling of my participation, shouting at me to “cut the music,” “you be quiet,” or “shut the piano!” I would generally comply with Beverley’s musical demands to meet her omnipotence in the way that Winnicott identifies as vital to a child’s emotional development. The good-enough mother meets the omnipotence of the infant and to some extent makes sense of it. She does this repeatedly. A True Self begins to have life, through the strength given to the infant’s weak ego by the mother’s implementation of the infant’s omnipotent expressions (Winnicott, 1984, p. 145). Clear boundaries, however, were necessary in other areas. For example, Beverley would want to take my shoes off or braid my hair. I felt that this kind of closeness would not be helpful to the therapy, so I would state clearly, “I’m keeping my shoes on” or “My hair’s fine like it is.” I would also monitor my countertransference response to her frequent commands for me to “stand up,” “sit down,” or “go in the corner.” If I began to feel despised or abused by Beverley I would reply firmly that I would stay on my chair and allow her to experience the frustration of not being able to control me. I wanted to demonstrate that it was possible to have a relationship which was based on respect, not on domination or bullying. Beverley would generally take on another persona in the sessions, imitating well-known pop stars or a boxer or wrestler, famous from a television show. Another figure who often

dominated the sessions was a hell-fire religious preacher. When she took this role her excitement could turn to near hysteria, with her singing transforming to shrieking or screaming. There was often a feeling of disassociation, bordering on the psychotic, when she became deeply involved in her fantasy. I would match her emotional intensity with strong playing, and found that the music could organize her responses and keep her in touch with external reality. Her innate musicality would draw her to complete a phrase at a cadence or to wait for me to give her a musical cue. Although her words were hard to understand I would catch short phrases which seemed significant and sing them back to her. I would also frequently introduce a refrain, such as, “We’re singing together on Monday” or “This is Beverley’s song” to try to keep a connection. Here is a transcription of part of a session in the fourth month of therapy. Beverley begins by telling me that “we’re making a little bit of music, a little bit of sound, we’re making a show.” She instructs me to sit and watch her while she sings into a drum beater “microphone.” She sings unaccompanied. B: This is my song, this is my friend, this is my friend, this is my friend. I played the drum in music, I played the drum and drumpet [sic]. And the rain is falling down. I then sing back to her, unaccompanied, the essence of what she had sung. H: That was your song, a song about a friend, You played the drum in music And the rain was falling down. This structure is repeated for a second verse, both of us listening attentively to the other, but when I extend the words and sing “Beverley and Helen are singing together” the connection between us is suddenly lost, and she begins to scream and gyrate like a pop singer. She moves to the back of the room and flings herself at the wall, still singing/screaming. At this point I go to the piano, feeling that she needs some containment and grounding. I sing and play with strength. H: This is Beverley’s song, she’s singing in music today, Beverley’s song, she’s singing in music today. Beverley waits till I’ve finished my phrase then joins in, with the same tune, extending it. I can only make out a few of the words: B: My name is Beverley, take me, and see. You can sing, you can cry. Again I reflect back to her the words which seem important, “crying and singing.” Her singing becomes more intense and passionate, with the phrases lengthening, Beverley allowing me to support her musically. Just as it feels as if we will come to a satisfying ending together Beverley suddenly switches to her “preacher” persona. B (shouting): Alleluia! Amen! Cut the music! God is Bible, My name is Bethlehem Jesus.

Remember me for the discipleship. Young woman! (to me) You better rise up. Beverley then prowls round the room like a boxer, punching the air and muttering “the death of Jesus” and “the blood of Jesus.” She throws herself at the wall dramatically and falls down groaning. I sing “Poor Beverley, she’s hurt,” at which she jumps up and commands me: B: Stand up! Close your Bible, turn to chapter 3. (Then more softly and prayerfully) The God is my shepherd; she made me lie down in green pastures. Thou anoint my head with oil and my cup runs over. They threw me in the path of the shadow of death — no evil. You want to listen to my prayer. Just close your eyes. Father, we bless you tonight, I want to go away, Shepherds, just leave me alone. Thank you for your old mum and your school, Thank you for your music therapy. Amen. This session illustrates Beverley’s sudden changes of mood and subject and the muddling together of home, school, and music therapy with images from the Bible and a church service. It also shows how structure, both in the music and in the poetry of the 23rd Psalm, which she was quoting in the above extract, could help her become more coherent and expressive. In her dramas Beverley generally took the role of a powerful male adult, often threatening me and attacking me verbally. Her characters were unpredictable, suddenly becoming angry and losing control. In this way she made me experience her own unarticulated feelings of vulnerability and powerlessness. An example of this comes from a session in the sixth month of therapy. In this part of the session we are speaking, with no music. B: Shut the music! (Threatening gesture) H: You want me to shut the piano. (I shut it) B: What you doing to my wife? (Throws beater at me) H: Somebody’s very angry. (Beverley hangs her head) Somebody’s sad? (Beverley pushes me) B: You told me what to do, I don’t even tell you, Helen. You keep on picking on me. H: I keep on picking on you so you’re getting angry with me? B: I didn’t tell you what nothing. H: I kept telling you what to do... B: Yes, man. H: And you got angry... B: Yes! If you do it one more time... (threatening gesture) H: And now you really want to hit me. B: Yes! If you do it one more time I’ll GET THE WOLF PACK!

H: And now you’re shouting at me because you feel really cross. B: If you do it one more time, YOU’LL FEEL THE BANG! At this point Beverley rushes out of the room but I call her back, saying that I want to listen to her. She then goes on to say that the “Wolf Pack” will whack me and throw me through the window. I continue to reflect verbally how I think she is feeling and despite her agitation, she at last seems to recognize that I am hearing her. She then comes very close to me, wanting to take a hairclip out of her hair to put in mine and saying, “Shall we get married?” Her mood has changed from aggression to intimacy and then, just as quickly, as though discounting what has gone before, she shouts exuberantly, “Let’s have a party!” and starts dancing. At this point I begin to play music for her dancing, and this then leads into a shared “good-bye” song. There was a sense of relief in having survived the confrontation and all the feelings it stirred up, while being able to make music together at the end of a stormy session was an affirmation of the reality of our developing relationship. Winnicott says that children’s play is “inherently exciting and precarious” and can lead to a high degree of anxiety. He suggests that the precariousness derives from “the interplay in the child’s mind of that which is subjective (near hallucination) and that which is objectively perceived (actual or shared reality)” (Winnicott, 1999, p. 52). The “near-hallucination” refers to the dreamlike state of children playing which can conflict with the reality of the situation. This seems to describe Beverley when she became deeply engrossed in her fantasy play. Her anxiety was apparent, and she needed constant grounding by the reflections which I offered her, whether musical or verbal. Another feature of Beverley’s fantasy play was its punitive nature. The preacher, in particular, threatened blood and death, and most of her characters were aggressive and violent. Kalsched (1996, p. 118) writing about the archetypal figures who appear in dreams, refers to “gigantic, fantasised beings” which are “of two types, malevolent and destructive on the one hand, benevolent and protective on the other.” The man who promises salvation but also threatens punishment and death is surely an example of this, expressed in play, not in a dream. It was important that I could withstand these attacks and not retaliate, nor make myself into a victim. As our relationship developed, Beverley began to show a strong emotional reaction to breaks in the therapy, either planned holidays or sessions which were missed through illness or problems with school transport. After six months of therapy there was to be a four-week holiday break. Beverley comes into the room saying “I missed you.” I take that to be a confusion of tenses (meaning “I’m going to miss you”). I begin to talk about the break, but she immediately drowns me out with loud drum and cymbal playing. She finds it too close for me to reflect her feelings so directly. She then begins to proclaim in a deep voice, half-singing, halfchanting: B: My name is Sunkanan. The Bible says you ought to believe in the drum. I want to bring up my mum, my’wife, my sister, and Helen, all my family. You’re gonna miss her tonight, I’ll miss you tomorrow. H: (singing) I’ll miss you next week... B: Bye, see you Helen, I’ll miss you tomorrow. (leaves the room)

She goes out of the door and sings “pop style” outside. Again, it seems that she cannot tolerate me expressing her feelings for her. H: (calling to her) Beverley, where are you? B: (marches back in) I’m doing my exercises. Alleluya! (exercises vigorously to marching music) Then, another mood change as picking up the drumbeater “microphone” she begins to sing. I accompany at the piano. B: You’re my wife. I’m gonna sing a song for Mother’s Day. [This had been the previous day] You can touch me, you don’t touch me. Your mum is dead, your Nan is crying for yourself, And I am pregnant, I am pregnant. H: Your mum is dead, your Nan is crying and you are pregnant. B: My mum is dead, you’re gonna miss me tonight, You pray for me tonight, say good-bye to me. H: A sad song, for Mother’s day, you’re gonna miss me. No music next Monday. At this point Beverley cuts across the mood of shared sadness, screaming and running around. I stay very still, and, when she is quieter, ask her if she would like to come and sit at the piano by me. Unusually, she agrees, and we have a brief turn-taking exchange before leading into a familiar good-bye song, which we sing calmly. As Beverley leaves she asks me three questions, “Are you my friend? What’s your name? Let me see your teeth.” These questions seem to reflect her growing awareness that she can trust this relationship, I am a real person, and I can, like her, be strong and show my teeth. However, I am also behaving like an unreliable or absent mother, in leaving her abandoned for the holiday. Middle Period—The School Game After this break, Beverley introduced a new scenario in which she was a teacher, and the instruments were pupils. She gave them the names of children in her class, so it felt as though they had come to join us, almost as though going back to group music therapy. The “children” were invariably badly behaved, and therefore Beverley could vent all her anger on them. Typical phrases were: “Don’t you swear at me or you’ll get a whack on the head,” “Don’t even hit anybody,” and “I HATE it!” After the long summer holiday at the end of the first year of therapy Beverley came back to sessions concentrating on the school game. In the first session after the break she allows me to join in, telling me to play “relaxing” music and ordering the children to “just relax and listen to the music while your feet grows.” Here, despite her restlessness and constant criticism of the children, she accepts that I had something to give her through the music even though she cannot stay with a quiet mood for long. When characterizing the instruments, the drum was usually “the winner,” the “best behaved,” while the wind chime, erratic and hard to control, was the naughty one. The cymbal too was frequently sent out of the room for being noisy and indeed, the session sometimes

ended with no instruments left in the room. This made explicit Beverley’s need to be the only one. It also seemed that she could now symbolize her feelings, rather than needing to act them out by leaving the room herself. The instruments represented the parts of herself which she found difficult to manage, and in bringing their conflicts into our session, she was enabling us to work on the issues together. Klein, in describing her psychoanalytic play technique sessions says: The variety of emotional situations which can be expressed by play activities is unlimited: for instance, feelings of frustration and of being rejected; jealousy of both father and mother, or of brothers and sisters; aggressiveness accompanying such jealousy; pleasure in having a playmate and an ally against the parents; feelings of love and hatred towards a newborn baby or one who is expected, as well as the ensuing anxiety, guilt and the urge to make reparation. We also find in the child’s play the repetition of actual experiences and details of everyday life, often interwoven with his phantasies (Klein, 1991, p. 43). The symbolic use of the instruments was part of Beverley’s exploration of relationships. All her issues--low self-esteem, rivalry with her peers, lack of self-control, and aggressive outbursts--could be contained and worked on during the sessions. For example, I developed a song about “trying to be good--it’s really difficult,” reflecting on the struggle of “the other children.” At about this time I discovered that Beverley’s mother was pregnant, although it was not known when the baby was due. This made sense of some of Beverley’s play, in which she would throw herself to the floor, writhing and groaning as though giving birth. I also wondered whether she had been present during her mother’s previous miscarriages. It seemed even more significant that she frequently brought material relating to jealousy and the need to be special. Ending—Becoming Beverley Gradually, the school game developed and there was generally a calmer, more constructive atmosphere, Beverley decided that each person, including me, could choose a song to sing. Those that were good would get a prize (a drum beater or a shaker). For the first time, she actively wanted me to play with her, accompanying the songs, rather than controlling me or just tolerating my participation. The songs ranged from nursery rhymes such as “Old MacDonald had a Farm” and “Three Blind Mice” to “When I’m 64” and “Waltzing Matilda,” songs enjoyed by any nine-year-old. Beverley allowed herself to become one of the children in the class, and let go of the punishing super-ego figure of the teacher. At the same time she was able to accept me as a benevolent figure. She also began to take pleasure in dancing to my accompaniment on piano or drums, no longer avoiding my gaze but experiencing my full attention. She was now able to accept my praise and value her own worth, wanting me to give her “a prize.” A more childlike quality came into her voice in contrast to the forced and strident sound of earlier sessions. Beverley was developing her musical skills and, what was more important, the selfcontrol to use them. I brought a xylophone into the session, and she immediately picked out the children’s song “Twinkle, Twinkle, Little Star,” correcting herself when she miss hit a note,

and looking very pleased with her achievement. Having worked at an unconscious level for the first eighteen months with the music as a supportive accompaniment, it seemed that she was now able to experience it in the here and now. Free association and the dreamlike state had been replaced by a purposeful and intentional involvement in the music therapy sessions. Beverley’s baby brother was born sixteen months into her therapy, an event which she seemed to take in her stride. Shortly after this she announced that the instruments were too small and gave several other indications that she was moving into a new stage of maturity. I began to consider finishing the therapy and in speaking with Peter, her teacher, I learned that she was showing improvement in all areas, with an increase in her concentration span and a leap forward in her reading and writing. Peter and I both felt it was time to draw her therapy to an end, at least for the time being, with a planned ending. Beverley was well aware of the forthcoming ending and was able to join me in counting down the weeks to finishing. The final sessions were, in Beverley’s typical style, acted out in the context of a school leavers’ ceremony. In it, she announced that she was leaving and going to another school; that it was sad but she would have to say good-bye. She told all the children to “be good for Helen” when she had gone and everyone would get a prize. Then she improvised a “leaving song” and allowed me to watch her, support her, and sing with her, as we both expressed sadness at the parting. Nevertheless, there was a celebratory feel to her final song and dance, as though she knew this had been an important achievement. Discussion An interesting aspect of Beverley’s treatment is that the point at which she began to use her musical ability in a more intentional and focused way, in the playing and singing of known songs, was the time when I began to think of terminating the therapy. I felt that the further development of her creative abilities through singing, dancing, or acting was not my primary task. My hope was that the insight she had gained through the therapy would facilitate her in experiencing these activities in other settings. This was a situation I had experienced with other children in therapy, for example, Joe, a twelve-year-old boy with Asperger’s syndrome about whom I have written elsewhere. Our stormy and often chaotic music therapy sessions eventually became more ordered and productive and we mutually felt an ending was appropriate. With Joe, leaving therapy coincided with him giving away his toys to his younger brother and starting to have “proper” piano lessons rather than the free musical play of the therapy sessions. It was as though he recognized that music therapy had addressed the angry, fearful, and omnipotent infant part of himself, and that it had helped him to contain and manage it. This was made explicit in our final session when he told me that his dog was getting out of control so perhaps he could send it to live with me (Tyler, 1997, p. 231). This might lead the reader to the conclusion that the psychotherapeutic function of the sessions with Joe and Beverley outweighed the musical therapeutic dimension, but this could be as a result of what Ansdell has termed “the music therapist’s dilemma.” He says “Whilst musicians have a limited vocabulary for musical ‘objects’ and techniques they have almost none for musical experience — arguably the starting point for music therapy” (Ansdell, 2001, p. 2). In describing Beverley’s music therapy I am aware that it is more straightforward to transcribe words and actions than to convey the essence of the musical interaction. However, moment-to-

moment in the therapy I was making musical decisions and monitoring my responses with my “internal supervisor” (Casement, 1985, p. 49). There were endless choices to be made, such as to play or not to play, to sing or speak, to match Beverley’s music or be separate musically, to build up or draw back, to increase the musical tension or relax it. The choice of instrument, the key, mode, meter, tempo, and dynamics all had to be decided at every moment of each session. As Pavlicevic (2001) writes, “the powerful flexibility and shifting nuances of improvised clinical music can resonate with, and sound, the child’s totality” (p.20). In order for this to happen, the therapist must be finely attuned to the child on all levels. Aiding this process for me was the discipline of recording every session on either audio or video and listening back to the tape, making detailed notes or an “index” of the session using the method devised and advocated by Nordoff and Robbins (1977, p. 92). This careful study of the weekly session tape helped me to grasp the complex musical self-portrait that Beverley presented to me, with its many forms and facets and this, combined with regular supervision, enabled me to recognize and nurture Beverley’s authentic voice. I began this chapter with thoughts about the care and treatment of disturbed and distressed children. The poignant image of the motherless child was evoked by Victorian authors and philanthropists wishing to raise awareness of the plight of such children to improve their lot. Throughout Beverley’s therapy I did not meet her mother or have any more than the minimum of information about her, but the maternal figures she presented to me were generally weak, ill, pregnant, or abused, and in need of prayer. All the power was situated in the male figures who dominated the sessions with their physical or verbal bullying. Beverley’s recognition of me as a person who could be strong but not persecuting and who could withstand her assaults without retaliation gave her the strength to find her authentic self. In her role-play as a teacher she explored issues of control and power, and through the school game, eventually allowed herself to be the child, Beverley, for the first time. Being Beverley, a child who could sing, dance, laugh, cry, love, and hate, without the need for concealment behind another persona, was the achievement of the therapy. References Alcott, L. M. (1994). Good Wives. (First published 1869.) London: Penguin. Ansdell, G. (2001). Music Therapist’s Dilemma, British Journal of Music Therapy, 15 (1), 2-4. Axline, V. M. (1989). Play Therapy. Edinburgh: Churchill Livingstone. Casement, P. (1985). On Learning from the Patient. London and New York: Routledge. Docker-Drysdale, B. (1993). Consultation in Child Care. In Therapy and Consultation in Child Care. London: Free Association Books. Kalsched, D. (1996). The Inner World of Trauma. London and New York: Routledge. Klein, M. (1991). The Psychoanalytic Play Technique. In J. Mitchell (ed.) Klein: Selected Letters. Harmondsworth, UK: Penguin Books. Nordoff, P., & Robbins, C. (1977). Creative Music Therapy. New York: John Day. (Out of print. New edition forthcoming: Gilsum, NH: Barcelona.) Nordoff, P., & Robbins, C. (1992). Therapy in Music for Handicapped Children. (First published 1971.) London: Victor Gollancz Ltd.

Pavlicevic, M. (2001). A Child in Time and Health, British Journal of Music Therapy, 15 (1), 14-21. Tyler, H. (1997). Music Therapy for Children with Learning Difficulties. In M. Fawcus (ed.), Children with Learning Difficulties — A Collaborative Approach to Their Education and Management. London: Whurr Publishers Ltd. Wagner, G. (1979). Barnardo. London: Weidenfeld and Nicholson. Winnicott, D. W. (1984). Ego Distortion in Terms of True and False Self. In The Maturational Processes and the Facilitating Environment. London: Karnac Books. Winnicott, D. W. (1999). Playing and Reality. (First published 1971, London: Tavistock Publications.) London: Pelican Books.

Part Two: Improvisational Music Therapy for Adults

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

CASE SIXTEEN The Case of Marianne: Repetition and Musical form in Psychosis Jos De Backer Jan Van Camp Abstract The significant aspect of our work is the finding that, in the treatment of psychotic patients, music is especially relevant in creating a psychic space. Since the psychic space originates from the transformation of sensorial impressions into a form or a representation, and since we know that the capacity to make representations is seriously affected in psychosis, there is a need to find out by which means this capacity can be reestablished. Working with such patients in a music-therapeutic context, we encounter the phenomenon that they often repeat the same musical pattern. In their musical improvisations, they constantly repeat a specific rhythm or a small melodic sequence. It becomes an endless iterative playing, a kind of musical rocking. From our research, we describe this repetitiveness as the presence of the psychotic “experience” of the world. Psychotic patients, from their pathology onward, do not dispose of a psychic space to reach symbolization, which means, in music-therapeutic terms, that they are not able to create a musical form in which they can exist as a subject. Therefore, the therapeutic transition from sensorial impression to musical form (protosymbolization) is a basic condition for the treatment of the psychotic patient regardless. In this case study of a psychotic woman involved in a music-therapeutic treatment, we explore and describe three important levels or moments of the music-therapeutic process (synchronization, development of a musical form, and the musical ending of an improvisation). Introduction Psychosis and Music The world of the psychotic patient is often unknown and inaccessible. Many years of experience with psychotic patients has convinced us that through music we cannot only find a gateway to the amazing world of the psychotic subject, but that we can also develop the means to give a certain shape and termination to the disintegration and timelessness of the psychotic world. It is not the first time that it has been shown that music moves on the same level as where the central problem of psychosis is located. This relationship between music and psychosis gives music therapy and “the thinking from music”1 a crucial place in the treatment of psychosis.

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

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

patient, the therapist experiences a constant subtle defaced rhythm or a continued “disharmonization” which excludes him from playing together with the patient. Sometimes these disruptions are so barely objectively detectable that they also can barely be imitated. We are therefore able to assert that this sound object is not erogeneized, not involved in an exchange with the other. It remains caught within an autoerotic circuit. This refers to the failing construction of an unconscious body image, owing to the absence of the primary narcissism of the psychotic patient. The primary narcissism only develops through the labor of representation, which is produced by the erogeneization of the body zones which are initially involved in the satisfaction of needs. At this stage, it is important to refer to the crucial significance held by the disruption of the pure repetitiveness by surpassing the sensory level of the satisfaction of needs. A mother gives her child true contact and exchange when she does not remain equal to herself and when she brings all sorts of subtle variations (deprivation) in the way in which she meets the demands of her child. The rhythmization of presence (satisfaction) and absence (privation) can convert the sensorial impressions into drives, and by so doing brings them into mentalization. Speaking about the psychotic sound object, we shall use the terms “sensorial object” and “sensorial play” to denote that this object is not integrated into a movement of drive and erogeneization and as such, remains locked up in its quality of real, unimaginable, and indivisible substance. The isolation of the sound object, however, can also be the result of the fact that it is not part of the psyche of the subject itself, but that it is an extension of the psyche of another, namely one or both of the parents. In this context, we should speak of an incorporated object, or, in the terminology of Abraham and Torok (1978), of an object that has not been introjected but rather “included.” The status of this object reflects the fate of having to undergo a trauma when it could not be coped with in a former generation and so was transmitted to one or several following generations. As this object is not imaginable (the “thing presentation” remains absent to the subject itself), it stays subjected to the principle of repetition. That means that the object is only present when it is made present in the most concrete manner and namely in a corporeal-sensorial way. Peculiar to this object is, contrary to the purely sensorial object, that it has been subjected to a (transgenerational) displacement and because of this acquires a psychic character and thus a form. The therapist is often amazed to see the appearance of a musical form which is significant to him, whereas it remains meaningless to the patient and cannot be integrated psychologically by the latter (Van Camp, 1999). The repetitiveness and the character--often experienced as strange by the patient--of a musical sequence, signals to the therapist the possible psychotic status of the sound object. Here, the inability to have the musical sequence take place in a musical thought is as strong as in the purely sensorial play. Sometimes, the psychotic sound object has the shape of a “passionate” object. We sometimes notice in the music therapy session that psychotic patients can be passionately seized by the musical improvisation or by listening to music to such an extent that they lose themselves totally in it, get confused, and even are driven to psychotic decompensation. The object comes to the foreground so prominently that the patient goes into a state of being defenselessly delivered to it, possessed by it, even to the extent that the boundary between subject and object disappears completely. Contrary to the neurotic overinvestment or idealization of the object, there is no symptom involved of something the patient does not want to know and therefore displaces to an object containing the psychic elements of what has

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

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

as the point of culmination of an old situation in which the mother was perceived always as over controlling and inhibitive to her development. The patient is the youngest from a family of three children. The father is retired and, according to the patient, rather aloof with regards to family life. The mother is the housekeeper. After her secondary education, the patient started to study literature at the university. She was passionate about literature and wrote a great deal of poetry and stories. Owing to the many “literary encounters” in pubs/bars, she concentrated little on her studies and did not succeed. After this year, she had a short but very intense relationship with a man. She finally chose another area of study, but also gave this up after two years. At this time she is unemployed. The patient situates the beginning of her troubles around age 20, when her relationship ended. She started to suffer increasingly from feelings of fear, which did not allow her to lead an independent life. More and more, she was convinced that she was being controlled by her mother and that her mother even hired other people to control her. Situation at the Moment of the Admission The patient came across as reserved in the contact. Her facial expression was flat and she had a staring look on her face. The patient seemed to be cut off emotionally. There were a few depressive complaints: sad mood, adynamic, anorexia, sleeping disorder, “anhedony” and fear outbursts. She expressed a passive longing for death and depicted herself in a selfdeprecatory way. She spoke of being overtaken by crying fits and how she had the tendency to regress. The patient did not report any hallucination. There were no disorders of formal thinking, although she had heard a voice in her head once in the past. Conclusion A 25-year-old woman was admitted because of a vital depressive situation, functioning on a psychotic level. The depressive complaints cleared up gradually under an anti-depressive treatment. The patient was referred to our department for young psychotics, for a psychotherapeutical treatment of the underlying psychotic problems. Psychodiagnostic Research Marianne is a talented woman with a general IQ of 126 (W.A.I.S. test), with a big difference between the verbal IQ of 133 and the performant IQ of 112. The balance between the “hold” and “don’t hold” tests indicate deterioration on the organicity scales. The patient has few complaints and does not have an expressed request for aid. Formally viewed, there is a protective shield, especially in terms of her emotional life; she cannot let herself be touched. She tries vehemently to give an answer at the expense of the reality. The theme of her relationships is receiving. There are many conflicts and quarrels. Aggression and sexuality obviously do not have a specific place in her life. She is a very independent woman who functions on a psychotic-like level. There is nothing that is manifestly

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

transference and countertransference. (In certain therapeutic situations it could make sense that through projective identification the therapist makes a choice about the instrument, or because of the psychohygienic nature--see Session 2--he plays along.) Progress of the session. Marianne chooses the metallophone, the same instrument that she had been playing for eight months in group music therapy. In this choice, she shows her emptiness, the necessity for security and the inability to bring variation in her contact with herself or the therapist. She also chooses a metallophone for the therapist. Marianne places the two metallophones facing one another. She immediately starts to play. The music is as sensorimotoric as during the last eight months in the group music therapy. In an endlessly alternating motorical movement, her arms go up and down along the metallophone. Musically there is no phrasing, no dynamics, and no accentuation. Her improvisation is comparable with “musical rocking:”

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

successiveness of time, so typical for psychosis and trauma, does not allow it. Her noncommunicative playing refers to the non subjective character of the repetition. Therefore, there is no other for the therapist either. In the beginning, there is only music. The therapist is focused only on the musical part, the sound.

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

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

But, Marianne endlessly keeps on playing the same pattern. The style is purely impressionistic. She plays for example a high tone but does not repeat it. There is no structure in it, no phrasing. She is not developing anything and, therefore, is not able to repeat anything in a reprise. She probably hopes that a melody would originate, but that does not happen. Also, she does not integrate anything from the previous session into her music. For instance, she

could have integrated the bourdon of the music therapist, but obviously she is not able to do that. The only change is an acceleration of the tempo. But in the end nothing happens. Through Marianne’s accelerando a certain tension in the musical play is born. “You left me to fend for myself” hangs in the air. Marianne seems to plead to the therapist. He has to create space. She cannot create this space by herself, yet; it can only come from the therapist. She totally depends on him as a therapist. The therapist lets the sounds come to him completely. He experiences something unbearable, something has to happen; she makes an appeal to him. The patient plays for about eight minutes by herself until he moves himself intuitively toward the piano, which is at the left side of him. Without having to move the chair he starts to play a simple melody. The timbre and the volume are amazingly equal with that of the metallophone. One almost cannot distinguish his melody from hers in regards to timbre, tempo, and volume. They are completely at the same level. The therapist puts his psyche in the service of the psyche of the patient.

The beginning is almost a shock: Suddenly there is this melody. Somebody says: “Here I am.” The “unbearableness” of nonexistence finishes. Suddenly, the therapist poses subjectivity. Suddenly, a clear melodic line originates; a kind of anti-poison. The melody evolves into a harmonic entirety, a chorale. The therapist embraces the patient’s sensorial music, even though he does not experience getting into contact with her. He continues playing because he wants himself to be heard as a subject. After about five minutes, the therapist plays a definite cadence, to which the patient does not react. She continues playing on her own. Again, after a subverbal intervention she stops her music. From the short verbal reflection that follows the improvisation, it is obvious that the musical part does not penetrate her. She did not even notice the therapist’s piano playing. Just like the previous session she leaves the music therapy room shuffling her feet. Does the musical play even make sense? At this moment one could wonder whether it ever did make sense. Does it have any significance in this therapeutic context? Diagnostically, it definitely does. This playing is a perfect illustration of how music can enter the traumatic level. The musical play is a purely successive sound, without any form. There is only repetitiveness, without reprise.

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

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

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

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

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

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

else, her voice sounds sometimes sweet and reassuring, then again insecure and full of sorrow. This whole play of variations of a mother which is not always similar to her forces the child to develop the capacity to recognize the same mother in all these different forms of appearance. This preverbal internalization of an image--what we call “recognition”--is originally very similar to a hallucination. The hallucination is being constructed as a way of resisting this play of variations and of guaranteeing the non-variety of the object in the outside world. The recognition, on the other hand, accepts the variations in the outside world thanks to the construction of an original inner space. Finally, between hallucination and recognition there is still a transitional space in which one still frenetically clings to the musical phrase, but at the same time without coinciding with it any more. These different modes of relating to the absolute repetition of the phrase can also be recognized in the different forms of popular and art music. The capacity to abandon the ecstasy of the repetition and the analysis of the resistances against it form, in our opinion, the most essential, although sometimes hardly manageable, tasks of music therapy. When the work of variation and development--which can be considered as a form of primordial mourning--is completed, the patient is also able to finish his improvisation musically. If everything is all right, the traumatic affect and speech are no longer disassociated. In his speech, the affect can be heard. Like a tragic actor the patient has now broken away from the ecstasy of the Dionysian choir and he is now able to speak for himself. References Abraham, N., & Torok, M. (1978). L’Ecorce et le Noyau. Paris: Aubier-Flammarion. De Backer, J. (1993). “Containment in Music Therapy.” In T. Wigram & M. Heal (eds.), Music Therapy in Health and Education. London: Jessica Kingsley Publishers. De Backer, J. (1996). “Regression in Music Therapy with Psychotic Patients,” Nordisk Tidsskrift for Musikkterapi, 5(1), 24-30. De Backer, J., & Van Camp, J. (1996). “Muziektherapie in de behandeling van psychotische patiënten.” In M. De Hert, en E. Thys (Eds.), Zin in waanzin. De wereld van schizofrenie, Amsterdam: uitgeverij EPO. De Backer, J., & Van Camp, J. (1999). “Specific Aspects of the Music Therapy Relationship to Psychiatry.” In T. Wigram & J. De Backer (Eds.), Clinical Applications in Music Therapy in Psychiatry. London: Jessica Kingsley Publishers. Lacan, J. (1981). Le Séminaire, Livre III, Les Psychoses (1955-1956). Paris: Texte établi par J.A.Miller, Seuil. Ogden, T. H. (1992). The Primitive Edge of Experiences. London: Karnac Books. Ogden, T. H. (1994). Subjects of Analysis. Exeter, U.K.: PBC Wheatons Ltd. Ogden, T. H. (1986). The Matrix of the Mind: Object Relations and the Psychoanalytic Dialogue. Northvale, NJ: Jason Aronson Inc. Tustin, F. (1981). Autistic States in Children. London: Routledge. Tustin, F. (1986). Autistic Barriers in Neurotic Patients. London: Karnac Books. Tustin, F. (1990). The Projective Shell in Children and Adults. London: Karnac Books. Van Camp, J. (1999, November). “Musique, répétition et affect,” La Revue de Musicothérapie, 4. Association Française de Musicothérapie, Paris.

Van Camp, J. (2000). “Musik, Wiederholung und Ritual,” Musiktherapeutische Umschau, Band 21. Van Camp, J. (2001). “De muzikale vorm,” Tijdschrift Beroepsvereniging Muziektherapie, Leuven. Notes Acknowledgment: This article is based on a more extensive research study (Ph.D. Program: Aalborg University, Denmark). The authors would like to acknowledge the research supervision of Pr. Dr. Tony Wigram.

Taken from: Lee, C. A. (2003). The Architecture of Aesthetic Music Therapy. Gilsum NH: Barcelona Publishers.

CASE SEVENTEEN Case Study–Michael: Music and Loss Colin Andrew Lee The mellow touch of music doth wound the soul, when it doth rather sigh than sound. –Robert Herrick, Soft Music, (189 1) The strength of music to express loss is inextricably a part of the Aesthetic Music Therapy (AeMT) process. Loss is fundamental to living. As we face beginnings and endings our need to overcome the trauma of loss becomes necessary if we are to live. To face the intense catastrophe of death is not to mend or overcome but rather to provide an opportunity to reflect and realign with the reality of living. Finding a path through the maze of bereavement can be both intense and illuminating. The music therapist working with bereaved clients must guide, through music, the anguish of surrender and grief. Confronting and acknowledging the expression of loss is ultimately therapeutic. Music therapy is able to give voice to the meaning of loss at its most spiritual level. Music has a beginning and end. It exists in time, then dies. Is the composition of music similar to the composition of living and dying? If so, how do we link music to the cycle of life? Some of the greatest music was inspired by loss. Composers such as Dvorak, Berg, and Poulenc composed from their personal experiences of bereavement, producing works of heightened emotional intensity. Is it possible then that the nature of music can translate the gravity of loss in a way that is not possible through the explicit nature of words? Through musical examples this case study speaks from sessions alongside reflective interpretations from client and therapist. It does not aim to give an exhaustive summation of our work but rather tries to capture the essence of our musical relationship in helping Michael to confront his grief. This was one of my first experiences of working with a bereaved client and as such my frame of reference came from my ongoing supervision without which I would have been unable to continue this work. The uncertainties of the developing process were not unlike my previous work in palliative care and I struggled with every therapeutic decision as it occurred. In terms of AeMT this is perhaps the clearest example of the therapeutic process immersed in the essence of music. As the work unfolded so the music became ever more central to the process and understanding of Michael’s search for balance. The quality of the improvising on the accompanying CD provide a glimpses into a dynamic representation of music therapy in the face of loss. The Client Speaks

I first met Colin through the referral of a music therapist who supervised my voluntary weekly music sessions with an autistic girl. When hearing the recordings of our music, my supervisor would often wonder why I didn’t seem able to match the intensity of musical expression which this little girl of five brought to life. When finally I told my supervisor about my mother’s recent and unexpected death she immediately understood that I had not worked through the grief of this bereavement and suggested that I should meet Colin. Little more than one year before, my mother’s body had been found frozen in a lake near her home on January first. Nobody knows how she got there and whether she committed suicide or not. She had suffered from manic-depression for several years, never having found herself the help she would have needed. Being her only child in a divorced family, her death meant both grief and relief to me. On the very day before she was buried, my father married his second wife - emotional support from his side was not to be expected. I was in pain and loneliness when I met Colin. My first impression of him was that of a very skilled pianist and able music therapist who, nevertheless, would not be able to face the emotional intensity I needed to express. Luckily, Colin took on the challenge of this rather misguided assumption. The Therapist Speaks Michael was referred through my supervisor. I had little information other than that his mother had died some years earlier and that he was interested in exploring the potential of music therapy. I knew my first impressions of Michael, during our assessment session, was of a quietly determined and expressive young man. He spoke with precision and clarity even though English was his second language. Michael explained that he was curious to experience music therapy and the potential it could have to explore his life at this time. We talked of improvisation and that this would be the potential focus for our work. I explained my approach came from a belief that music was at the center of the music therapy process. In discussing music and words we agreed to find the balance necessary for the changing nature of each session but that I would not attempt psychodynamic interpretations of our work. We agreed on an initial series of ten one-hour sessions to be held in my room at the Hospice. It is interesting to note that we did not discuss Michael’s bereavement during this assessment session. After he left I remember being both excited and apprehensive at the potential work that lay ahead. Beginning Communications Some years after our work, and since beginning this book, I contacted Michael to see if he would be interested in collaborating with me on an evaluation of our initial ten sessions. Having used this case study extensively in teaching and presentations I thought it would make an ideal contribution to my developing philosophy of AeMT. I proposed that we meet and listen to the sessions together. We would then both comment freely about our feelings now and how we recalled the sessions. I was aware this may be a difficult experience for Michael, so wanted to be sure he felt strong enough for such an undertaking. We agreed to meet for two days at Berklee College of Music, Boston, where I was teaching at the time.

Through our initial correspondences Michael reflected on the potential for our evaluative work: I am interested in working with you and reflecting on our sessions, but more in terms of personal exploration. If I am to address again the pain through this work, that is undeniably still entangled with my mother–and always will be–it will be in my interests first, and in everyone else’s second. Thinking back to the sessions themselves, I had doubts at first if you would be prepared to accept my emotions. Would you be willing to deal with my pain? I knew that in working with you I would have to address emotions that you may not have been able to work with because they were so intense. During the sessions I knew you heard my pain and accepted it, though as I suspected you could not become it. This was one of the fundamental principles of our work and was one that helped me to understand my grief. One aspect of our work that I appreciated was that you only played when I did. It took getting used to. Your attention and intention was always clearly directed toward me. I felt uncomfortable in the beginning because I could not hide from you and be without you. You were always there with me. Once I understood and accepted this I began to appreciate your musical support and reflection. This made an impression on me in several ways and I am still thankful for this approach and what I discovered from it. I remember you saying you considered me courageous. But I wouldn’t have been able to do this with just anyone. Having had this experience with you, I am only now able to consider such a crazy thing–courage seems to be a two-way process. I also believe in admitting to one’s vulnerability. I am still learning this but now seeing it as a source of strength. This is one of the key reasons that I now dare to look deeply into what the music therapy experience was for me. I now see that not knowing may be essential to the therapeutic process. Music Therapy Schema Michael described how he remembered the ten sessions falling into the following six sections: -

Setting the Scene (sessions 1–4): Anger, grief, and how to deal with it. Ways of interacting with Colin. Negotiating Relationship (sessions 5–6): Struggling for common ground. A modus operandi. Pain (session 7): Question: ‘can I take Colin to the painful place?’ Reaching Out: (session 8) Colin listens to my song. It is painful and it is beautiful. Something profound is happening. Plateau (session 9): What is there left for us to do? Music (session 10): Whistling–without emotional urgency– mainly music. General Reflections

Our observations were based on listening to the ten sessions. After this we identified sessions seven, eight, and ten as appropriate for more detailed analysis. During this meeting the intent was for Michael to review his therapy, for me to ask questions about aspects of the process, and for him to remember, as well as possible, his feelings about certain pivotal parts of the work. Michael also made notes which have been incorporated within the text where appropriate. The qualitative nature of our meeting allowed our conversation and listening to be free and improvisational in nature. Pulses M.

C. M.

I remember there were times when you followed me and I followed you . . . that’s really interesting. And then there is the opposite . . . it’s almost like you suggest something. I’m also interested in the pulses and tempi that I initiate. In the beginning the music was very fast and then it became slower and slower as the sessions progressed. I think I played a constant xylophone pulse throughout and wondered how that may have related to all the other pulses. Your xylophone-pulsed playing was a common thread throughout the sessions. I remember thinking that I was giving myself a structure, giving myself some unity, something that I could hold onto.

A constant or changing pulse either within the confines of a single session, or as a motive taken from session to session, can tell us about a client’s need for stability. By its nature, music falls into structures and patterns. Improvisation has the potential, however, to be free from formation and shape. In my experience it is rare for a structureless improvisation to be therapeutically appropriate. Most clinical situations require some shape or form for a musical dialogue to take place. In describing how his overall tempo became slower Michael gives an indication of the intensity of his developing expression as the sessions progressed. Sorrow and Sadness M.

C. M. C. M. C.

One thing I want to hear are the different gestures and emotions. In the beginning I remember a sense of acting up . . . and then there is a point where I justify my grief and sadness. To hear unlimited amounts of energy and anger . . . well, maybe anger is not the right word . . . just high energy. The amount of time that I can bear to be in these different emotions is limited. Improvising with you was tiring yet invigorating. You always propelled the music. The music propelled itself. It’s like the pulse goes on and on and on. Something that suggests . . . that long after . . . and then just when you suggest something like a root . . . but I say to you: “I’m not having it!” I didn’t know how to get out . . . that bothered me. You wanted to get out? At the time I’m not sure . . . I started singing . . . I remember thinking how long it took to find my voice. My singing was like struggling for words. I had an idea of what I wanted to express and the way I wanted to go . . . but I was very shaky. My worries were to do with facilitating that space that would allow a clear expression of

M. C.

your confusion and anger. What musical and clinical decisions and interventions would be appropriate? I was respectful . . . though at times fearful of what you were expressing. There were times when I had to pull back from your expression . . . both in terms of our therapeutic alliance and my personal safety as a therapist. My perceptions of your expression were different than yours, I think . . . that was the enormity of your challenge to me as therapist. Yes I became more aware of that dynamic as our sessions progressed...and then in the years that followed our work. I wanted to be able to touch on sorrow and sadness . . . but then be able to draw back from it. I remember times when I wanted to meet your musical expression but couldn’t bear to be with your rawness and pain.

In music therapy we aspire to meet a client’s expression simultaneously as it is experienced. Through music the truth of that expression can be authentically touched. There is danger, however, that the therapist may become too embedded in the client’s intensity. Michael’s musical manifestations of loss and pain were at times overwhelming in terms of the actuality of sound and meaning. It became dangerous for my personal safety to continue building with his expression of anger and pain. I had to distance myself musically and emotionally. This establishment of personal boundaries became a clear part of our therapeutic alliance. How best could I be a therapist for Michael within these musical volcanic explosions? How could the enormity of his loss be transferred to such an intensity of improvised musical expression and how should I facilitate this? I felt as if I were stepping into the unknown. Music M. C. M.

C. M.

Everything you did was what I needed. I feel it says something about who I am. I have contemplated suicide a lot of times in my life, but never for real . . . at some point it was like a method for giving . . . for setting the boundaries. You were forceful and would let me know when I did something musically you didn’t like. This is true. I sensed your respect from the beginning. These sessions were about me and that I had the right to speak to whatever I needed. This is what made the whole experience so valuable . . . because I knew this was my space . . . and I knew that you would go along with whatever I needed. I completely trusted and still don’t doubt that. I think I always did. There were times when I was apprehensive and wondered if I could come up with the goods you needed as a therapist. I didn’t know at the time that you trusted me so much. It had to do with your musical expression . . . how you made music . . . how you responded to my playing . . . because you were up to it. There was never any point where I felt this man can’t improvise . . . in the first session maybe . . . I wasn’t sure . . . but from the second or third session I knew there was no place on this earth musically that I could go that you couldn’t also. I’m still absolutely convinced that musically speaking that I could do anything and that you could respond to it. This is also the miracle that once we had established this relationship that I never felt absolutely unsupported. Well, there was one . . . that is the funny thing . . . but that wasn’t because

C. M. C. M.

you were unable to meet with me but rather that I felt I didn’t want to go with you. Did you realize how enormous your musical expression was? No, I couldn’t perceive how big it was from your perspective, I just knew from my point of view it was gigantic. I was constantly amazed at your musical expression. I still feel unable to give an impression of the enormity of it . . . the significance of it . . . that it would be possible to just take a part of it and spend time really analyzing just one section. There were times we made musical contact. They were on one level affected by how we interacted as therapist and client . . . but that’s not the real stuff we are talking about . . . the musical relationship. It’s unbelievable where these moments come from.

Michael raises the need for music therapists to be musically competent. Is it important that music therapists are strong musicians as well as therapists? I believe that if a music therapist does not try to support and develop musically they will not be able to support and develop therapeutically. Music and Words C. M.

Do you think we could have expressed these ideas and concepts to the same level in words? It was so valuable to do this in music. Words are the way in which everybody relates to each other in this world. At some point I had a verbal counselor at college. What she always said is that we need to find, live, and experience the emotion . . . without giving any sense of actually experiencing it. I find that outrageous. This is perfect and in hindsight I can see a huge difference between the music therapy we did together and the sort of therapy I did in words. What we did was right because it wasn’t about a method of living . . . it wasn’t about how to deal with my life. It wasn’t pragmatic . . . it was pure emotion, and that was so necessary for me. Even today I can’t put words to it.

Boundaries C. M. C. M. C. M.

What boundaries do you think there were in our work? I think you said at the beginning of our work that you were happy for me to say whatever I wanted to say but that you wouldn’t interpret my music. Were you happy about that? Yes I was. I think it happened more than once after a session, it became almost meaningless that we were trying to talk and verbally interpret...it didn’t add to the experience . . . it would have detracted. This is against psychoanalytic theory. Yes, I know, but our musical expression was beyond words and so to try and put it into words would have diminished what I was exploring. Everything happens in the music. The emotional work . . . you need to establish the climate and relationship every time you meet. If you go and see a therapist and talk to him you probably won’t get through the real issues until further into the sessions . . . whereas in music it happens faster and

more dynamically. Relationship and Reich M.

C. M. C. M.

I remember thinking: “I’m going to music therapy” . . . I was trying to find an alternative. We both knew that what needed to be said would be said. It happens . . . it could be the most profound thought. Here is another person, the therapist . . . if I want him to swim with me I have to get him used to the water. You take my hand and even though you don’t want to go there yourself, you are leading me to the water. It’s intriguing, the achievement of knowing there is a place that you–the therapist–doesn’t want to go because it’s not yours, but at the same time you encourage someone else to go with you. You lead and I immediately follow. When I think of your music I think of the composer Steve Reich. I love Steve Reich. Reich enables individual players to become one. This musical parallel tells you a lot about me.

Steve Reich as a leading figure in the minimalist movement had a significant impact on my work as a music therapist and composer. Minimalist composition is controlled and has ostensibly little connection with the process of improvising. The merging and development of small figures, can however have direct applications on the developing clinical/musical relationship. By focusing on minimal patterns as the core of musical development an intimate merger can appear that can have important consequences for the developing relationship (note: for further discussion see Chapter sixteen). These patterns, often initiated by the client, can also be introduced by the therapist as a direct clinical intervention. Once a minimalist merger has occurred it is the therapist’s responsibility to understand and interpret the nature of such a musical union. The danger is that as individual players unite the music can also become relationally and musically redundant. The therapist must know how to move toward and away from such a musical dialogue in a way that is pertinent to the direction of the work. Following the Path C. M.

C. M. C.

I’m amazed at the intent of our musical dialogue. It’s like looking for the path . . . we both have a serious intention to find significant music . . . important things need to be expressed. Sometimes you need time to pause. I can only get help if I make myself available. If I talk in a foreign musical tongue to you . . . if I decide I am going to scream at you and yell at you it won’t work . . . the only way I am going to get something is to find a way of talking to you. I can only relate to other people if I don’t run, crush, or smother them. Did you feel at times that you were trying to smother me? Yes, and I think that’s valid therapy and social learning therapeutically. It’s like rebellion because at times I had an image of a place I wanted to go. When you didn’t always go there it frustrated me and I would rebel. There were times when I would test you musically.

M.

This is what makes our work therapy . . . we could very justifiably claim that this is music psychotherapy. For the record I think an analytic therapist would talk about everything that’s happening here in terms of narcissistic personality. That the client is expressing intense emotions and yet he’s not talking about it. Musically we are communicating at a deep and intense level . . . that is the paradox. To communicate with you I had to offer something you could embrace. I have tried to qualify different types of grieving in sorrow. I believe there are different areas of emotion and expression . . . and then there’s anger and other kinds of grief . . . another kind of sorrow. There are musical leitmotivs that help us find these modes of expression.

After the opening general dialogue we move to a more in-depth analysis of sessions seven, eight and ten. Audio File: Michael—Excerpt 1 (Session 7) After 10 minutes after the opening: • • • • • • • • • • • M.

C. M.

Michael settles on a repeated A (xylophone) The therapist plays the same tone on the piano Michael begins to vocalize and the therapist joins him A vocal dialogue develops alongside the repeated A on xylophone and piano Michael starts to play the cymbal Michael finally moves from the A and the therapist begins to introduce a harmonic accompaniment Michael’s vocalizing becomes more impassioned The music builds in intensity Michael’s singing turns into screaming/shouting A section of extended cymbal playing The improvisation finally subsides

What we are doing here is totally liberating . . . it’s like flying. The cymbal playing with piano is commanding and yet it doesn’t divert attention. I started using my voice and wrote: “What is there about this music that so evidently points to the fact that I am vulnerable?” My vocalizations sound fragile and vulnerable whereas everything else is so forceful . . . not everything . . . but so much is determined. And when I heard the repeated “A” on the xylophone I wrote: “What song is this? . . . what are we singing? . . . I don’t know.” You were only playing an “A” too? Yes . . . I made the decision to stay on the same pitch as you. We started the “A,” hovering with our voices. I haven’t an image of what this song was about. I couldn’t tell you . . . I’m full of questions... and then I play the cymbal again. This helps me. It’s an aid for my expression. My voice grows stronger and higher. The cymbal is ambivalent. In one way it helps and in another it detracts. The cymbal has a role . . . it’s like setting the scene. It’s a contradictory role even though it’s serving a purpose.

C. M.

Then I do lots of playing that sets the scene for the scream that never leaves my throat. I make an effort to set the scene but I can’t do it. I don’t think I fully screamed . . . I’m trying but I can’t fully express it. The cymbal is like an anchor to express what I otherwise can’t. It’s almost petty . . . until we get to the real expression. And then you reintroduce the funeral march and I say: “ No one would want to listen to this!” This session seems to be like a diagnosis where you can see the real issues and the aim of the therapy. The pathology. And then there is the gong and I remember thinking that it’s like a reminder of the enormous emotion that is threatening and looming in the background. It’s a threat because there is a rhythm that goes on forever. This experience for me was totally embodied. There were moments in this session when I did things in spite of myself, as if I didn’t mind doing it even though I didn’t know why.

Audio File: Michael—Excerpt 2 (Session 8) After 15 minutes after the opening: • • • • • • • • • • • • • • • M.

C.

Michael sings quietly–long sustained phrases–the therapist accompanies The therapist begins to sing also Michael begins to sing the therapist’s name: “Colin” He sings part-sentences “I . . . , I have . . . , but I have . . . , yes I . . .” The music builds in intensity Instrumental climax one The music subsides–Michael and the therapist sing quietly together Michael sings: “Now listen”–the therapist stops singing Michael continues singing: “Listen to my song. Listen to me. Listen to my song.” Instrumental climax two The music subsides and Michael continues singing: “My song it is sad . . . and my song is long . . . it is sad and it is long... and my song it had a beauty . . . yet it is sad, so sad.” Instrumental climax three Michael’s cymbal playing becomes loud and free The music subsides and Michael continues singing: “And my song, it is high and low, high . . . low, high . . . low . . .” Instrumental climax four The music becomes quieter and more gentle

It’s interesting to see how we were developing our conversation in close contact right from the beginning. Unlike the previous session when we took nearly half - an - hour to negotiate our relationship. In this session it was there immediately. Listening now I am struck by how much of your music is in the dialogue. You are taking a more confident musical role. Even though I play musical tidal waves you are still prominent. You are not retreating. Our relationship is different in this session. I am musically more prominent and

M.

C. M.

C. M. C. M.

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directive. It was a conscious decision because of our developing relationship and the nature of the musical expression at this time. When you started to sing my name I was shocked. This was the first time a client had done that in therapy. It felt uncomfortable . . . like being in a dream and being called to. I remember thinking: “Why are you calling me?” “What do you need from me?” . . . so many emotions raced through my mind. Do you remember this as clearly as I? I find it hard to reconnect with the emotion or the intent of my singing. I really don’t know. I’m perfectly sure it did mean something to me then . . . but couldn’t tell you what. I remember this moment when I had an idea of calling your name. I was hesitant because I knew it was daring. It was like standing across a boundary . . . even though we had never agreed there would be this boundary. It’s something to do with connecting to another person. We were playing music together on an equal basis, even though it was understood that I was the client. We were two equal people expressing through music. From the second session it was clear that we were musically standing on the same plane. Your musical ability and technique was better, larger, and more sophisticated than mine. But in terms of what we expressed together it was an equal contribution. I felt honored to be an equal musical partner. I know I have pain, loneliness, and depression. I am in this world and I can engage in some kind of communication that enables me to look outside. But at the same time I say: “Hey, look at this . . . It’s me . . . listen to me.” Reaching out to another human being. It was one of those scarce moments when I was in a position to let someone in and openly share. This was more distinctive and intense than anything else we had shared before. What implications would this have to sing your name?... and yet it seemed so natural. In the music you were following, you were reacting to me . . . this is why it was so extraordinary. Then came the moment when you started to sing. I don’t know what to say. Do you remember? I wanted to express that my song is both sad and beautiful. There is beauty and there is sadness. This is what I was struggling to express. It’s a powerful example of how important words can be with singing. The last time I sang, I sang that my song was both high and low . . . they are just words. For me this was a stunning experience. It’s absolutely profound I’m sure . . . it’s not the words themselves. I wanted to use words to try and acknowledge the fact that life is challenging and that it’s hard and sad and yet it has beauty . . . I guess that’s all. That in itself is profound. I was more struck by the intervals that we were using . . . the musical things that happened between us more than the words. The recorder was a substitute for my voice. It was painful and like weeping but that was the closest I could get to the actual expression of weeping. Then I introduced the cymbal. It was such an integral part . . . it was always there. I’m amazed at how I keep it going. There is a loud passage and then the constant pulse. Throughout this session the balance between us is wonderful. There was only one moment when you didn’t go

C. M. C. M.

along with me . . . one brief moment until I got to my senses and we could take it from there. You follow wherever I went except for a very few instances. This is a perfect example of AeMT. In retrospect I know this expression was good for me but I can’t say more than that. Maybe it’s like a security mechanism for me now not to be able to reconnect . . . because it’s history. Perhaps it would be too much if you did? Exactly. If we had to tell anybody what an experience these sessions were and why they were so profound I would have a really hard time. I’ve been talking about our sessions to a lot of people and I’m completely convinced that it was absolutely profound and yet people have asked: “What did you do?” “What did it do for you?” “What was the point of it?” These are hard questions because it was so intangible. The core was that I was able to express my pain, to address it and then finally transcend it.

Audio File: Michael—Excerpt 3 (Session 10) After 10 minutes after the opening: • • • • • • • • • M. C. M.

Michael sings alone Michael whistles disembodied music Michael play the recorder and the therapist sings The therapist stops playing the piano leaving voice (therapist) and recorder (Michael) The therapist resumes playing the piano Voice (therapist) and recorder (Michael) Two voices a capella The music subsides leaving Michael singing on a chant overtone Both players eventually rest on the same note/chant tone The music dies away to nothing

How equal do you think the musical relationship is here? Totally equal. That’s what I felt. I have written: “simply music.” We were simply playing music, I don’t think it’s any more than that. The Therapist Concludes

In articulating clinical work where music is the essence, there is the potential for misconception even more strongly than through the written word. Music can be our ally but also our nemesis if we do not, as therapists, clarify its role within the process. Music-centered approaches to music therapy, I believe, are still misunderstood because the role of music in therapy itself is misunderstood. Clinical improvisation continues to inspire yet perplex. Structure and freedom balanced within the framework of intrinsic personal creativity is a complex yet liberating

phenomena. This case study as a clear example of AeMT, shows how music as a therapeutic force can be a process that is complete within itself. Michael’s musical clarity and reflective analysis shows his belief in the potential for music to expressively articulate loss. His words give support and accuracy, but it is in his music that the kernel of therapy is born and cultivated. Improvisation is at the core of his therapy and to understand his journey we must understand the nature of his musical persona. Thus the audio examples hold the key–returning always to the music–in realizing his musical journey through bereavement. Michael’s presence in my life during the sessions and now as we prepare this work has been considerable. The musical challenge he set me as our work began often felt overwhelming. Could I meet this challenge and what it would mean to musically translate the intense pain of his mother’s death? In asking him to meditate on our work some years later, I was equally aware that this could be very painful to reflect upon. Had I the right to suggest such a venture and could this work become in itself another therapeutic process? For me the opportunity to analyze our work was indisputably therapeutic. As we unearthed ever more complex aspects of our alliance I began to further appreciate the nature of our musical relationship. I hope the outcome, not only for Michael but for music therapy as a profession, has been worthwhile. Clients teach and define a music therapist’s practice. Michael’s sessions were pivotal in helping me further realize the balance and interplay between the “art” and “science” of improvisation and that neither are mutually exclusive. The “science” of creativity is equal in stature to the “art” of empiricism. It is how we define their limits that provides the necessary opening for each individual’s conception of music and therapy. This case study highlights this developing balance and search that is concrete and yet inherently creative. The Client Concludes When listening to the music, I immediately understand that what is being negotiated in sound reflects a therapeutic process that has taught me something very important. With hindsight, I understand that the mere expression of emotions in the presence of a therapist is not necessarily therapeutic. When I first listened to the extracts Colin had chosen for this case study, I thought: “There isn’t enough of the furious gong-bashing in it! People won’t really understand just how great my pain and suffering was!” Only later I realized that the sheer loudness and sustained drum beating of mine was not very meaningful at all. Only now I understand that what Colin’s unfailing presence offered me was this: to reach out to him from my remote point of loneliness. Rather than making a big noise so that he would reach out to me and comfort my wounded soul, my only chance to find help and comfort was to reach out to him! Naturally, less imposing music that leaves more room for refined interaction was what I needed to offer him. I am glad I did. Because what I found was a therapist who was every bit as passionate, courageous, and humorous as one can only wish for, when a client really needs help.

Taken from: Lee, C. A. (2003). The Architecture of Aesthetic Music Therapy. Gilsum NH: Barcelona Publishers.

CASE EIGHTEEN Living In Playing: A Group Case Study Colin Andrew Lee They said, “You have a blue guitar, You do not play things as they are.” The man replied, “Things as they are Are changed upon the blue guitar.” And they said then, “But play, you must, A tune beyond us, yet ourselves, A tune upon the blue guitar, Of things exactly as they are.” –Wallace Stevens, “The Man with the Blue Guitar” (1937) This chapter is an evaluation of ten sessions with a group of clients living with HIV/AIDS. The extracts from sessions on the accompanying CD emphasize the importance of musical reality in assessing AeMT. Music is the most important component of this chapter. Music holds the clues to understanding the therapeutic process and creative expression of living with HIV/AIDS. The words are a guide to help balance and provide a framework for understanding the musical and therapeutic form of this compelling work. Music therapists tend to focus their energies on either group or individual work, the choice often coming from the exterior sources of the setting in which they work. The therapist’s own preference–depending upon theoretical and philosophical orientation–is a more fascinating and complex subject. As my clinical work developed I became more invested in individual work. I found the musical elements of group work to be complex and challenging. Meeting and reflecting the many sounds of a group improvisation invoked a collective potency that needed intricate understanding of the process. During my formative years as a therapist I felt unable to provide the necessary responses, musically or verbally, this work demanded. Balancing musical and therapeutic meaning, especially with verbally articulate clients, I felt at the time would need further education in group psychotherapy. As my work became more immersed in music and with the inception of sessions with clients living with HIV and AIDS, I again returned to the potential of group music therapy. This case - study is described from an Aesthetic Music Therapy (AeMT) perspective. The

musical interactions come from a belief that the improvisational structure is based on an understanding of the musical qualities in each developing moment. While that is not to deny the potential for a psychotherapeutic perspective, as in Music at the Edge (Lee, 1996) I have chosen not to offer in-depth nonmusical interpretations. Rather, this case - study focuses on the immediacy of interpersonal contacts within the group and how they were reflected through the music. The precision and collaboration of discourse in this group was sophisticated and presented many fascinating conundrums in further questioning the musical processes of group improvisational music therapy. Therapeutic Structures and Musical Interventions Group work often takes the form of words-music-words (Priestly, 1994). Music is used as a means to access and promote verbal interactions: Through music, there can be a resonance of . . . thoughts and feelings. For many . . . , words are not sufficient to portray what they feel, so music becomes their mode of expression. Through the musical expression, new roads are traveled, new signposts seen, and answers come not only musically, but often back to the spoken word. Thus a full circle is realized in the process beginning with words, leaving the words to explore musically, and then coming back to find the right words for verbal processing. (Borczon, 1997 ,p. 9) What then of group work that does not necessitate the need to begin or return to words? The potential form becomes silence-music-silence. To find the “right words for verbal processing” I believe places an expectation on music to be something other than itself. AeMT is concerned with finding the right music for the expression of the group rather than a means to aid verbal interpretation. This, I believe, places music as the core rather than as a by-product. The question often raised is that if the musical experience is not placed within the conscious logic of a verbal framework, then its clinical validity is questionable. I believe the insistence on words to interpret musical articulation to be equally questionable. To bridge the gap between the unconscious articulation of music and the conscious rationality of words is, I believe, a specific endeavor. Verbally articulate clients often express their desire not to talk through extended and potent silences. Does the therapist impose that to complete is to speak, or do they allow closure through the natural completion of music and silence? That AeMT is not dependent on verbal processing means that our understanding of clients’ growth can be understood through the structures of music itself. For nonverbal clients moving between silence-music-silence; this can release the expectation of words that so often causes frustration in the therapeutic alliance. The challenge of “to speak or not to speak” is equal of “to play or not to play.” To create music, hold silence, or verbally intervene is a clinical choice that should be taken individually and not theoretically. Thus music psychotherapy should be able to embrace purely musical expression and AeMT needs to include verbal processing when appropriate. So what of the musical role of the therapist in AeMT and what interventions are clinically appropriate in group work? AeMT group work is based entirely on clinical improvisation. The following observations are written from an improvisational perspective. The ideas presented, however, are appropriate for therapists who also use improvisation as just one

part of their therapeutic offerings. Taking a continuum from nonparticipation (playing little) to full - participation (playing fully), the therapist must decide when to intervene, on what level, and the intensity of music needed to reflect the moment-to-moment expression of the group. Typically in group music psychotherapy the therapist does not take a leading musical role. The therapist is physically connected to the group by playing similar percussion instruments and sitting as an equal member of the group. The therapists’ musical voice in this instance is essentially non-directive. Therapists also use their principle instruments other than piano (e.g. flute, cello, guitar), as a means to mediate the dynamics of the group. The use of orchestral instruments in group work provides a balance for the therapist’s role and allows group members to feel physically connected. The therapist’s musical role here often has a greater impact on the overall texture and form of the improvisation. The piano brings both problems and advantages to group work. Due to its size it is impossible for the piano to be an equal physical member of a group. Its musical potential, however, far outweighs its disadvantages. The piano can enrich the musical intricacies of a group. It has the ability to provide melodic simplicity as well as complex harmony, counterpoint, and orchestral textures. The piano can capture the embodiment of a group while allowing individual voices to be heard. Using the piano as a musical catalyst in group improvisations can enrich and help promote music therapy goals. It is important to clarify the role of the therapist-pianist within the musical exchanges of the group. When facilitating a group from the piano it is the aim of the therapist to meet and communicate the musical expression of the group. The therapist may contest and confront the group dynamics if this is considered appropriate. Because the piano is potentially directive it is important that the group understand that the therapist’s skills help determine the instrument’s role within the group, and that the role of the therapist-pianist is to meet, reflect, support, and confront. The therapist may sense an experience the group is trying to reach that through specific musical techniques it is possible for the group to achieve. From an aesthetic perspective in group improvisations the therapist is concerned with the actualities of sound as they impact the process, thus providing for the group a musical experience they may not be able to achieve alone. AeMT differentiates itself from other nondirective group improvisational approaches with regard to the therapists input. Decisions and boundaries of the therapist are dependent on a balance between the aesthetic and the clinical, and clarity of group goals. Transforming the strands of individual voices is a challenging musical process that once attained can bring enlightenment to the group. Techniques and resources provide the necessary skills for the specific needs of AeMT group work. The musical components used in group work are integral to the therapeutic process. The use of clinical music should be conscious and finely graded. Listening to the often disparate sounds of a group requires good clinical musicianship. To reflect and transform a coherent musical whole is one of the main aims of AeMT group work. While this does not negate the clinical relevance of containing and accepting chaos as a group expression, it is my belief that simultaneity is the first step in the developing therapeutic process. The therapist’s skills in facilitating group improvisations is highly complex. Not only must the therapist be able to clinically listen to each voice and combinations thereof, he/she must also be able to respond and make sense of each of the intermusical and interpersonal representations of the group. Clinical listening in group work demands meticulousness and perception of response.

The Lighthouse Group London Lighthouse, a residential and support center for men and women affected by HIV and AIDS, was founded in 1986 (Spence, 1996) in response to the pandemic of these viruses. Most of the documented music therapy work detailed from London Lighthouse is based on individual work (Hartley, 1999, Lee, 1996, Pavlicevic, 1997). Group work with clients living with HIV and AIDS can be difficult due to the different needs of asymptomatic and symptomatic clients. My experience at Lighthouse was based on closed groups that ran for ten-week cycles. The maximum number in each group was eight and every self-referred client met with me, the therapist, individually prior to the commencement of sessions. Regular attendance was often difficult due to the changing nature of some client’s health. The therapeutic process shifted accordingly. The three groups I facilitated at Lighthouse were influential in the evolving principles of AeMT. The musical sophistication and explosion of group dynamics can be heard in the accompanying audio examples of this study. They demonstrate the potency of improvisational groups with HIV and AIDS. The clinical applications and aims of AeMT group work grew spontaneously during my work at Lighthouse. I had been offering individual music therapy sessions for almost a year prior to the inception of group work. I tried not to premeditate what the aims of this work might be. I guessed that the issues facing a group of clients with HIV and AIDS would be different from individual work. Some of the aims of individual and group work shown below highlight the differing needs for inclusion in each process: The aims of individual work are: • to express frustration and anger at living with HIV and AIDS to face personal loss • to express nonverbally intense feelings and emotions to find healthy alternatives of coping and living • to share individually with a therapist • to face one’s own death and dying The aims of group work are: • to share with other people living with HIV and AIDS to express collective feelings of frustration and anger to share personal loss • to find collective musical rapture • to build healthy group relationships • to support peers living with HIV and AIDS It is interesting to note that referrals to individual work mention the need to face loss, whereas in group work a need to share and support seems most important. The following musical and therapeutic themes were crucial in the developing group work at Lighthouse: • • •

the use of descriptive musical textures the use of specific instrumental combinations the balance between words and music

• • • •

the meaning of one complete improvisation per session as opposed to several smaller ones the musical representation of loss the use of tonality and atonality to express the group process the use of untuned percussion in portraying frustration and anger

As these themes developed and grew within the group, certain characteristics of improvisational playing became evident: • • • • •

lack of rhythmic clarity–rhythms with little or no regular pulse and rhythms that were perseverative and lifeless musical aggression–loud playing, often over long periods the avoidance of melodic expression a preference for minor keys, modes, and atonality the use of the cell and seed motive musical representation of opposites

The balance between therapeutic aims and musical representation is at the heart of this work. The aesthetic content of sessions was often brutal and offensive (Lee & Khare, 2001), and the aesthetic consideration of group members and the process, intricate. Moments of introversion did appear as crucial experiences of musical rapture. These moments were significant in the cohesion of the group. The balance between words and music found a natural level as the improvisations became a clear representation of the groups’ needs and direction. As with individual work the more influential the music became the less need there was for verbal processing. The move from words-music-words to silence-music-silence was witnessed in each of the three groups at Lighthouse. The Sessions The four members of the group were: John (25)–a quiet retiring man who played and spoke only when he had something to say. His music felt like an accompaniment for the rest of the group. Ian (28)–came to sessions with vigor and determination to play. His music was often based around rock rhythms that were influenced by his experience as a young man in marching bands. Terry (20)–was immediately aware and sensitive to the group dynamics. His music was strong and rhythmic. Simon (23)–the least sure of the group, who missed several sessions. His place in the music was not always clear. His most personally influential improvisations were at the piano. All were HIV-positive and asymptomatic though Ian began to show symptoms as the sessions progressed. John, Ian, and Simon had never improvised before. None of the group had

received formal musical training and no one knew each other before the sessions began. Sessions were one hour in length. The group found styles of improvising that reflected the unique nature of each member and the group as a whole: • • • • • • • • •

fast, furious, atonal percussion playing melodic improvisations on tuned percussion the use of recorders as a means to “sing” long, slow tonal moving phrases rhythmically pulsed playing rhythmically unpulsed playing the piano as a vehicle for harmony (note: the piano was used not only by the therapist, but by all group members) improvisations with no piano long extended silences

A sense of chamber music permeated all the sessions. The sessions were held in the music therapy room, Ian McKellan Hall at London Lighthouse (Lee, 1996 p. 5). Included was a grand piano and an extensive range of tuned and untuned percussion instruments. The following description, taken from my indexing and assessment notes, are written in a free-flowing format. This shows, along with the two audio examples, the sense of excitement and fervor this group entered into as a part of their therapeutic process. Session One The session opened with a verbal discussion on the possibilities for the group. Everyone introduced themselves and made a brief opening statement. Each member expressed their eagerness to explore through music. My role as therapist was defined as one who would musically and therapeutically meet, contemplate, and contain the revelations of the group as they occurred. Verbal reflections would be included if needed at the end of the session or directly after an improvisation. It was felt that words should be in a physically different space to music-making. A circle of chairs was therefore arranged next to the instruments. The one improvisation of this session began with everyone playing fast, furious music. As is natural for a group of people who have never played music together, everyone improvised constantly, loudly, and frenetically. Underneath this explosion of sound there was also a sense of rumbling that was to become the cornerstone of Terry’s emotional/musical contribution to the group. After approximately twenty minutes of continuous playing, where there seemed little or no sense of group listening, the intensity of the music suddenly ceased: Audio File: Group—Excerpt 1 (Session 2) Twenty minutes after opening:

• • • • • • • •

Ian/Terry–drums and cymbal, John/Simon–xylophone, Colin–piano A sense of quiet exploration (20:44) Xylophone and percussion explore the group musical relationship The therapist reflects the musical dialogue from a distance The xylophone initiates a clear rhythm in 4/4 This theme moves the music into an exciting affirmation of playing A rock-based experience that Ian described as being reminiscent of the group Santana Listen to the excitement of beginning musical identities and group music-making

My assessment of this session included the following notes: • • • • • • •

huge musical experiences–organic and free an immediate sense of group improvisation influenced by drum and rock music a sense of energy and expectation a sense of gentleness and vulnerability a group that feels alive and running (I think I am trying to catch them!) carefully balanced texture of xylophone, drums, and piano a group with overwhelming promise

I left the session enthralled and astounded at the accomplishment five people, who had never improvised together, had achieved. Session Two The group entered and they immediately expressed their desire to play. The first improvisation (12’31”) was firmly grounded in a rock idiom, and exhibited acute listening and shape with an already complex dialogue of musical voices. The second improvisation (32’02”), was bigger in architectural form; a slow and gradual build of emotional/musical form. The xylophone (John) introduced small almost imperceptible themes that would be taken as a group theme. These were interspersed with sudden intense explosions of drumming (Ian), that would come to the fore and then pull back–a sense of needing and breaking free. Toward the end of the improvisation (25’56”), the music became caught in patterns strongly reminiscent of minimalist music. There was a pause and a coda of quiet nonpulsed playing. Session Three The one improvisation (45’33”) of this session was impenetrable. The structure was enormous and fell into the following form: A (forceful loud,) B (calm and gentle), A, C (without piano), A, D (Ian –piano), A. Words and phrases from my assessment best describe the essence of this session:

• • • •

musical exploration as therapeutic process complex dialogues–my role as therapist facilitating the organic growth of the group does this music portray the battle of living with HIV and AIDS? a balance between consonant and nonconsonant expression Ian’s beautifully controlled and expressive piano playing was an inspiration

The group dynamics were becoming complex and stronger. In the discussion following this improvisation John and Simon expressed their feelings of acceptance: that although their voices were not equal in dynamic musical content, they felt heard and embraced by the rest of the group. Ian’s musical voice was becoming stronger and more personal. Terry seemed confident in his playing and would always meet Ian’s rock style of improvising. Session Four (Simon absent) The two improvisations of this session (16’37” and 11’39”), were structurally led and developed through the xylophone playing of John. The long extended silence held at the beginning of the session was broken by Ian’s quiet solo piano playing. This felt like an extension of his piano improvisation from the previous session. As the music developed, a granite-like quality emerged providing music that was syncopated and forceful. After a huge climax (10’15’), the music subsided, building again to another peak dominated by Ian’s piano playing. The second improvisation was calm and musically lead by John on the xylophone. At the end of the session, even though Simon was absent, a discussion took place as to the developing relationships and group process. I wondered if Ian’s growing dominance within the group, always supported by Terry, might in some way undermine or usurp John’s more introverted contributions. The group indeed seemed more aware of their differing roles and levels. My sense that Ian was surprised at his developing place within the group was supported through his declaration that he was potentially becoming symptomatic. This news along with the possibility of a new drug regime had given him a new sense of creative freedom. Ian felt able to take musical chances, to dare to express parts of himself that he would normally keep hidden. He felt that even after four sessions the group was sufficiently supportive and able to allow him such personal release. The response from the group to this statement was overwhelming. Session Five The words that opened this session were important as they acknowledged Ian’s testimony from the previous session. The silence that followed led into the one improvisation of the session (32’52”). The first extended section (A) was on untuned percussion without piano. This led (27’44”) to an unexpected light and frivolous Spanish passage. The piano was initially played by myself and then Ian as he accompanied the wood block (John) and tambourine (Simon). A sudden menacing explosion broke across this music (Ian and Terry) providing a feeling of being on the edge of a precipice. The music unexpectedly returned to the

lightness of the Spanish idiom. This idea was developed to the end of the improvisation. There was little conversation at the end yet a sense of struggle between the intensity of Ian and Terry and the lightness of John and Simon. Session Six The group entered and immediately began playing scattered frenetic music. As the therapist I tried to contain the disparate strands of their music. The sense of freedom and excitement was addictive. The music built and built and built . . . there were screams of excitement . . . complex rhythms appeared . . . the music momentarily stopped (8’41”) and then built to an ever greater peak of total frenzy (9’31”). My assessment notes gave an indication of the fervor of this session: • • • •

what’s happening?–the wildest improvisation I have been a part of playing of extreme energy that gets more and more energized difficult to find my place and role in the music everyone is caught in the musical hysteria the improvisation gets faster and faster . . . wilder and wilder a sense of total musical and therapeutic cathartic freedom

There were no words at the end of this session, just feelings of exhilaration and exhaustion. Session Seven (Simon absent) A quiet session led by John, supported by Ian and Terry. A sense of quiet after the storm. Session Eight The opening verbal dialogue acknowledged the three sessions left before the end of the group. Following an extended silence the first improvisation (12’38”) explored musical floating and glass-like textures. The improvisation was devoid of established rhythmic or melodic content. Supportive listening continued as the group attempted to find an equality of musicmaking. The second improvisation (19’55”) was similarly calm and nonintrusive. The four members rarely played together, the two extended chamber music sections consisting of A) piano (myself), xylophone (John), and recorder (Terry) and B) cymbal (Simon) and piano (Ian). The musical/personal intimacy captured in this session was enigmatic. Session Nine This session contained the apex of our work. The one improvisation (42’31”) was created with musical and therapeutic precision. It began quietly building through exquisite serenity and equilibrium.

Audio File: Group—Excerpt 2 (Session 9) Fifteen minutes after the opening: • • • • •

Ian/Terry–drums/cymbal/gong, John/Simon–xylophones, Colin–piano xylophones and piano explore melodic phrases Musical strands naturally interweave Gong and percussion appear as the intensity grows Music that is both sensitive and yet powerful

This is one of the clearest examples of AeMT I can offer in this book. It was a perfect example and union of therapy and art. My voice both leads and contains the emotional edge of the music. It was not subservient and yet was delicately poised over the group as clear negotiator. As the music became more and more intense the dynamics of the group melded and the five players became one. The short verbal discussion of this session was limited to a few simple words that tried to help describe the intimacy we had all shared. Session Ten The group entered and immediately began improvising. There was a quiet determination from everyone. This improvisation was the longest we had created (58’32”). The structure was based around the opposing music that had been the hallmark of our work. Delicate music on tuned percussion was balanced with loud aggressive music on untuned percussion. The improvisation was grand and emotional. Small chamber music combinations balanced with elaborate orchestral textures. Toward the end of the improvisation an extraordinary event occurred: the music began to fall apart. It was as if the group tried to sabotage any sense of a coherent ending. An extroverted and playful rhumba (49’12”) appeared that was menacing and cliched. I was initially surprised at this musical turn but soon realized that a balanced ending would be impossible for the group. Staying and holding their musical insecurity, here the intensity of four was far greater than the similar individual experiences I had encountered. It was difficult to stay and hold this intense and strange turn of events. As the music concluded there was a long and uncomfortable silence. Each group member simply said “thank you” and left the room. Three of the group members self-referred themselves for the next set of sessions: John, Terry, and Simon. Ian did not return to Lighthouse. Reflections This group, the first of three at Lighthouse, was an important step in my analysis of the sophistication of a music-centered approach to group work. My role as composer/music therapist was tested to the extreme. What resulted was an eruption of artistic, clinical, and compositional connections that combined to present another approach to my developing work in AeMT. The musical components of every moment, phrase, and complete improvisation were

intensive and complex, yet structured from the simplest and logical of ideas. The music shaped the therapeutic process with a different clarity from that of individual work. The many sounds introduced a complexity of musical/group dynamics that further validated the need to look at the musical structures of the process. Clinically listening to groups and attempting to find a form of indexing that acknowledged the complexities of group form continued as I attempted to delve deeper into my understanding of the link between therapeutic intent and musical articulation. Analysis of the therapeutic process is critical. To interpret music as an agent of change we must first understand the structures of music itself and how it is communicated between fellow human beings. In group work the precision of musical contact and analysis becomes ever more complex. This case-study does not include the verbal reflections or my counter-transference responses. You will note that even though verbal processing did take place, it was not the central focus of the group. This material is presented as factual and unbiased in the hope that colleagues from different philosophical backgrounds may interpret and understand the group’s meaning from their own perspective. It is my hope that through the description of the process the reader/listener will gain a sense of the emotional strength of this group. The power of the audio examples included attest to the potency of a music-centered approach to group work with clients with HIV and AIDS.

Taken from: Lee, C. A. (2003). The Architecture of Aesthetic Music Therapy. Gilsum NH: Barcelona Publishers.

CASE NINETEEN Moving Into the Age of Aquarius: Aesthetic Music Therapy with a String Quartet Colin Andrew Lee

When a performance is in progress, all four of us together enter a zone of magic somewhere between our music stands and become conduit, messenger, and missionary. In playing, say, the cavatina of Opus 130, we join hands to enter Beethoven’s world, vividly aware of each other and our objective performance responsibilities, and yet, almost like sleepwalkers, we allow ourselves to slip into the music’s spiritual realm. It is an experience too personal to talk about and yet it colors every aspect of our relationship, . . . Arnold Steinhardt Indivisible by Four: A String Quartet in Pursuit of Harmony (1998) I have explored, through the writing of this book, the aesthetic qualities of music therapy; to bring together the strands of clinical practice from a music-centered perspective. The work described in this chapter, perhaps more strongly than any other, illuminates this striving for cohesion between clinical and musical form. To be innovative is to contest that which we consider fact and allow it to become an enigma. Music therapy over the last fifty years has acquired a broad range of theories and knowledge. Future inquiry will determine how these outcomes influence contemporary questions raised in the next millennium. The challenge is not whether we should be focusing on empirical evidence or qualitative and humanistic thought, but rather how we refine the quality and nature of these discussions for our understanding and the substantiation of practice for others. While being only one part of this growth, I believe a music-centered perspective as advocated in AeMT is, nevertheless, a fundamental one. It is our inner self-analysis and openness that will establish the credibility of music therapy with affiliated professionals in the future. If we are to gain respect from the field of music we must be prepared to demonstrate the quality of our musical interventions. Working with musicians is a natural and liberating evolution in this process. Even though potentially daunting, this work can provide an opening for future practice that is informed from music itself. To face the challenge of this work is to expand our musical and therapeutic horizons and in doing so discover new ground-breaking models of music therapy. Music therapy with musicians has gained little recognition in the evolution of clinical practice or in the literature. Rachel Verney’s (Ansdell, 1995) description of her work with Jane, a

flute teacher, provides a powerful testament to the potential of this work. In speaking of her music therapy encounters Jane expresses that: I experienced that all the possibilities in music–if they are used creatively and sent into the center of us–are like a self-regulating system. My singing, my making music has really changed, and also the way I listen has changed (p. 185). Jane came to music therapy because of a presenting problem with her wrist. Once becoming immersed in music, however, her physical condition disappeared and her involvement in improvising, particularly singing, became the therapy. Her words are a clear indication of the strength of this work, but it is the audio extracts that speak most clearly to the vitality of music making. Listening to the first audio example (note: please refer to accompanying CD, Music for Life, Ansdell, 1995, track 21), one is struck by the strength and unity of the musical relationship. The section of improvisation included is an aesthetic experience embedded in the developing relationship. Rachel’s exact clinical listening as therapist, the simple yet directed piano accompaniment, and the interpretations of Jane’s vocal phrases allows a musical and therapeutic creative duet of epic proportions. This work shows that clinical improvisation with musicians depends, even more explicitly than in other areas of clinical practice, on the immediacy of the musical moment. Exterior interpretations serve to inform the process but it is the music itself that is unquestionably the therapy. In the final chapter of Music at the Edge (Lee, 1996), in the section On Being a Musician as Client in Music Therapy, I wrote: Musicians often lose spontaneity in their trained renderings of other people’s music: improvisation permits the intuitive expression of a musician’s authentic sense of music self. For the therapist there is often real testing of musical ability. The therapist must . . . be assured of his or her improvisational skills when working with musicians. This does not mean that the music therapist has to be up to a virtuoso standard. It is possible to work with musicians who have superior musical skills; what is important is to listen carefully to their musical contribution. It is not enough to think in terms of an overall musical structure. The therapist must consider the smallest intricacies of expression within the music relationship. (p. 153) This challenge to the therapist is to provide musical commitment. I remember vividly my reaction to meeting Francis; that when learning he was a musician I wanted to run and escape. It can seem a daunting task to improvise with a musician. That the musical demands of this work are great there is no doubt. If we are prepared to risk the challenge, however, and strive for ever more higher musical standards, than the rewards of this work may be even greater. Louise Montello developed work culminating in the Music Therapy for Musicians (MTM) method (Montello, 2000, 2001). She initially used breathing techniques to consider the stress facing professional musicians (Montello, 1995). Techniques have been further explored, considering the underlying problems of performance stress and repetitive strain injuries, using breathing, guided meditation, and clinical improvisation (Montello, 1996, 1997). Improvisation is used as a specific tool to “express the energy of a bodily symptom musically, in order to give voice to feelings that may have been suppressed or dissociated” Montello, 1996, p. 5). Through

research of the MTM method she has discovered that specific music therapy techniques not only reduce performance anxiety but also increased musicality. Background The summer of 2000 was spent in England visiting family and friends, and contemplating my fifteen years of work as a music therapist. Having made the critical decision to stay in Canada, I found myself reviewing past achievements and planning future ones. What new avenues of work would I now explore and how could I further combine my roles as musician, composer, and therapist? I had a feeling of being at a musical and personal crossroads. Having worked within a music faculty for two years I had become immersed not only in the running and teaching of the music therapy program, but also in interdisciplinary connections with composition, performance, and musicology. These professional affiliations had a significant effect not only on my developing musicianship, but on my insights in understanding the strands of clinical improvisation. The string quartet is a medium that has always fascinated me. Inter-musically and interpersonally I am intrigued and in awe of this, the most personal of musical associations. Wilfrid Laurier University is privileged to have as quartet-in-residence the Penderecki String Quartet. Listening regularly to their concerts I began to hear and see patterns in their playing that fascinated me and gave rise to questions. What where the intricate musical and physical gestures they used and how did these relay the subtle communication needed to perform the often intimate works of the string quartet repertoire? What personal dynamics, if any, were occurring between players and could these in any way be related to the dynamics of clients in music therapy? Could a music therapist work with a string quartet in the same way as a group in music therapy? The more I pondered these questions the more absorbed I became by the potential of working with the Penderecki String Quartet. On one hand it seemed a natural evolution of clinical practice but on another I wondered if this would be classed as music therapy at all. On returning to Wilfrid Laurier I decided to approach the quartet to see if they would be interested in working with me on a pilot project. I explained little other than this was an idea that had come to me during the summer, and wondered if they would be interested in professional contact between us. They agreed, acknowledging that it might be difficult to arrange a series of concurrent sessions due to their busy teaching and concert schedule. The work described here is based on the two sessions we have held to date. The Sessions Note:The author suggests reading the text describing session one,and then listening to the excerpt, and then doing the same for session two. Afterward, read the transcription of the interview and listen again to both improvisations. Session One I had many apprehensions preparing for this, our first session. How would I explain clearly my ideas? How would I take the role of therapist? What would their expectations be of me and

the session? Was I musically competent to meet the potential of their playing? Where they feeling as nervous as I was? I prepared the room in the same way as I would for a group session though I decided not to have available percussion instruments (note: these first two sessions have been held solely on their string instruments. We have, however, discussed the idea of introducing percussion instruments in future sessions). Entering the clinic the quartet quietly prepared and tuned their instruments. My opening words were (nervously) concise. I explained these were ideas in formation based on the hypothesis of musicians improvising together within a music therapy framework. I further went on to explain that it would be my role as music therapist to contain and reflect their playing. I explained that it was important that they start the improvisation, that the direction of the music should come from them. The silence that ensued was broken by an opening violin phrase; the rest of the quartet soon joined in. I listened intently to the quality of their playing and tried to discover some kind of tonal center. Taking a deep breath I entered their musical arena beginning with the suitably ambiguous interval of a major 7th (G and F#). The music immediately took on a life of its own. Structurally the improvisation was not dissimilar to the long improvisations I had become accustomed to in my developing work with clients living with HIV and AIDS. The seven sections were divided with short resting plateaus. As each was introduced the more inventive they became. I was caught in an experience of musical liberation that left me breathless. As the improvisation came to a close there was a long extended silence. It seemed that the quartet were as intrigued as I at what had taken place and were eager to talk about the experience. The opportunity to play both free from a score and have no musical expectations placed on them were dynamics not often available. We talked about what would happen if we continued the work; what would be the focus and how would working in music therapy help them as a quartet? After much discussion two main questions appeared: Could clinical improvisation affect the quartet’s concert playing outside sessions? How might the interpersonal relationships of the quartet be explored through the musical dialogue? We decided to arrange another session later in the term. On reflection I knew something extraordinary had happened. Listening back to the tape I tried to uncover why this musical experience had been so powerful. It seemed that the aesthetic perception of music and the human connections made were more precise than I had ever encountered in other areas of clinical work. What impact could this work have, if any, for music therapy? I felt a sense of looking into a huge canyon. If this was music therapy then perhaps it was the purest form of music, communication, and the human condition I have ever been privileged to be a part of. What were the boundaries of the therapeutic relationships and process in this context? How was the music balanced as pure expression and relationship? I decided that what had happened in this session was either highly significant or highly irrelevant. What of my roles as composer, pianist, and therapist? To musically hold, contain, mirror, and reflect with such remarkable musicians seemed a daunting task. Should I musically intervene and challenge? These questions and others continued to penetrate my thoughts until the following session. Session Two The second session was different from the first on various counts. First, we decided to

change the venue to the Maureen Forrester Hall so a better quality recording could be obtained. Second, I had been approached by Helen Montague, a producer for CBC radio, to include our work in an upcoming program on music therapy. We agreed that Hele would interview us directly after the session. There were two improvisations included in this session. The quartet asked for the first improvisation that the violins (Jeremy and Jerzy) and viola (Christine) could be free to move around the platform, while the cellist (Paul) sat immediately in middle stage to my right. The piano lid of the piano was opened and at various times during the improvisation members would play into the sounding board which I would allow to sound by keeping the sustaining pedal down. The opening of the improvisation was exploratory in nature. Audio File: Quartet—Excerpt 1 (Session 2) • • • • • • • • •

The cello plays a descending glissando heralding a slow, defined, and romantic legato theme. The music becomes tango-like with clear phrases and open textured playing. Rhythms are established and thrown from player to player. A short bridge passage allows the music to find a new direction. A fast-moving and syncopated section develops. The music builds in dynamic and emotional intensity. Fast repetitive phrases lead into the following section. Romantic tonal music builds slowly. Stunning, intense listening and an exquisite sense of chamber music playing evolves. The music reaches a climax ending with a high ascending phrase on the violin. Bridge passage. The final section is syncopated and rhythmic. The music moves toward a coda and the rhythms become less intense. End of improvisation.

For the second improvisation the quartet again requested a change in their positions. This time they asked to sit equally around the piano. The sense of being enveloped was a powerful one that had a great impact on my playing. The music was developed from the opening violin D. It is this note that contains the overall musical invention and floats over the improvisation as the architectural tonic. The intensity of relations and the theatrical/emotional quiet of this improvisation is a testament to the power of musical and emotional form. This, I believe, is a clear example of music therapy with musicians. Audio File: Quartet—Excerpt 2 (Session 2) • • •

An intense silence is broken by D on the violin. Small transparent textures are intertwined with small motifs. Sounds come and go. There is a sense of acute listening. The music gains more direction and strength. A climax ensues.

• • • • •

The music becomes lighter and more open in texture. A second huge climax takes the music to its highest emotional peak. The music dissolves and the viola leads a new melodic invention. The music continues to be small and transparent. A third fleeting climax leads again to quiet inner music. The music becomes smaller and smaller. The improvisation ends with a held silence.

After the improvisation we sat in silence for a time, before moving to the room for the radio interview. The Interview HM HM CL

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Helen Montague (interviewer), CL Colin Lee (music therapist), JK Jerzy Kaplanek (violin), JB Jeremy Bell (violin), CV Christine Vlajk (viola), PP Paul Pulford (cello) When you were first approaching the members of the Penderecki String Quartet, what is it that you told them? The idea of working with the quartet came quite spontaneously. I had worked before as a music therapist with musicians so in some ways this was a natural extension. I remember hearing the Penderecki and thinking about the way they made music. How they interacted together musically and interpersonally. I thought it might be exciting if I could give the quartet the chance to play and freely explore with me as music therapist. It seemed a simple idea though at the same time I was aware that it was potentially loaded. What did you say by way of explanation? I kept it open. That this was just an idea. I hadn’t theoretically or clinically made any assumptions beyond the idea itself. I think even now after two sessions we are at the beginning, so I’m starting to have questions and to think what it really is that we are doing. Is it music therapy? Is it simply us improvising together? What are we actually doing? In our first session we all discussed this at length. What should be the aims of our work? I think that’s still being formulated. As a qualitative researcher I wanted to be open so that the work would find its own level and direction. (To PP) Why did you think this would be an interesting project? I think the concept of improvising for a group such as ours, which puts such a high premium on exactness and getting it right and consistency, at least for me, was kind of frightening. You’re basically losing control of those elements. You never know what’s going to happen. You have to be responding constantly rather than having any kind of plan, although even in improvisation presumably there is some kind of plan. We all have the same training in Western music. For me personally, it was a challenge. I was curious to see what would happen and I was curious to see whether the quartet could do it. I was interested in working with Colin; he’s a fine person aside from being a very wellknown music therapist, but just the energy I felt from him as a musician and person. I thought as a group we could benefit from working with him. I too felt open-minded about what might come up. The idea of participating in something with the quartet that is not so exacting–it’s really in the moment and it’s fresh and it’s being created by us– and then it’s gone. I like that.

JB

For me it feels immediately therapeutic, that we can let our guards down. You can’t even begin an improvisation if you’re feeling defensive or competitive–that premise cannot be in the room. It’s a more pure way of communicating with music among the four of us. It feels like doing scales as a group in terms of being cleansing emotionally. You can let your personality come out. You try to engage other people in the flow of the music. It reminds me of a comment from Anner Bylsma, an amazing European baroque cellist, who in a master class made a point of saying the first thing you should do in the morning is to improvise for twenty minutes so that you cultivate your own voice-– cultivate what you want to feel, get in touch with your emotional response to music. I think this is a wonderful idea; it’s a very basic exercise and I think it’s terrific.

JK

Being able to explore different angles of music is very important as a musician and improvising has always been a big part of that. Even though I don’t improvise very much on the violin I improvise quite a bit on the piano and when I was younger I played the organ and improvised. Improvising always freed me up and after working for so many years with my colleagues in a very scheduled and profound way, I realized that I had never really got to know them as creative improvising musicians. I was really curious to explore that. After spending so much time trying to get everything done perfectly and in a certain way with stylistic differences and intonation perfection, one can get away from that when one is improvising. It was really interesting to see the different responses and emotional contents of responding to each other’s phrases and sounds. We’ve worked so much together. With new music, where we sometimes get asked to improvise, you can sometimes hear our direct emotional response. You know, I’m not really able to completely let go. There were times during the improvisation that I would feel like–well, I would like to follow this person, or follow this person and even if I don’t think about it my instincts would push me there. That would really not happen when I did it myself. So not having a particular plan like you would have for our other improvisations–it keeps this angle completely open–yet all the time coming back to those habits from rehearsals, and from the music that you’ve been learning, and then having Colin around that. I was interested to hear how he would read our responses and I was interested to talk to him about it afterward. What happens in a session? Is it structured in any way? I always wait for the quartet to start so that the musical direction is open to them. In the first session we played and then we talked for quite a long time. This morning we played two improvisations and this is the first time we have talked about the experience. How do you know when it’s time to begin? When we started the second improvisation everyone was quiet. In the first improvisation we experimented walking around with our instruments and so the leadership was almost shared by that too. When we started the second improvisation we said, let’s sit down and see how different that would feel. When the tape started nobody made a gesture, nobody made a sound. I was sitting more like a first violin–I should explain that Jeremy and I switch violin positions in the quartet– and I suddenly felt like, wow, somebody needs to give a cue, so I did that. I played one note and everybody started to join me. The first sound is the piece, so this beginning was interesting.

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There can be tension at the beginning of an improvisation. Who will start? If nobody takes the initiative there can be a sense of tense suspension–this of course is a part of the therapeutic process. Sometimes the opening silence can get to the point where no one dares play and then tension begins. The amazing thing is that there are many levels of silence. For me that opening silence was very cleansing. Absolutely. I felt as if whatever I do this will initiate the whole first part of the improvisation and the direction that it is going to take. That is a real responsibility. Part of the tension was because our first improvisation included a fair bit of activity. There was much energy initially and then in the second improvisation I think we all thought, How can we make this different? Where can we explore this time? I think we had to back way off and that’s exactly how the second improvisation felt: calm. In the first improvisation we walked around except for Paul and Colin. They were stuck to the ground. In the second improvisation not only did we all sit down, we sat around the piano. I felt in a sense we were all facing each other–there was a certain vulnerability in that. We all closed our eyes, but still you could feel the presence of people right there. This silence reminds me of what the first performances of John Cage’s 4’32” must have been like, where someone comes and sits at the piano and prepares to play and doesn’t. The piece becomes the silence and the response of the audience to the silence. It’s a brilliant concept. Would that be therapeutic for an audience? I think it potentially could be. Silence is as much a part of improvising as playing is. Stravinsky said music is a series of tensions looking for a resolution. Do you agree with that? Obviously tension and release–the scope of that–can be very different depending on the context-how things are going along. I think in improvisation there is that basic narrative and it’s generally in play, especially the first improvisation of today. There was very much a sense of well, if we’re going to go this far, then somehow we have to balance that with something else. I’m not sure if it’s because we are accustomed to that as a narrative with Western classical music; that we feel that’s polite. I thought the second improvisation had more sense of spatial–more Feldmanesque, less goal oriented. (note: explain that the quartet have played music by Morton Feldman and who he is) That’s a guy I wouldn’t want to improvise with–Morton Feldman! A more fundamental question: everybody is classically trained and you do have that classical sense of music, but what is that sense of music? What is your sense of what music is? And the second follow-up question would be, How does this work with Colin alter that, change that, move that, reaffirm that? This is a big question–a historical thing, a learned thing. How is coming together to improvise a therapy? Does this experience reevaluate your sense of music, what music can be? One of the things that fascinates me about Western music is the concept that the music of different composers represents the world in which they lived. The music of Bach in many ways is an aural representation of the world in which he lived, just as the music of Stravinsky is an aural representation of the world in which he lived. As we move into the 21st century and we start to see the impact of technology on the music that’s being

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created. Being trained to play music from other centuries–it’s kind of curious. You end up playing music which is not represented in the world we live in on a daily basis. We kind of time travel. When we play Mozart we are in a time when there were no machines. Probably the loudest noises you would hear would be a blacksmith, or a horse going down cobble- stones, or thunder. The sounds of nature very much would have been the dominant sounds. When you are improvising there is no way to leave your world behind even when you’re using harmonies or gestures from Mozart or Beethoven or Brahms. There’s no way you can leave your world behind and the things that impact on you every day. What Jeremy was saying about how it feels therapeutic– for me that’s one of the things–the dirt of your everyday life comes out a bit. You soothe yourself with these gestures which might take you to another time, another place, which in many ways was much gentler than walking down the street today in Toronto. Being in a professional string quartet you are asked to play a certain piece and the concert date is set, and you wake up that morning and you don’t have a choice; the show must go on no matter what’s happening. You wake up that day and you may not really feel like playing Shostakovich. What’s good about improvising is that you can have complete control–well, not complete control. You encourage your colleagues to put the improvisation in a certain direction by coaxing them politely. What I found in the first improvisation–I wanted there to be a kind of energetic, motoric section. I felt like I needed to do that, I needed to just go there for a while. I really wanted my colleagues to go there and we did it and it was exciting. For me that is what music is about–you want to feel the kinetic energy, you want to feel the vibration in the way which most immediately grabs you, that you’re always very, very connected. The most exciting thing about music is when you are feeling that. When you’re in a string quartet you may get glimpses of that but there are times when you have to focus on something else. You have to focus on ensemble-those feelings can be fleeting-that’s another wonderful thing about improvisation. (To CV) Have you led in the improvisations? I led the first improvisation of the session–that feels a little odd for me as a violist. That may sound strange but sometimes I lead and I certainly I have my stubborn side. I can be vehement about things at times but during the improvisations many times I felt like I wanted to stay stage left–if you’re looking at the audience this is where I sit. I kept feeling pulled to Paul. I’m finally getting this off my chest just something about that. I almost had to force myself to not be there–but yes I lead. I want to say one thing about what music was if I could just take a moment. When I think about music I think about universality, the universality of it and how it exists in all cultures. The primitive, primal nature that we all need to express ourselves, that every culture has. There is some quality about improvising that reminds me of when I was a child, when I was engrossed in the sound and experience of it. It’s a feeling that oftentimes as a professional I long to feel. In improvising I feel free and childlike. A few words on your question about the broader view of music–I feel that music in a big sense is for me a tool of communication, like a language. Being in the role of communicating between myself and the audience, that’s what I usually do. We try and bring the interpretation of the piece to the audience that they will understand what the

composer wanted to say. Being able to improvise, it felt almost as if I was able to write my own journal. We often think of therapy sessions as being a place where you can speak and be listened to by someone. I felt having Colin there was for me maybe this moment–being very personal and having him there, not necessarily as an interactive person, but as the one that lets me be vulnerable, be open to say what sits inside of me. (To CL) I would be curious to hear a little of how you see that as certainly for me there was a moment of letting go and being able to talk from my own vocabulary. CL It’s not my job to over identify with whom I’m working with. I need in some way to remain apart and reflect. Having said that I think things change and in the second improvisation I felt a surge of intimacy between us and I was very moved. I felt as if the five of us were totally together and at that point I did let my guard down. This changes how I perceive music therapy. It can’t be like other work that I’ve done. I didn’t want to come into our work full of assumptions. I felt strongly the need to be open and I think your question about music and how we as human beings–if in any way us working together could change the quartet’s perceptions of how they relate to music then these experiences will have been a success. I know that it’s going to change my perceptions too. I want to go back just briefly to the universality of music as it makes me consider why I am a music therapist and why I’m so passionate about the music in music therapy. I think music therapy is and has been in danger of eliminating the aesthetic qualities of music. I feel so strongly that we mustn’t allow that to happen. Working with the quartet is the finest example of doing that. Working with the quartet is both therapeutic and aesthetic and therefore this has been one of the most exciting experiences for me as a music therapist. You can work with a severely disabled client that can’t speak, that is profoundly physically disabled and yet in music we can be equal. That’s why I’m also passionate about what music therapy can achieve–that I can be with somebody no matter how ill or disabled and we can experience music equally. In the second improvisation I feel we were equal. For this reason alone I feel this makes what we did together clearly music therapy. JK Yes, we don’t look for particular musical effect from the tape–we just . . . we did what we did, felt what we felt, and that more or less is where that stops. When you’re always performing music, even improvising in different circumstances–in jazz–you would look for a particular music effect and artistic statement. I don’t think this was like that. It was just for us. HM How is what you’re doing different from a jazz improvisation group? JB To elaborate on an earlier comment, Jerzy was saying that we have a vocabulary that we draw from, in fact there were moments where it sounded like one of the Schafer quartets. Tone moments, like Webern and there were other moments like Debussy. That struck me as something that’s enriching that, our own repertoire in that sense, that we’re extrapolating the repertoire which we’re doing professionally. HM (To CL) You talked about the aesthetics falling out of music therapy. Can you talk about that and why you feel aesthetics are important in music therapy? CL I am trained in the Nordoff and Robbins approach to music therapy which was started by Paul Nordoff, an American composer, and his colleague Clive Robbins. Being a composer for me is a fundamental part of my thinking as a music therapist. I want to

HM PP

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wave the flag of the musical interpersonal relationship. What happens when we improvise together musically? What are the qualities of the music itself that makes it so powerful? We can talk about this until the cows come home but I don’t think you can ever articulate accurately the experience through words. You might indeed be able to quantify the musical experience and turn creativity into numbers, but what does that mean? What does it tell us other than, yes it works? How it works–well, that is altogether another and more challenging question. You have had two sessions. What’s the progression for the quartet as a group? Is there something that’s beginning to change, or evolve, or alter in some way? Or is it too early to say? I can only speak for myself. The key for me is not to have any expectations–not to expect change, not to expect growth or stasis–simply to have no expectations, and that includes an expectation of whether it’s going to be good or bad or indifferent, but rather to try as much as possible to be in the moment and let that moment lead you. If at a particular time you don’t feel you’ve got anything to say, not to manufacture something just to stop playing until you feel you do have something to say. To that end the answer to your question is “no.” I don’t see it going anywhere other than it is fascinating and I think I feel I’m learning about people, but not in a way I could put into words. The music resides in a place that is not a verbal place. It’s something else. I’m not sure I want there to be in-depth verbal psychotherapeutic meaning to what we are doing. I think what we’ve done must mean something, but it’s enough to be as it is at this time. I’m not burning to make it any more that what it is now. I think it would be interesting for our process as a group, to have some summary of what our roles are. I think we’re expressing various aspects of our process, not musically but interpersonally. I’d be curious to know what a music psychotherapist would have to say –perhaps we would then say “no” and we would argue with her just like groups can do. Your such a typical violist! No, I’m not, I’m just curious to see the summary of our dynamics. If I were to assess what is taking place and what has happened in an interpersonal way, I always sense a desire when we are improvising that the four of us want to be equal. No one is looking to be the hero, or be passive–there may be moments where someone is leading, or someone is bowing out for a bit. What strikes me is that as a collective, we’re trying to come together and create something as one in a very nonhierarchical way, and there are times when we don’t always get the opportunity in our work to do that–so that’s wonderful. Having an opportunity to improvise together, it means to me that I was able to be there with my colleagues and they know that I was able to express something very personal. I was trying to be very personal in the music and I think you all were too. Just having this around us–that we actually have done it, and that we are not afraid to go into this room and do that and just be who we are–it might help somehow down the road. In a very different way, on the stage, we do have to use this feeling of improvising–I shouldn’t use the word improvisation– rather, being spontaneous. I think that’s maybe just another step to achieve a little more of that on stage. We all were able to have this experience

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without any expectations and without judgments. I think it’s a very valuable experience. The question of composition being an act of therapy. Paul, you mentioned that every composer writes from their era and time, but are your improvisations, are they compositions, and if so is what Schubert was doing, or Duke Ellington, a kind of therapy? I think it’s very different when you write something down and you publish and sell it. That’s a very different sort of gift, than having people who know each other and it’s not leaving the room. I might call it a piece and not a composition. Somehow composition implies notation and writing down. A jazz tune has the tune, or the head, and then one improvises off that, off the chord progression. So it’s not a piece in that sense. I’ve done spontaneous improvisation in jazz class and it was similar to what we’re doing now, but there are a few more jazzy riffs and licks in it. I think what we did today was a piece. It was sound, music, and expression and it happened. We even have a tape to prove it! What we were doing had an element of performance. When a composition is created, I think there is a sense or at least a hope, if not an expectation, that somebody will play it and other people will listen and hear it. One of the fundamental elements of what we are doing–at least up to this point–is that we haven’t been doing it for anyone else, we’ve been doing it for ourselves, and since it’s not performance, it’s not anything other than interaction. It just happens that we’re using our own instruments to interact. It’s defined by how we’re communicating, not that we’re communicating. Nothing is done for posterity’s sake. If by composition you mean “form,” then it was a composition. But it’s not a composition in terms of something that’s completed and written down. I think the important thing about any improvisation is that it has form, that there is a sense of shape and architecture about the whole experience. Your imposition of a very human and intellectual concept of structure which could have been random. One could record the sound of the wind or the ocean and with our human attitude find a structure and say it’s a composition therefore we’re imposing an external structure, but in fact it doesn’t need to have structure. I agree that what we did has structure, but one need not necessarily see it in those terms. I think the music therapist’s job musically is to provide a sense of shape and structure, so going back to what Jerzy said when he played the opening D of the second improvisation–I always see a note suspended over the whole piece–and in this instance it was Jerzy’s opening D. I think I played an A in response. The D potentially gave the music shape and continuity. So even though it’s spontaneous and of the moment, I’m thinking intellectually as well. Yes, I understand.

This interview is interesting on many levels. There is a sense of work in transition. After two sessions the quartet is committed to future work. That none of us are fixed in our ideas means all possibilities remain open. The musical examples speak to the potential of music therapy with musicians, not only for the quartet, but for music therapy as a whole. Reflecting on Christine’s (viola) question, how a psychotherapist might view their work, I decided to invite a group music psychotherapist to give her impressions on the evolving process. The following

interpretations give a psychotherapeutic viewpoint and adds further richness to the discourse. Perspectives from Heidi Ahonen-Eerikainen: A Group Music Psychotherapist As a group analyst and music psychotherapist I have experienced that non-referential improvisation can be a powerful technique and that different musical images can be used as a pathway to the unconscious. It is music itself that is the therapy. And still there can be many things that happen in the player’s minds. Individual group members sound different and together they make music. Each instrument is needed to make the unique sound of the group. But–as typical for the musical expression–it is often more than words can articulate. It goes beyond words. I was interested to read the interview from a group analytic perspective and to investigate whether any elements that are common to group analytic music therapy (AhonenEerikaninen, 1999) occurred during the two sessions with the string quartet. Group analytic music therapy offers a view into the individual’s internal world and psychodynamics–he interactive field between members of a group and the group matrix, i.e., the group as a whole. Music also has its own role when moving on different levels of the group matrix: on the level of social interactions, on the level of transference, on the projective level, and on the level of collective unconsciousness (Foulkes 1964; Kreeger, 1991; Salminen, 1997). These levels of the group matrix which can be identified in the music therapy process, can also be found in this work with the Penderecki String Quartet. The Level of Social Interactions The interaction between group members can be achieved by the nonverbal language of music. The role of music includes a means of communication–telling a story about oneself and to others. In music it is possible to send messages and receive them without talking. At the same time, one can experience being understood and accepted on an emotional level. The level of social interactions is presented in group music therapy, this idea being aroused in the interview after the two improvisations: • • • •

“I feel that music in a big sense is for me a tool of communication, like a language.” “Being able to improvise it felt almost as if I was able to write my own journal.” “It was interesting to see the different responses and emotional contents of responding to each other’s phrases and sounds.” “You try and engage other people in the flow of the music.” “Have to respond constantly rather than having any kind of plan.”

The Transference Level Music may take the player to his/her past and represent life situations or portray people with a similar mood that was reflected through the music. For example, music may remind us of a situation or person we have known. Music can also “feel” similar to previous life situations.

The group member at the level of everyday defenses acts according to the same operational strategies and emotional patterns as in his/her everyday life. The stage of the group and the transference of emotions allows these strategies to move and allow protective measures. The improvisation of the quartet was a pure expression of the players relationship; “I always sense a desire when we are improvising that the four of us want to be equal. No one is looking to be the hero, or be passive . . . “ During free improvisation the sound may create various transference figures in which a group can place his/her emotions and thoughts: “There’s no way to leave your world behind even when you’re using harmonies or gestures from Mozart, Beethoven, or Brahms. There’s no way you can leave behind the things that impact on your everyday life.” The Projective Level The group member may feel that the music represents “me.” “This is how I am.” “This music sounds like me.” We can transfer our own primitive fantasies and internal world, for example: hopes, fears, different kinds of internal figures and partial objects, to music, other group members, and to features of the entire group (Foulkes, 1964; Salimnen, 1997). Projective identification also comes in musical images: • • • • •

“You can let your personality come out.” “You soothe yourself with these gestures which might take you to another time, another place, which in many ways was much gentler than walking down the street today in Toronto.” “In improvising I feel free and childlike.” “You want to feel the vibration in the way which most immediately grabs you.” “You are always very connected.”

The Level of the Collective Unconscious As a music therapist working in a group analytic model, I believe that the imageries and symbols aroused through music are personal objects which carry meanings that are potentially charged. They are like dreams that one can reflect upon the following morning: “Why did I have that dream last night?” Everyone has a certain mental picture of himself/herself and their internal and external world. The task of improvisation is to expand the internal imagery map of oneself, find new alternatives, activate problem solving, new points of view and possibilities. The goal can also be to bring out subconscious material, confront new feelings and mental integration. It would have been interesting to share the feelings and images of the string quartet during the improvisations because often the level of collective unconscious becomes obvious in the musical images of the group members. The collective symbols derive from dreams, fantasies, and fears of the early days of humankind (Salminen, 1997). It is common during improvisations that there will be group associations around similar themes. When Colin asked me to write some psychotherapeutic views of this work I decided to start by first listening to the music. I closed my office door, turned off the brightest light, took a

relaxed posture in my chair, closed my eyes, and prepared myself to step into the world of music. I had a beautiful “trip” and many different feelings and images. Some of these images, such as the ones referring to nature, were archetypal: Silence Peace on the earth Calm surface of the deep waters But I am not alone. And we all wait. Waiting fulfills the landscape. Is it already coming? I am ready. The surface of the waters is bright like a glass. Or is this only a reflection? Sorrow? Slow sorrow that slows everything down? Now it begins The surface of the water is moving. There is something there. It waits for THE moment . . . YES! That’s it! It’s there! The fireworks. The Northern lights. The volcano. The top of the universe! It is full! And it ripples! And it is SO full. It is free! I listen. I meet you. I share. We are together. We are alone. We are equal. After listening to the music and writing my images and feelings I read the interview. It was astonishing to find that they had similar feelings about their playing. My feelings of being equal was also expressed by one member of the quartet. We all experienced some level of catharsis in the tension resolutions and freedom. For example the quartet described the process as: “Losing control” and by saying: “You never know what’s going to happen,” and “can let our guards down,” and “being cleansing emotionally.” Stravinsky’s idea that “music is a series of tensions looking for resolution” was highlighted in my music images also. The Role of the Therapist

The role of the therapist in the group was crucial. The therapist’s improvising was full of therapeutic interventions. He supported the group members (harmony, themes, dynamics), reflecting the different musical ideas as they occurred. He also respected the musical pauses of the group, one member of the group noting that: “Silence is as much a part of improvising as playing is.” It was important that the therapist did not try to lead the group but rather let them choose the direction of their improvisation. The therapist’s music was both holding and containing. With his musical interventions he reflected the feelings of the individual group members and the music of the group as a whole. He was supportive and gave group members permission to express themselves freely. I think the therapist created the protective conditions to allow the therapeutic climate to develop. “I felt Colin was there . . . being very personal and having him there, not necessarily as an interactive person, but as the one that lets me be vulnerable, be open to say what sits inside of me.” Closing Thoughts Chamber music is one of the most intimate forms of musical relationship. Groups often work together closely for many years, there being a sense of “marriage” in their commitment to music and fellow members. Just as with an ongoing group in music therapy, struggles and tensions appear that must be resolved if the group is to flourish and survive. What makes one group’s playing great and another’s sedentary? It is more than the combination of notes that result in mystical playing. Outstanding chamber music is a combination of musical sensitivity and understanding of each player’s idiosyncratic responses. While musicians may not always acknowledge the importance of interpersonal relations, there is no doubt they play an equally important role. The same issues arise for music therapy. How does a group facilitate a way of playing that is therapeutic? The connections between group members and their relationship with the client, the ensuing musical dialogue, the musical input of each group member, and the expertise of the therapist in reflecting and challenging this results in the potency of the process. To play in a sensitive and open manner with a group of fellow musicians, either artistically or therapeutically, means each member must listen deeply and on many levels. I believe that the Penderecki’s sense of chamber music in improvisation became ever more acute because they were able to listen and respond on a level that is not possible through precomposed music. They were able to traverse the rigors of musical precision and enter into music that was a true reflection of their relationships. This highlights that the process of chamber music and group music therapy have many elements in common. The evolution of AeMT is based on the assumption that musical and clinical form have rudiments in common. Music therapy with musicians is the quintessential essence of combining music and therapy, an example of AeMT in its purest and truest form. Throughout my years as an active music therapist I attempted to find that balance between being a composer and music therapist, to embrace a way of working that could be respected in both therapeutic and musical circles; a link that would result in a truly music-centered approach. The symphonic reaction of AeMT to the emphasis on empirical and scientific evidence comes from a deep-seated belief in the human contact of music. That to be artistic and creative is to be free and whole. That music therapy with a string quartet could provide new approaches to clinical practice bears testament to the potential of other sapient ideas. To be open to new developments, such as these, is to

rejoice in the limitless possibilities of our work. The questions and approaches raised in this chapter are not infallible but they are unashamedly and intensely musical. I believe that this work with the Penderecki String Quartet opens many doors; what lies beyond I am not sure.

Updated from: Hibben, J. (Ed.) (1999). Inside Music Therapy. Gilsum NH: Barcelona

Publishers.

CASE TWENTY Singing My Way Through the Cancer, the Darkness, and the Fear Maria Logis Alan Turry Alan’s Introduction Maria came into music therapy with a willingness to open herself to new experiences. It was clear that she loved music, and as she playfully explored the instruments and her voice, she began to allow herself to express her feelings through creative interactive music-making. Despite tremendous upheaval in her life, she seemed determined to gain from the crisis, to glean something meaningful from it. Often at her most painful moments of despair and hopelessness, Maria would begin to create a melody or the potential for a melody and words from deep feelings. I admired her integrity as she entered into the unknown. We have used the writing of this narrative as part of our ongoing therapy. For Maria, the act of participating in this writing project is one more way of overcoming the lifelong feeling of being silenced. Maria has written her account from her journals and tapes of the sessions, and I have added my experience of the music. Maria has always been open about her experience in therapy and is proud to use her real name. Crisis

Maria’s Experience

I was diagnosed with non-Hodgkin’s lymphoma in the fall of 1994. I was in shock. I could feel nothing; silence and paralysis took over. In the midst of all my anguish, I turned to God for help, and the help that came was not at all what I would have imagined. I found music and, in it, a balm that made it possible for me to resist the crushing silence that enveloped me when I learned that I was sick. As I look back now, I know that the experience forced me to decide whether I was going to fight for my life or not. The diagnosis shook me deeply and somehow made it possible for me to break out of my habitual thinking patterns. I began to search for and was open to new experiences. Finding Music The thought that came to me was that I should sing. My musical training was limited to piano lessons that my mother forced me to take — that I hated — and some singing lessons as

an adult. Some 10 years before my diagnosis, I went to a music and t’ai chi workshop. All 80 participants got to sing and improvise. I had a ball. People there encouraged me to sing. I started private singing lessons and enrolled at a music school for theory and duet singing. I was very excited and had a great time! I had never dreamed I could sing. Soon I joined a gospel choir. It was all quite wonderful! My friends were excited for me. Slowly, the lessons got tougher. I wasn’t good enough; I didn’t practice enough; I lacked discipline; I couldn’t read music; it was taking too much of my time. I dropped the choir and then I dropped the classes, hoping to salvage the singing lessons. But after 2 years of singing lessons, I gave up, totally frustrated and defeated. It was absolutely clear that I could not keep up with even the most minimal standards. I kicked myself for ever thinking I could sing. So the recurrence of the thought that I should sing seemed pretty ridiculous, yet I pursued it. I got names from friends. On some days, I had appointments for tests (to pinpoint the diagnosis), and on others, I went to see singing teachers. I really had no idea what I was doing. I just was putting one foot in front of the other. My dentist gave me a name that turned out to be a colleague of Alan’s, and since she lived too far away, she referred me to him. The first time we met, we made lots of sounds, and I found myself laughing for the first time in the weeks since the diagnosis. I decided to come back. What began in November of 1994 and continues to this day is a process that has completely transformed my life. My struggle to accept my diagnosis and my great fear of treatment came up as soon as I started to sing. We created music together in which I expressed my terror of treatment and my deep distrust of the doctors. The words just kept coming. I surely had a lot of feelings about the doctors and chemotherapy. Alan treated my music and words like they were important; he kept me going by improvising on the piano. So I kept singing and more and more words and feelings came out: She didn’t want to go ahead with the treatment. She told herself it wasn’t what she wanted to do. She didn’t trust the doctors. She didn’t want to get sick. She didn’t want to follow their advice. She said ... No, I’d rather not do it!!! But all the logic said, You have to go for this treatment. Oh ... No! No! No! No! No! No! No! Oh yeah, you’ve got to go for this treatment. Audio File: She Didn’t Want to Go Ahead I sang about myself in the third person, trying to get some distance on the situation. It was deeply satisfying to sing “No.” I didn’t dare say those words to the doctors. Then there is another voice, the one that tells me that I must go for the treatment. It is the voice of all the doctors and my own logical thinking side. The logical me starts to yell at the frightened me, and in fact the volume in the following section is quite high and scary to listen to.

I don't want to suffer I don't want to be sick So that's it I think treatment is making me sick Because I don't really believe that I am sick now Tell the truth, tell the truth, tell the truth Tell the truth, tell the truth, tell the truth Tell the truth, tell the truth, tell the truth….yes What is it? Tell the truth Stop this stuff What is it? What’s the truth? Tell the truth…..awgh…..argh ugh…ugh…urgh Oh I love to sing And tell my story to you in a song Oh I love to sing And tell you my story They tell me I'm sick They tell me I'm sick They tell me I'm sick And so I proceed To learn all I can I organize everything They tell me I'm sick They tell me I'm sick They tell me I'm sick I move ahead I make appointments I take notes I analyze everything They tell me I'm sick They tell me I'm sick They tell me I'm sick And I have to learn to believe it They tell me I'm sick

Audio File: They Tell Me I’m Sick Alan had told me it was okay to make any sounds at all, so from the yelling, I started groaning, and then all these sounds led me to a deep lyrical lament. THEY TELL ME I’M SICK

Figure A When I would speak to my friends about my illness and my concerns, I was logical, organized — and even if I was upset, I had a plan. It was when I sang that I felt my fear and anguish. The words that came out of my mouth both surprised me and didn’t surprise me because they were about my “truth.” I had not expressed that level of feeling to anyone, yet I knew the feelings well. Alan’s improvising made it possible for me to get the feelings out into the open in sound and to create melodies in the process. He communicated a deep acceptance of my words and music. I was amazed but did not have time to reflect on that for several months. Alan suggested that I might want to tape our sessions; this sounded like a good idea, so I started to bring a tape with me to each session. (Alan’s words throughout this chapter are italicized) I thought it might be helpful for Maria to listen to these improvisations and suggested she could make a tape of our sessions. In this way, she could have something to hold on to — I hoped a way of expressing, identifying, and containing feelings that threaten her emotional stability. I hoped she would gain some sense of control over what was happening to her. Maria asked me how she would feel listening to the tape. I told her I didn’t know, but after she began to talk about it, I encouraged her to listen not as a music critic but as a person searching for her truth and to express herself honestly. She spoke of how hard it was for her not to be judgmental. She continued singing and started listening to the tapes outside of our sessions. She listened to one session and said it was intense and sad. It helped her deal with her ambivalence about picking a doctor and having courage. She began to share the tapes with other people. This led our therapy in a novel direction.

A Breather In January 1995, I went for a second CT [computed tomography] scan in advance of chemotherapy and, much to my surprise, learned that the lymph nodes had shrunk. One doctor, a world-class lymphoma expert, insisted I start the treatment immediately because the lymph nodes may “wax and wane, but your lymphoma is in the bone marrow, and if you wait till you have symptoms, it will be too late for the chemotherapy to be effective.” I got a second opinion, and that doctor felt that I could start treatment right away, but [because of] the shrinkage of the lymph nodes, he saw no harm in waiting for a month or two. He emphasized that lymphoma can’t be cured and [that] at some point in the near future (as soon as the lymphoma became more active), I would need treatment. The third opinion I got was like the second. I struggled in rejecting the first doctor’s solution because of her highly regarded expertise and the fact that neither the second nor the third doctors thought her course of action was off the mark. They were simply willing to wait and she was adamant about the need to start immediate treatment. I could not decide which doctor to pick. So pick a doctor you can trust. Pick a doctor you can trust, And trust your judgment; you’ll pick the right one. You’ve certainly done a lot of research I breathed a sigh of relief once I decided to wait; it felt like a stay of execution. I was full of gratitude for each day. Singing for My Friends While working with Alan, I also met Janet Savage, a wonderful singer and coach, and started to work with her, too. She listened to some of the tapes from the sessions with Alan and said, “These are songs.” I was really astonished when she suggested that I perform these “songs” for a gathering of my friends. I had already begun sharing the tapes with my close friends; they would stare at the floor, unable to make eye contact, since the intensity was sometimes too much to bear, yet they genuinely thanked me for sharing this music, so I prayed about Janet’s suggestion and discussed it with Alan, and soon we were planning a celebration of 1 year without chemotherapy, a celebration in song. Maria selected musical motifs she found meaningful. She began to memorize the words and melodies, creating songs. We had not thought of them as songs before this point. It seemed to be a way of containing them in an aesthetic way that would reach others. This was not something we set out to do, but it became a part of the therapy process. It took a while to get used to calling some of these improvisations “songs.” What did that make me, I asked myself again and again, a musician, a singer? No, it was not possible for me to call myself a singer or a musician. I wasn’t disciplined, I lacked training, yet I moved ahead, trusting Janet. It is hard for me to describe how fantastic the process that we then entered into was. Janet coached me, helping me to put a program together, to sequence the songs, and,

together with Alan, we began to rehearse. It was like dying and going to heaven. It was absolutely unbelievable. Rehearsing was fun; I felt so important. I let my fantasy go wild. For the hours that we were rehearsing, I was a singer. It meant so much to me that these improvisations [that] came from my guts and my heart could have value to someone besides [me] and Alan. When I called to invite my friends, they were flabbergasted. Here I was dealing with a lifethreatening illness, yet I was inviting them to a concert of original music at my house. When Maria first introduced the idea of a concert, I was unsure. I wanted to support the natural direction that our therapy was taking. We discussed the idea together. Would it contribute to the therapy process? The event itself fueled the therapy process as Maria focused on the event in the next session. She wondered what her mother, with whom she struggled throughout her life, would think of her involvement in music. DO I DARE IMAGINE

Figure B Audio File: Do I Dare Imagine Preparing for the concert was an exhilarating experience. I practiced the songs and rented a piano for the concert, thinking that I might eventually decide to buy one (this in the face of the terrible experience I had playing piano as a kid). Singing the songs for my friends was one of the happiest days of my life, and I have had very few days in my life that I could describe as happy. When I look at the photographs, I see myself smiling in joyous exuberance. I was celebrating a year without chemotherapy. It was like flying. I felt so alive. I was “singing my way through” the anguish of this illness.

The freedom of the music therapy process was exhilarating. I could not get over the fact that I could not make any mistakes in improvisation. I sang not only about being sick but about my lifelong sadness and despair. Pain and Darkness As I sang, what started to come out was the despair and the sadness and silence of my life. The lyrics poured out of me. I was going beyond my cancer to my lifelong depression, my own oppression. Somehow I was able to give it sound and to express my feelings in a way that I had never done all my life. What I discovered in music therapy was that I had “no voice.” I would not have used that term before, but it came out of the music. Images of silence, oppression, and darkness abound in the improvisations. I was overwhelmed, full of tears, and wondered why all this was coming up in me after so many years of psychotherapy. After many years of psychotherapy, I had come to understand that much of my sadness went all the way back to a toxic relationship with my mother. I was to have no individuality or identity. I was to be an object perfectly in tune with my mother’s desires. But it didn’t work out that way. Instead I was fat, ugly, sad, and stupid. My mother got frustrated. I just went through the motions. I was compliant, but I started to eat compulsively, was depressed, had no opinions, and was convinced that I would not or could not live to be 25 years old. However, I always acted as if everything was fine. It was a requirement that I never questioned. So I never learned how to know what I was really thinking or feeling. I sang about my pain and about having “no voice.” Ugh, ughh, ohh choking, choking on her tears choking on her tears suffocating silent tears choking on her tears the song of the tears the song of the tears oh….oh…oo woman why are you weeping? woman why are you weeping? woman why are you weeping? why are you weeping? they've taken away my song they've taken away my voice I have no voice I have no song they’ve taken away my voice woman, why are you weeping? they've taken away my voice, my song

what do you want to sing about? what do you want to sing about? I don't know anymore I don’t know anymore it's all gone I don't know anymore whatever was there, I don't know anymore it's all gone woman, why are you weeping they've taken away my voice and my song and I can't find it anymore it's safe to drink the water cool and refreshing, cool and refreshing life giving water cool and refreshing life giving water it's safe to get up it's safe to drink the water tell your story….tell your story drink the water sing your song tell your story…tell your story I was lonely, I was lonely and afraid, afraid I was lonely. I was lonely, and I was afraid I was lonely, no one to talk to,, no one no one I was lonely and afraid and afraid I was lonely, lonely, lonely. I was lonely and afraid I was lonely I didn't say a word. I didn't say a word I tried to do what I was told. I didn’t say a word I was lonely. I was lonely. keep drinking water, keep drinking sing, sing the song keep singing the song and tell the story keep singing your song and tell your story keep singing the song and tell the story I don't like to talk about it, I don't want to talk about it I don’t want to talk about it I don't remember it I don't know what happened I don't know, please don't ask me, I don't know

Audio File: Woman, Why Are You Weeping? WOMAN, WHY ARE YOU WEEPING?

Figure C The image of pain that came up for me again and again was a dark place with two people in it, the oppressor and the oppressed. In some songs it is a dark cave and I sing: She was silent. She asked for nothing. She wanted nothing. In the face of destruction, she was silent. In another song, it’s a dark cellar: Struggling to keep quiet, Struggling to keep silent. What’s the sound inside the child? Choking, choking on her tears. Choking on her tears,

Suffocating, Choking on her tears. In another, it’s the Everglades, with the silent alligator ready to “mangle” the child if she steps out of line. I looked up the definition of mangle, since that was the word I used in the improvisation. It said: “mangle: to disfigure or mutilate by cutting, bruising, crushing, to mar, ruin, spoil.” And in many songs, I sing about a dark castle. Bartók’s opera Bluebeard’s Castle inspired this image. In his opera, there are only two characters, the oppressor and the oppressed. The walls of the castle are covered with tears and there are seven locked doors. The terror of the castle is behind them: moaning, a torture chamber, a garden of flowers covered with blood, brilliant jewels tainted with blood, a lake of tears, and, finally, dead women. The music made it possible for me to explore these images in a very deep way. By singing, I found out how much power these images had for me and I began to see that it might be possible to journey out of this darkness (see “Rats in the Cellar” lyrics — “why do you go back to the cellar?”). I was trying to give up my deep attachment to the oppression. The process of singing about the oppression is the very process that is freeing me from it. Because of the music, the images came easily, and the images, combined with the music, illuminate the dark and hidden aspects of my pain and anguish. Trusting God When I was diagnosed with cancer, the old issues came to the fore: Was I worthy to live? Was I willing to lift a finger to help myself? Something miraculous was happening as Alan and I worked: melodies and words poured out of me. Do I really want to be alive? Do I really want to get through this or not? Maybe I would rather not make it. I kinda just want to slide, Slide down and give it all up. I was grateful that when this illness hit me I had a relationship with God that I could turn to. I found myself praying in song. Alan and I were improvising vocally, an a cappella duet, which then led me into a time of intense prayer. The words of Mary’s prayer (the “Magnificat”) in Luke’s gospel filled my being. Alan played the melody that I was singing and enhanced it, making it more beautiful. When he sang with me, we just took off. Then I came back to my solo and my tears and my fear. My soul magnifies the Lord, my God And my spirit rejoices in God my savior. I prayed for courage and for the strength to tell the truth about my illness and my sadness.

Through God’s grace, I found music and, in it, a balm that made it possible for me to resist the crushing silence that enveloped me once I learned that I was sick. As I look back now, I know that the experience forced me to decide if I was going to fight for my life or not. The diagnosis shook me deeply and somehow made it possible for me to break out of my habitual thinking patterns. I began to search for and was open to new experiences. I turned my life over to the power of God and found music. “Rats in the Cellar” I was singing about being invisible; it was something I longed for when I found myself with people. I never knew what to say; my mother had done her job well. The melody that accompanies the words I want to disappear is incongruous with the words — it’s a kind of piano bar music that seems to have no importance. making believe that I’m not here suppose I wasn’t here, suppose I wasn’t here suppose I could just disappear that’s what I’ve always wanted to do I’ve always wanted to disappear, to disappear, to disappear I’ve always wanted to disappear I don’t want to be seen, I don’t want to be here, I don’t want anyone to know me I don’t want to be seen, I don’t want to be heard, I just want to disappear, I want to disappear, I want to disappear, I want to disappear so you can’t see me Audio File: Rats in The Cellar - Disappear Yet as I sing, I am filled with despair. This then leads to me imagining an invisible world with invisible people. I go to the invisible world. I go to the invisible world — It gets too hard in the real world — The invisible world. I sleep, I sleep, I sleep. I don’t do a thing but sleep, Go through the motions. I sleep, I sleep, I sleep, I sleep. I hate to remember my life. I sleep, I sleep, I sleep.

Audio File: Rats in The Cellar - Sleep The music changes to a softer dynamic, is rubato with alternating minor and major chords based on the Dorian mode with some delicate dissonances. There is more of a sense of fragility in the music, as the chords are in inversion and not in the bass end of the piano. I have finally said what I feel when I sing “I hate to remember my life.” It took going through the anger about food, the desire to disappear, and the invisible world to get to the deep despair. At this point I started looking for an instrument and I found the guiro. The scratching sound was fearsome. A scream started to come up in me. The sounds I made imitated the shrieking/screaming guiro and I was filled with the image of rats. I wanted to scream. Ka ... gruks ... kruks. Rats in the cellar ... rats in the cellar, Rats in the cellar. Ugh ... rats in the cellar, eating my bones, ooh. Rats in the cellar, eating my bones, ooh. Rats in the cellar, eating my bones. Rats in the cellar, eating my bones. Rats in the cellar, eating my bones. Rats in the cellar, rats in the cellar, Rats in the cellar, eating my bones, ooh. Audio File: Rats in The Cellar - Bones The music builds to dissonant clusters as Maria alternates between singing a line and vocalizing long tones on “ooh.” Maria’s voice has changed here. It sounds more rooted in her body, in her lower register, and supported strongly with her breath. The music has an ambiguous tonal center; it alternates between a Phrygian and Locrian mode. Maria herself is helping to shift the tonal center, widening her vocal range. I was overwhelmed with sadness, and the next melody knocks me out as I listen to it now. It is a poignant moment when I ask myself to give up the return to the painful and oppressive cellar. It is a heartfelt plea for sanity and I ask, with the utmost care and gentleness, “Why?” It is so clear to me that another alternative exists, yet I persist in repeating the same old destructive patterns. Suddenly Maria sings a very clear melody as she asks her question, “Why, I’m asking you why?” The time for the dissonant clusters is over. Now she needs harmonies that would help her to explore this melody. As she sings about the turquoise waters and sailing south, I encourage her with flowing arpeggiated chords. Her voice and lyrics are full of a very deep sadness. As Alan played, I could see and feel the turquoise waters, the warm sun. He played music that was exactly in tune with me, and I felt my sadness more intensely. My song continued. RATS IN THE CELLAR

Figure D I should ask you why; I am asking you why. Why do you go back to the cellar? Why do you go back to the cellar? Why don’t you stay on the ship sailing south? Why don’t you stay on the ship sailing south? Why? ... Oh why do you go back to the cellar? Why, tell me why, tell me why You go back to the cellar. Why, oh why? Stay on board; we’re sailing south. Stay on board; we’re sailing south.

See the dolphins, see the dolphins Jumping, leading the way, jumping. See the dolphins, see the water; we’re sailing south, Sailing south. Oh, woman, Stay on board, stay on board. It takes courage to stay on board. Stay on board; we’re sailing south. Blue skies! Turquoise waters. Would she rejoice? Would she rejoice for me? We’re sailing south. It takes courage to stay on board. Audio File: Rats in The Cellar - Bones The music that Alan played with my turquoise water lyrics was refreshing and delightful. Again I asked myself, “Would she rejoice for me,” referring to my mother and to the improvisation in another session where the turquoise waters originated. The theme of courage came up again — I had been singing about courage from the very first session. The music gives me courage, so I continue to explore the images and themes again and again, trying to learn, to change, to gain the courage to go on. “There, There” The angry inner critic laughs at my pain and mocks me; I deserve no sympathy. I inflict the damage on myself. There is energy and strength as I mock my pathetic self. But I continue singing and soon I hear the voice of compassion, the voice that understands my pain. I am not a pathetic creature, I suffer, as many suffer, and I am comforted. No one sees me when I am eating chocolate I make sure no one sees me, I make sure I disappear And yet in my own little world I’m thrilled I’m thrilled, it’s just thrilling You can’t see me I can eat all I like Oh it’s thrilling, it’s thrilling No you can’t see me, I like it that way I like it that way But then I come out, out of my bubble I come out, out of my bubble, I see what I have done I see the mess that I’m in I hide so you can’t see me, I hide so you can’t see me

I hide so you can’t see me, I hide so you can’t see me I hide so you can’t, so you can’t see me I step out of the bubble I’m a mess I’ve been cut and slashed I’m bleeding I’m throwing up My knees are weak My ankles can’t hold me up very well Everything’s fine, everything’s fine but I’m bleeding You do it to yourself You did it to yourself, who the fuck cares? I’m bleeding, I can’t walk, I’m bleeding I can’t walk What’s the use of helping you There’s no use in helping you There’s no use to help you because you’re just going to do the same thing again Why should I help you any more? You keep coming in this room all bloody Oh you keep coming in this room all bloody I’m supposed to wash you up and put bandages and ointments on you Comb your hair, wash your face Give you a place to sleep, comfort you, talk to you Listen to you, play music for you Cuddle you and say “there, there my dear” “There, there my dear it’s going to be ok” “There, there my dear it’s going to be ok” Oh my dear, oh my dear Rest with me it will be ok Oh my dear it’ll be ok I’ll wash your face, I’ll dry your tears I will bind up your wounds, I’ll wash your face I’ll clean you up, I’ll bind up your wounds I’ll comb your hair Rest my dear, rest my dear The broken pieces have such sharp edges They’ve cut you my dear Oh rest my dear, oh rest, oh rest, oh rest my dear Oh rest I’ll wash your face, I’ll bind up your wounds I’ll comb your hair

Oh rest, rest in my arms I know what you’ve been through I know what you’ve been through Oh rest, oh rest, oh rest my child God doesn’t leave us, God doesn’t leave us God doesn’t leave us no matter what I do God doesn’t leave me, God doesn’t leave me, God doesn’t leave me Audio File: There There “I Don’t Know How You Love Me Through It All” This music is about the deep struggle to accept myself and to believe that I am worthy of love. In the session, I start out talking to God, wondering how he can continue to love me despite the fact that I continually go backwards, repeating the same destructive behaviors again and again. Audio File: Oh my Child I don’t know how you love me through it all. I don’t know how you love me through the stubbornness. I don’t know how you love through the selfishness, The insensitivity. I don’t know how you love me through the self-will, Through all the times I ignore you. I don’t know how you love me through it all. The melody haunts me and I long to repeat it. Alan is playing strong chords and they keep me going. The tears start to overwhelm me when I decide to try to sing God’s voice responding to me. The tears choke me, but I keep on singing, as Alan echoes my melody and words to give me the courage to go on. Oh my child, oh my child, oh my child, Oh my child, oh my child, oh my child, Oh my child, you are precious in my sight. Oh my child, you are precious in my sight, in my sight. All the hairs of your head are numbered in my sight. Oh my child, you are precious in my sight. When I sing God’s words for a second verse, I am. far stronger vocally. Alan continues to sing with me, giving me the strength to go on. I end up belting out God’s words to me: “Believe you are precious.” This leads me to a prayer where I ask God to give me perspective and vision. To see myself through the eyes of God, To see myself through the eyes of my father,

Not to see myself through the eyes of my mother, To see myself through the eyes of God, To see myself through the eyes of God, To see myself through the eyes of God, This is my prayer, Oh ... God ... my God ... most high. Intellectually, I can say that God loves me, therefore I am worthy of love, but as I sang about it, I believed it; it was real to me and that’s why I was overwhelmed with tears. No longer was this a concept about God’s love; it was the real thing. My loneliness started to have less power over me. What followed next [was] a dark piano duet that led slowly to a mood change. I started to fool around vocally and on the piano, the dark mood lifted, there was lots of laughter, and pretty soon, I was singing. Maybe we should fool around a little. The piano has the giggles. We’ve got the giggles, we’ve got the giggles. We’ve got the giggles, we’ve got the tears, And everything in between. Audio File: Piano Has The Giggles This led us to a lyrical piece full of gratitude and joy. Alan was a little surprised when I said, “Who’s better than us?” He laughed and repeated my question, not quite sure what I meant, so I went on to explain and he echoed my melody and words for a very touching closing. The closing soared to a spiritual high.

Sharing the Songs

Who’s better than us? Who’s having more fun than we are? We have the tears, we have the giggles, And everything in between. We have the music. We have the music. We have the music. It goes to our souls. Our souls can sing. My soul can sing! My soul can sing!

A few months after the concert in my home, I had one at my church for a larger group of friends. Their support and love was deeply satisfying. In the spring of 1996, Alan arranged a concert at New York University where I sang and shared recorded excerpts with an audience of music therapy

professionals. Many presentations at a variety of Music Therapy conferences followed. In 2001 the Creative Center for Women with Cancer invited me to present my music and songs. I wrote a script and together with four fantastic jazz musicians and Cinzia Sarto, a video artist and Director we performed Singing My Way Through It. Encouraged by friends and strangers I continued to write scripts and to perform. I wrote and produced two more theater pieces, one at the Blue Heron Arts Center and And You Gave Me Music at the 2003 Fringe Festival. My most recent theater piece, The Lemon Tree with eight performances in 2009, in Manhattan’s lower east side, was my most ambitious to date. I was a guest on NPR radio, along with Oliver Sachs, on Music and Healing, on the Greek station, Cosmos FM and on a couple of radio and TV broadcasts in Korea. In 2010 I addressed several audiences: International Symposium on Music Therapy and Cancer Care, Sloan Kettering, Grand Rounds-Palliative Care, United Nations Millennium Goals Summit on Music as a Natural Resource. The music from the improvisations is rich with much musical interest and many professional musicians encouraged me to record the songs. My first CD, Do I Dare Imagine was issued in 2002 and Room for Something New, my second CD was released in 2012. www.marialogis.com Each experience of sharing the music has helped me to claim my “voice.” Making Music I am trying to understand the process by which all this music is created. I meet with Alan; everything is externally okay in my life; the cancer is in a partial remission; work is okay. We start making sounds, and ideas, words, and feelings come up out of me. Where do they come from, I wonder. How can I understand this? Pain and anguish pour out. Silliness and fun abound. I weep. The critic yells at me. Alan listens intently. He plays such beautiful music. I am touched deeply. A story unfolds over several sessions as words from one session come up again and again. For example, “Rats in the Cellar” eventually leads to the image of broken pieces all over the floor; they are the broken pieces of my life. The music allows me to discover my deeper reality. Alan and I build on each other’s music, and at the end, the music brings me to a compassionate place of sanity. A Radical Change By creating all this music, something is changing radically in me. I found my life at last, Leaving the darkness behind. Music sustains me. I am deeply involved in listening to music, practicing music, taking singing lessons, studying music theory, rehearsing with musicians. My cancer was only the starting point as life’s anguish and joy came pouring out in music. The many songs and lyrics tell the story of my odyssey from cancer diagnosis and dread to health and creativity. As we improvised

in music therapy I gave voice to my pain, fear, exuberance and love, finding the will to live and the desire to create. In essence, I sang the very substance of my artistic identity My life has changed fundamentally and dramatically. I went on a journey into my own despair and darkness, and discovered my voice as an artist. This discovery went well beyond my cancer and transformed my life-- from illness to wellness, from the life of a corporate executive to that of a singer/songwriter and playwright. Cancer Update As of this writing, the winter of 2012, I have not had to go for chemotherapy. I was diagnosed with a second cancer on 2008, thyroid cancer. This was treated with surgery but the cancer remains in the remaining thyroid nodule. I am in “watch and wait” with both cancers. I am grateful for every day. Why Music? As I look back now, I know that the experience forced me to decide whether or not I was going to fight for my life. I was going beyond my cancer to my lifelong depression and my own oppression. I discovered as I improvised with Alan that “I have no voice.” I would not have used that expression before, but it came out of the music. Somehow, I was able to give it sound, and to express my feelings in a way that I had never done in my life. Images of silence, oppression and darkness abound in the improvisations. I have often been overwhelmed and full of tears. I know now what I could never have seen initially: how perfect this solution is for me. I asked God for help. He knew that my lifelong anguish was about silence and oppression. What could make me feel better in the face of crushing pain and silence? Utterance. So he led me to music. Why music? Because music reaches me so deeply. The music made it possible for me to go into my hunger, my fear, and my anguish. I have taken a journey deep into my underworld and I have come back changed. I am a gardenia.

CASE TWENTY-ONE An Audio Case of Maria and Alan: A microanalysis of Our Song Improvisation “There, There.” Alan Turry This case study is a microanalysis of one song improvisation taken from the previous case entitled, “Singing My Way Through it: Facing the Cancer, Darkness and Fear,” by Maria Logis and Alan Turry. The purpose of the microanalysis was to examine the relationship between lyrics and music in improvised songs created in the context of Nordoff-Robbins music therapy sessions. The material was drawn from an eight-year therapy process of a woman who came to music therapy as a result of being diagnosed with non-Hodgkin‘s lymphoma. For further information on Maria and our work together, see the previous case. More information on the microanalysis can be obtained from my dissertation, The Connection Between Words and Music in Music Therapy Improvisaton: An Examination of a Therapists Method (NYU 2007), and a previous monograph in Qualitative Inquiries in Music Therapy (2010), Volume 5, pages 116–172. Song Improvisation Improvising songs within a Nordoff-Robbins context is a very extemporaneous process in which client and therapist listen deeply and respond to one another through words and music. This is how the process might unfold me. Each client utterance (in italics) is responded to by the therapist musically (indented regular type). You listen to me deeply Single tones from the piano gently, slowly, sounds sustained to create harmony which contextualizes the client‘s melody, creating momentum and leaving space for the voice to continue. And that makes me cry A new minor harmony from the piano supports the sentiment of the words Just when I got used to not ever being heard. The tender accompaniment pauses, then comes to a temporary resting place. I stopped talking A countermelody from the piano gently echoes the melody. Oh I seem to talk A pulse generated from the melody is now present in the harmony. People thought I talked There is a rhythmic quality that now creates a gentle swing. But I didn’t speak from my heart A song form with pulse and phrase structure emerges. Music goes to places that words can never go The intensity builds.

Music goes to places that words can never go The lyric repetition solidifies the song form. Finding my true voice The music begins to cadence, slowing down and clearly heading for the tonic. Not being afraid The music and words slow down. You listen to me deeply A final harmonic cadence. And that makes me whole. The music and words come to a place of completion. The interaction described above represents a decisive moment that took place in a music therapy session where the spontaneous vocal expression of the client combined with the therapist‘s music from the piano to create a song of great clinical importance that contributed to the client‘s overall improvement. The improvised songs that emerged over the 8-year period of time under study came in a variety of forms and styles. They were sung in different ways that revealed different aspects of Maria‘s personality and her changing emotional state. The unfolding of the song form allowed me as therapist to guide and alter Maria‘s psychological process while offering a creative vehicle of expression. A Microanalysis of “There, There” This section presents detailed descriptions and analyses of “There, There,” one of the excerpts I selected for further study. I developed a system of presenting each excerpt twice, once to familiarize the reader with the specifics of the excerpt, and the second time for a much more detailed description and analysis. The first description and analysis introduces the lyrics and the therapy process. I did this to familiarize the reader with the content and the context. I used different type—italics and quotation marks—to indicate the lyrics. The second analysis includes the same lyrics, but also includes musical notation, moment to moment analysis including past and present perspectives regarding clinical intentions, the quality of Maria‘s voice, and details regarding the melodies she created, and the relationship between the emerging words and the emerging music. Findings are embedded in this analysis. It is important to note that many of the clinical intentions and understandings that I write about from my current perspective as researcher were not conscious for me during the time of the creation of this material. The clinical approach calls for the use of intuition, spontaneity, and creative freedom in utilizing improvised music that supports and spurs on the client‘s development. Therefore some of what I did at the time was based on hunches, physical sensations, and emotional reactions, which fed into my musical choices. My music was informed by my clinical understanding of Maria‘s psychological state, yet was not preplanned or calculated, though it was influenced by the clinical indexing process that took place each week. I did come into each session with an idea about how music was affecting Maria and the clinical issues that were emerging and could potentially be addressed. Yet, the clinical interventions that I made with the music were not planned activities. The research process has yielded much more data and

my awareness and understanding has grown significantly in understanding what I was reacting to, what my intentions were, and how I was utilizing the music. Many of the findings embedded in descriptions found in this section emerged as tacit understandings I had as therapist that have become explicit as the research process has unfolded. “There, There” illustrates how music can assist in the development of contrasting perspectives, and how specific musical elements are utilized in response to particular descriptive imagery of the lyrics. This excerpt contains examples of the many attitudinal and emotional shifts that can take place within the stream of an improvisation. Maria sings about how she can take a superficial stance towards the world, and how this is a kind of protective shield, a “bubble,” that hides her authentic feelings. She sings of the pain she is in, and then sounds angry as she blames herself for the condition she is in. Much of Maria‘s frustration is expressed here not by singing, but by speaking the words. She has a conversation with herself, taking on an impatient tone as she criticizes herself for having the same complaints again and again, using the pronoun “I”‖in describing her pain and “you”‖ in expressing her frustration in dealing with the same issues again and again. There is also a dialogue taking place between us. This is because Maria uses quite descriptive imagery and as she pauses I play particular musical elements in response to the words. She in turn responds to my music and continues her lyric creation. In general, the music from the piano supports her shifting attitudes, playing repetitive music as she sings of her repeated complaints, and also animates her expression by adding sharply attacked single notes that are dissonant and trigger Maria to sing with more energy, at a louder dynamic and higher pitch. This seems to shift Maria‘s expression from a more cognitive experience to a more emotional one. The music helps to sustain this difficult emotional state. Then, in a mutual fashion, the music slows and becomes tender as Maria shifts her attitude from disgust and anger to tender and sad. She takes on the position of God in her lyrics, singing comforting words of nurturance. Maria cries as she sings. The excerpt ends as Maria sings about God, and the music shifts to a Gospel style. (Note: An audio file of the song improvisation is presented here in its entirety; however, the analysis that follows refers to different segments as they unfolded second by second). Audio File: There, There 0:00-0:25 Another thrill I hide so you can’t see me (Maria snaps her fingers) And I go for another thrill I hide So you can’t see me In a swing style, Maria sings happily about her self defeating behaviors. When she celebrates her shortcomings in this way, the swing style often helps her to become unstuck and more creative in the sessions. Rather than complain about the fact that she was driven to hiding from the world, here she brings out the sense of satisfaction that she derives from hiding with the quality of her vocal expression. There was a slight sense of irony in her attitude at this point. We both were aware that hiding was not

something to reinforce. Yet, in this instance the paradoxical experience of fusing happy music with this problem fueled her to explore it more deeply. 00:26-01:02 I hide So you can’t see me I hide So you can’t So you can’t See me The music changes here and Maria’s story unfolds as she creates imagery describing her desire to move past the isolated stance she often takes in relating to the world, and what lies inside her when she removes her outer “bubble.” 1:03-1:37 I step Out of the bubble I’m a mess I’ve been cut and slashed I’m bleeding I’m throwing up As the imagery becomes more graphic and violent, Maria’s voice becomes more detached. She begins by talking rather than singing. 1:38-1:59 My knees are weak My ankles can’t hold me up very well Everything’s fine Maria often commented critically about her ability to relate to others as if everything was “fine” when in fact she was experiencing emotional pain. She also knew there were times when she could keep the fact that she was in emotional pain from her own consciousness as she went about functioning in her daily life. Now she has a dialogue between her “I” and her “you.” 2:00-2:25 Everything’s fine But I’m bleeding You did it to yourself You did it to yourself, who the fuck cares? Maria often battled with her intense self criticism and judgment of herself. Two perspectives have clearly emerged. One persona is describing the pain and asking for help, and the other impatient, holding back and judging. 2:25-3:33

I’m bleeding, I can’t walk, I’m bleeding I can’t walk What’s the use of helping you? There’s no use in helping you There’s no use to help you because You’re just going to do the same thing again Why should I help you any more? You keep coming in this room all bloody Oh you keep coming in this room all bloody Maria often worried that she came to music therapy and described the same issues over and over. It was difficult for her to find a way to accept and be patient with her exploration of issues that did not easily resolve. She was also worried that I would become tired of hearing the same issues. It may have been that her words represented her fears of what she projected I might have felt as she kept “coming in this room all bloody.” By taking all of her expressions seriously and supporting them musically, I attempted to help her to dissipate her worry that I would eventually tire of hearing about her painful issues. 3:34-4:11 I’m supposed to wash you up and put bandages and ointments on you Comb your hair, wash your face Give you a place to sleep, Comfort you, Talk to you Listen to you Play music for you The quality of expression and the music start to shift here to a more gentle tone. 4:12-4:48 Cuddle you and say “there, there my dear” “There, there my dear it’s going to be ok” “There, there my dear it’s going to be ok” At this point a song form with a predictable meter and pulse has been established. Maria is singing now in a tender way. 4:49-5:59 Oh my dear Oh my dear Rest with me it will be ok Oh my dear it’ll be ok I’ll wash your face I’ll dry your tears

I will bind up your wounds I’ll wash your face There is a quality of nurturance in Maria’s voice at this point as she sings with reference to the Bible and God’s perspective. 6:00-9:02 I’ll clean you off, I’ll bind up your wounds I’ll comb your hair Rest my dear Rest my dear The broken pieces have Such sharp edges They’ve cut you my dear Oh rest my dear Oh rest Oh rest Oh rest my dear one Oh rest I’ll wash your face I’ll bind up your wounds I’ll comb your hair Oh rest, rest in my arms I know what you’ve been through I know what you’ve been through Oh rest, oh rest, oh rest my child God doesn’t leave us, God doesn’t leave us Another shift in perspective occurs and now Maria sings about God, reflecting on the words she has just sung from God’s perspective. The music shifts to a soft gospel feel. 9:03-9:31 God doesn’t leave us no matter what I do God doesn’t leave me, God doesn’t leave me, God doesn’t leave me The intensity and contrasting qualities of emotion contained in an improvisation that lasted over nine minutes combined to create a powerful experience for Maria. At times, the experience was physically exhausting for both of us. There was also a sense of relief and physical release. The pacing within the session was an important factor in modulating the emotional intensity. When the issues she was wrestling with were daunting, Maria’s ability to express from different perspectives was the key to enable her to continue her process. Detailed Description and Analysis Since much of the improvisation in “There, There” contains dramatic imagery, and the form of

the interaction between us is call and response, this example led to the emergence and consideration of specific ideas regarding how the words Maria chose and the quality of how she expressed them influenced the music that I played. The example begins with Maria snapping her fingers as she sings. The music has a jazzy swing feel here and Maria sounds happy, as if she takes pride in her ability to hide: 00:00-00:09

Knowing her issue regarding her conflict about hiding emotionally, about not being noticed but wanting to be noticed, contributes to my consideration of her lyrics and the significance of them for Maria. The fact that Maria’s pitch is not entirely accurate and her vocal quality is a little wobbly is also information that I note. The swing feel has often bolstered Maria in the past and connects her to her body as she sings: 00:10-00:32

Even as the jaunty swing feel continues, dominant ninth chords move in parallel motion containing a minor seventh interval that contributes to a more dissonant sound. This functions as a subtle form of questioning to Maria regarding her attitude about what she is singing. The chords happen after each short phrase that she sings, creating a subtle call and response form between her melody statement and an answering harmonic statement. This foreshadows much of the form between her melody and my harmony throughout this improvisation. As I play a walking bass Maria sings a melismatic phrase on the word “can’t,” a kind of bluesy sound that she sings with a sense of satisfaction: 00:33-00:52

There is some dissonance in the harmony and in combination with the bass this creates a momentary minor chord where there had previously been a major chord in the progression. There is also a subtle clash between her melody tone D and the E which is at the top of the harmony. The bass plays some tones out of the key, hinting at breaking out of the form. This is an example of a blend of emotions in the music as Robinson (2005) describes. The music is both predominantly happy and subtly questioning. Maria starts to sing slightly softer and holds her last tone even longer, changing the phrase structure of the melody. I respond by playing fewer notes, and the overall effect is that the music begins to lose some of its rhythmic drive. Maria leaves space in her melody after this last note and I slow down and then completely stop the walking bass. Maria sings this last “see me” with a gentle, vulnerable vocal quality. Keeping the same key of D major, I switch the style of the music and the emotional mood here. I play a melodic fragment A and then F# that breaks the swing feel, holding both tones. The tempo slows and I play the D chord in second inversion in an open voicing, giving the chord a less stable quality. I then move the A up a half step from the fifth to Bb. I play the same movement an octave lower: 00:52-1:00

This half step motion upward is clearly heard, and then Maria utters: 1:01-1:10

I continue the harmonic motion of a half step rising to represent the idea of stepping. The tone is a dissonance, and not in the key of D major. It is a step out of D major, mirroring a step out of the bubble. Tones that are dissonant are added to the harmony off the beat, creating a messy sound: 1:11-1:29

In response to the lyric “cut and slashed,” I move from the major triad to dissonant intervals moving down on the keyboard. The downward direction relates to the idea that being cut and slashed would trigger falling. The fact that Maria’s voice also gets softer and falls in dynamic, contributes to the descending direction of the tones at the piano as well. The form of our musical interaction is call and response, as Maria creates a lyric, and I respond, while sustaining tones from the piano between the interactions:

The contrast between the dramatic lyric and the hollow, almost numb tone that Maria uses to say the word “bleeding” more than sing it, triggers a musical countertransference in me. Rather than mirror the hollow tone, I respond to the painful verbal image her words evoke, playing forcefully with clusters in a higher register of the piano: 1:30

It is if I am saying “this is a terrible thing, the fact that you have been cut and slashed and now you are bleeding.” This is an example of a musical commentary as Robinson (2005) describes, the music commenting on the persona presented by the voice. My music continues to convey turmoil, yet Maria speaks the words rather than sings them with a kind of hollow detachment, with a hint of disdain: 1:27-1:40

In response to the lyric about her knees and ankles lacking support, I move to the low register, the supporting component of the piano, and play dissonant tones and intervals. The fact that the bass is moving and has dissonant tones creates a quality of instability, and this relates to the lyric describing her unstable ankles. The last harmonies that I play in the pause contain the tritone interval, amplifying the sense of instability: 1:41-1:57

Maria sings “everything’s fine,” in a high register with notes somewhat related to the harmony I have just played. In response I play the melodic rhythm of everything’s fine, using Maria’s last pitch as the first pitch of my phrase, and end with an ascending interval of a tritone, which gives the melody a quality of not being fine, of being strange, of being unstable. It is also noticeable because it goes up. My melody has highlighted and magnified the incongruity between the words that Maria has sung and her vocal and musical expression. Maria hears this melody from the piano and immediately picks up on the strange melody with the tritone: 1:57-2:06

Again I take the melody and echo it, moving it to different tonalities so that there is a questioning quality in the musical commentary. It is as if the music is saying, “everything is not

fine; something is wrong, and we are not sure what is happening.” This is reflected in my lack of a clear tonal center and the emphasis on the tritone. At this point, Maria speaks. In response to Maria bringing back the bleeding lyric, I bring back the dissonant clusters from the first time she used the words: 2:07-2:11

The repeating musical response to the repeating lyric statement gives the music a form. It also emphasizes the musical aspect as a contrast to the “verbal aspect” in which Maria has again gone back to saying rather than singing the lyric. The first time I created this cluster it was a spontaneous, unpremeditated reaction. This time it is somewhat more controlled, as I am returning to it with intention. The music continues: 2:12-2:16

Now Maria uses the word “you,” responding to the character that was bleeding. This character has little empathy for the bleeding character: 2:17-2:20

It is striking that Maria curses, as it is extremely rare for her. I sense the intensity of her turmoil. I continue the dissonant thematic music first used when Maria first mentioned her bleeding. At the end of the phrase I play a D in the bass, the key that the entire improvisation began with: 2:21-2:28

I start to play a bass line, creating a slight sense of pulse, without establishing a definitive tempo: 2:29-2:33

The lyric “I can’t walk” triggers my response to abort the establishment of a pulse. Music with a pulse would not support the idea of not being able to walk. Instead I hold a minor chord with dissonance as Maria continues to sing on the one tone D, wavering slightly below pitch as she sings: 2:34-2:39

Maria’s melody stays on the one pitch D as she sings “I can’t walk.” I sense that the lack of direction described in her lyric is reflected in the lack of a melodic direction. On the word “walk” Maria’s pitch is slightly below the D. In response I play a C# in the middle register of the piano and the grounding D tone in the bass. I then move this D-C# major seventh interval up a third to an F#-F: 2:40-2:49

The overall musical quality is that there is something unresolved, something painful, something unfinished. My analysis suggests that these two tones that form the dissonant interval are a manifestation of the conflict between the two personae that Maria has manifested in singing the lyric: the voice that is bleeding, and the voice that is frustrated and contemptuous of the bleeding voice. The two perspectives clash, just as the two tones clash. There is very little musical change suggested here. Maria continues to speak the words and the dissonant major seventh interval is sustained: 2:50-2:53

Now I play the dissonant interval and move it up again, as if mirroring the ongoing and intensifying frustration that Maria has, singing from the persona of the potential helper: 2:54-3:00

There is a pause here as Maria emphasizes the reason for not helping. She then

continues: 3:01-3:08

The statement—again spoken and not sung—of frustration with her repeated selfinjurious behavior, triggers a musical response for me. I begin an ostinato pattern, manifesting the repetition in the lyric. Upon analysis, this is a way for me as therapist to “join the resistance,” a psychotherapy concept that was congruent with my clinical ideas, but not conscious for me in the moment. There is strong pulse in the music here as the harmony moves from a consonant to a dissonant chord: 3:09-3:17

Maria continues to speak these words rather than sing them. The volume of the music from the piano is building. While Maria starts her spoken phrase, as she forms the word “keep,” I add a loud, sharply articulated single tone that is dissonant to the continuing harmony and hold it while the harmony continues to be driven by the same accompaniment pattern: 3:18-3:22

The note is a Bb, and because I play it an octave higher and slightly before the G7 chord it stands out against it. Maria reacts to the note by raising her voice to a higher register and beginning to sing rather than speak. It was not my conscious intention to trigger this, but Maria seems to sing with more energy. Upon analysis, it is as if the note jars her back into the act of singing. Perhaps the intensity of my reaction gave her permission to give fuller voice to her own feelings, breaking through an unbroken “sound barrier,” to feel and express anger, to embrace and embody more fully the critical persona. I repeat the tone several times, reinforcing a jarring quality in the music: 3:23-3:26

I play a C#, another dissonant tone as the harmonic accompaniment pattern continues. This C# played with the G major tonality emphasizes the tritone, a subtle reminder of the “everything’s fine” tritone heard earlier. It is clear that everything is not resolved, and the tritone embodies this, which is heard by Maria as she sings the C#: 3:27-3:34

Not only is there a tritone relationship between the bass note G and the melody note of C#, but there are other intervals – F/B, E/Bb – that are also creating the sound as well. As Maria continues to sing with some disdain about how she is “supposed” to have compassion for the persona who is victimized, the music from the piano starts to change: 3:35-3:41

The harmony continues to be dissonant but is softer. Because the previous syncopated harmonic accompaniment pattern has stopped, there is a sense that something new can develop. In place of the previous harmonic pattern is a kind of tumbling descending harmonic motion with dissonant intervals moving in parallel motion, and since there is no tonal clarity, it is not clear where the harmony is headed. Maria continues to sing in a kind of detached disdain, as if the critical voice does not believe it’s worth trying to support the character that is in pain, all bloodied: 3:42-3:47

The words describe acts of compassion, but the tone of the singing reveals a lack of compassion. I reflect this ongoing conflict continuing to play mainly dissonant harmonies, but a quick consonant C major chord is heard. This is a different tonality and hints at relating to the actual nurturing content of the words. It lasts very briefly and the dissonant chords continue: 3:48-3:50

The harmony at the piano is moving to a higher register as Maria continues to sing: 3:51-3:56

The harmony continues to contain dissonances but with a more gentle lyricism in the phrasing. An F# in the middle register of the piano is repeated and thus serves as a bass tone. The tones above it do not relate in a consonant way, but the fact that this F# tone repeats gives the music a little more anchor, a little more stability. Something is about to happen, but it is not clear what. Maria pauses briefly and so do I. Something is starting to shift, both in the piano and

in Maria’s vocal persona. The F# bass tone in the middle register now moves up and down a half step, as if manifesting the shift that is occurring and will continue to occur in the way that Maria is using her voice: 3:57-4:10

There is a little more of a pause before Maria utters “talk to you,” and in response I pause and hold the harmony notes before continuing to play. As Maria states “listen to you,” I move the harmony notes to a higher place on the piano. This adds a sense of building tension in the music. Then I play an ascending run that both responds to the growing tension and adds to it. After Maria gently and softly states “ play music for you,” the bass moves up, and while still below the other harmony tones from the piano, begins a melodic line that is chromatic, adding a searching quality to the music. The music has contradictory qualities - tumbling yet ascending, floating upward, lightly, heading for an unforeseen destination. The image I have is of a tumble weed being blown gently. Maria continues and on the word “cuddle,” she takes a tone played at the piano to this moment, a Db, and begins to sing the entire phrase: 4:11-4:18

The quality of Maria’s voice changes here, as she sings with a more sustained tone and a quieter dynamic. She has entered into the emotional quality of the lyric content, singing “cuddle” and conveying a quality of gentleness needed in order to actually cuddle. The rhythm of her singing at the end of the phrase implies a triple meter. In response, I play even more gently in the higher register, and hearing her Db, I prepare to harmonize it. After she sings

“There, There my dear” I play an Eb minor chord as she repeats the words and melody and create a phrase. An accompaniment pattern emerges just as Maria starts to sing : 4:18-4:32

Now the music has a clear pulse and meter, with gentle countermelodies occurring from the piano in the high register. At this point, the shift that has been anticipated for some time actually occurs. The piano music and lyrics now go forward jointly as the pulse and harmonic path can be anticipated by both of us. Maria’s voice sounds tender and fragile. She sustains her melody tones on the last word of the phrase and sounds as if she may be about to cry. On the last tone of her phrase, the harmony moves from Eb minor to Bb minor, so that she is singing the minor third of what is now the new tonic. The music from the piano has qualities of sadness and warmth - blends of emotion as Robinson (2005) describes - with the countermelodies actively conveying gentle support and compassion as a commentary, as Robinson (2005) also describes. Maria is reassured by her words even as she wonders if their promise will be borne out. The same phrase structure repeats, and Maria enters into the music with a little more support in her voice, anticipating the return of the chord that starts the phrase again. The harmony provides predictability and stability. A gentle countermelody continues in the high register of the piano, as Maria continues to sing now in a soft, sad voice, continuing to sing on the Db. A clear song form has emerged at this point: 4:33-4:43

After two repetitions of the same lyric and harmony, both Maria and I change the form of the music while keeping the same pulse. She moves to a higher tone while I move to a different chord. The form of the music is propelling both of us at this point, even while the arpeggiated accompaniment rhythm at the piano stops: 4:44-4:55

The forward motion is provided by the anticipation of the melodic rhythm. This adds a sense of mutuality to the music in that the creation of the pulse is shared between us rather than being provided solely by the piano. I stop the pulse, and play close to the melodic rhythm that Maria sings. I play a very soft tone that adds a dissonance to each of the chords, giving the music a sense that things are still not quite ok. But there is a gentleness created by the soft attack and articulation in the music that also lends it a comforting quality. My commentary from the piano is a gentle way of asking Maria “Are you sure it will be ok?” The music continues: 4:56- 5:06

On the word “ok” Maria’s intonation begins to rise above the pitch and falters. The piano has both minor arpeggiation that has a pretty sound along with dissonant tones. The music blends the emotional qualities of pain and comfort: 5:07-5:25

Now the pulse of the music is being driven by the harmonic rhythm, as chords are changing after every three beats and there is a clear tonal direction, while Maria’s melody leaps up an ascending perfect fifth interval and she sings the higher tone through the measure:

5:26-5:30

This is a wider interval and higher tone than she has been singing previously. The accompaniment pattern is a series of rising arpeggios. The high melodic tone that Maria is singing, plus the form of the accompaniment pattern, combine in a synchronous way, lending the music a flowing quality, as if flying. The chords of the progression – Eb minor, Gb major, Ab major - include several major chords, giving the music a more optimistic quality. This form persists as Maria continues: 5:31-5:48

The music gets softer and a little slower here, less rhythmically driven as the arpeggiation stops. Maria is able to support herself as she continues at a louder dynamic,

confidently singing with a sense of the form of the song as it goes forward: 5:49-6:20

There is a strong sense of mutuality in the music here as Maria and I both arrive at the same tonality after a series of chords and melody notes that created the possibility of moving in a different tonal direction. The pulse is not emphatic, yet the entrance to the phrase happens simultaneously between us. The form of the song influenced the arrival at the familiar Eb minor tonality: 6:21-6:35

There is a gentle, lilting quality to the music as countermelodies fill in the space between the sustained tones of the melody. As Maria sings “broken pieces,” the melody of the lyric goes up, while the bass in the harmony goes down. At the end of the phrase, the word “have” is sung with the highest note, while a surprising consonant harmony is reached. This gives the music a quality of expansion and reinforces the sense of mutuality between us: 6:36-6:46

There is a strong contrast between the vocal references to “sharp edges” and “cut,” and the smooth flowing consonance of the piano music: 6:47-6:56

This music is assisting the healing voice in tending to the wounds of the injured persona. Maria continues to sing as we both slow down. In response to the word rest, I stop the flowing accompaniment pattern and hold the tones of the harmony, playing the melodic rhythm as Maria sings it: 6:57-7:11

This creates the effect of reinforcing the sentiment of resting. Then a dominant B7 chord from the piano is slowly arpeggiated from low to high. The chord has an added flatted fifth so that a significant part of the chord is actually constructed with two tritones. Elements of the whole tone scale are heard in the high register. This lends a quality of mystery to the music, as if something new is going to happen. Something does happen as Maria begins to sing a new lyric: 7:12-7:30

There is a strong shift in the music as a rubato occurs in both the voice and the piano. On the word “wounds,” a sustained countermelody acts in a metaphoric sense to heal the wounds. Maria’s vocal quality is more gentle and relaxed here: 7:31-8:15

The tempo of the music continues to be very slow. Maria’s voice quivers as she sings, indicating she is feeling strong emotion here: 8:16-8:31

As Maria sustains the last note on the word “child,” I introduce a gentle countermelody in the high register. It includes thirds above a harmonic progression (also in a high register) starting in minor, moving to major, and then ending in minor chords: 8:32-8:46

Upon analysis, this is another instance of a moving interval reflecting an intrapersonal relationship. Earlier, the dissonant interval moving in parallel represented personae locked in ongoing conflict. Here, the gentle and consoling quality of the moving thirds represents the relationship between the healing voice persona and the wounded sufferer. The high register of the piano melody adds an ethereal quality to the music, hinting at a connection to Maria’s words being sung from God’s perspective. Maria does begin to sing about God, and the music shifts to a gospel style: 8:47-9:02

As Maria sings about God rather than from her perspective speaking through Gods voice, I shift the style of music to Gospel. The tempo is flexible, and the meter is shifting, but the low bass tone and chord progression with a sense of triplet sub-division lends the music this quality. The “us” she sings about could be understood as the two voices that have been in conflict with each other, but now join together to sing about God: 9:03-9:32

As the excerpt ends Maria sings using the word “me.” This is a significant indication of a shift in her psychological state. After singing from different parts of her personality and then singing about God not leaving “us,” she is singing as one integrated person now, rather than taking the position of one or other personae. The experience of dramatically engaging her different sub personalities helped her to bring those polarities within herself together so she could feel more whole. Reflections In reflecting on how I responded musically to Maria as a Nordoff-Robbins music therapist, I asked myself three basic questions: How did I listen? What did I listen for? And how did I therapist respond? In actuality, of course, these three questions arise simultaneously and continuously. The challenge of NRMT is listening while doing, and doing while listening. Before beginning the exploration of therapist technique, I want to reiterate that this was a collaborative process. Maria‘s willingness and ability to work on developing herself by entering into the creative process by singing was the major factor in making the music-word creations meaningful. Her desire to sing and to become more involved with music motivated

her to stay immersed in the process. Her particular attributes helped to make the musical process psychologically meaningful for her. Her unique combination of skills and needs were essential factors and cannot be overlooked. Her aspiration to be a music-maker allowed her to improvise melodies and tap into her dormant strengths as a lyricist. Her crisis became an opportunity in that her diagnosis spurred and intensified her exploration and expression in creating songs. How Did I Listen? This category relates to the state I was in, the approach I took, and my preparation in approaching the potential emergence of the improvised song. The actual improvisation process that led to the creation of the archived material under discussion was based at times on hunches, sensations, and preconscious responses. Intuition played a major role in influencing how I chose what to play and how the music ultimately developed. Brescia (2004) completed research that illuminated how music therapists experienced and utilized intuition in their clinical practice. She identified cross-case themes to relate the collective experience of the music therapists who participated in her study. The following theme expresses her findings on the use of intuition during improvisation: “When I open myself to the moment and listen deeply to the client, my intuition can guide the music that I play. The music comes from a place where I am not analyzing or organizing in a conscious way” (p.151). This is an apt description of my intuitive faculties as I approached each session. By listening closely to Maria‘s expression, I tried to base my musical choices on what I was sensing from Maria, what I was hearing, what intuitions I had regarding the unfolding musical process. My listening and responding emotionally allowed my music to be informed by my intuition. It is only due to this retrospective analysis that I can describe the therapeutic uses of the particular elements of music and the techniques and processes that I have uncovered regarding the music-word relationship. Many of the findings below were only tacit understandings at the time this music was created. At other times, I was aware of a particular clinical issue due to the quality of Maria‘s singing or the content of her words. Clinical interventions were embedded in the emerging musical forms I played with Maria, so that musical goals and clinical goals overlapped. Listening with the Whole Body Building on Robinson‘s (2005) ideas, I was prepared to be informed by my emotional responses as I listened. That meant being prepared to have emotional reactions which emerged and influenced the shape of my hands and the touch of my fingers as I played. I was prepared to be moved emotionally but not overcome by emotion. I was “poised in the creative now” (Robbins, in Turry, 1998, p.353), actively waiting and listening for the potential musical form in Maria‘s demeanor, tone of voice, content of lyric, and the rhythm of her words and/or music. Stamboliev (1992) describes the importance of the state of the therapist as he responds to the client, stating, “an alert and anticipatory relaxation is a prerequisite” (p.48). Maintaining this state allowed me to anticipate how the music would structure as a developing form. I was poised to create form as I listened, hearing the phrase structure implied by the fragment of a

phrase, the meaning of a word, or a physical gesture or motion. A very important factor in my listening process was my physical connection to the music. I was moving and using my body to lead what I would play and how I would play it. My hands were poised to react in a gestural fashion. The shape of my hands as I listened was a result of my reaction to the content of the words or vocal quality. Varieties of hand shapes included caressing, scrunching, spreading. All of these hand movements influenced my voicing, articulation, and texture. Moving my fingers closer together or farther apart related to my visceral reaction to the material. Widening the distance between my hands to play in contrasting registers of low and high related to my body‘s reaction to the lyric and/or musical content. My body entered into the flow of the ongoing pulse and influenced my pedaling and articulation. All of these musical elements influenced the development of a particular musical form as it emerged. Robinson (2005) addresses the mind-body connection explicitly stating that “physiological responses to the music are in fact emotional responses” (p.373). She goes on to say that “music affects us emotionally by affecting our bodies”‖ (p.411) and our bodies affect our emotions. By entering into the music in a physical way, I allowed myself to translate my emotional responses to Maria‘s expression through my body to my hands. My body‘s reactions not only informed my playing, but helped me to understand Maria‘s emotional process, and her emotional process informed the way I played as I responded to her through my physical sensations and actions. A Balanced Listening Approach I often asked myself questions as I listened to seek more understanding. To balance the questioning/listening stance, I simultaneously took a stance of unconditional acceptance towards what was happening and what was going to happen. For me, this is a spiritual approach; I accepted that what is going to happen is meant to happen. I attempted to embrace the unknown, living in the now, immersed in the loving creation of the music. I tried to do this with an absolute focus of attention. The combination of listening with questions as well as an accepting attitude helped me attain this kind of listening state. What Did I Listen For? This section includes how I listened for the content of the words to understand their meaning, and how I listened for the quality of how the words were sung. This contributed to the overall listening for the musical quality of the lyrics, the rhythm of how they were sung, the tones used, the metric implications of the words, the tempo implications based on the speed with which they were sung, and the volume of the singing. I listened for the harmonic or stylistic implication based on all of these areas. Two tables are included in this section that illustrate what the therapist listened for. Table 2 includes perceptions of the therapist regarding Maria‘s vocal quality including emotion, music, and the possible intention Maria had when expressing herself. Table 3 includes perceptions regarding Maria‘s underlying stance or persona, the form her singing took, and who she was singing to.

Listening for the Client’s Needs Related to the physicality of my approach is the idea that my playing was influenced by my sense of how Maria needed to be touched. How I touched the keys was informed by how I sensed she needed to be touched. Rather than a reassuring clasp of her hand, I would articulate my music with the same supportive energy. If I felt she needed to by soothed, my hands touched the keys informed by my assessment. If I felt she needed comforting, if she needed physical support, if she needed stirring, if she needed to move—all of these apparent physical needs influenced how I would touch the keys. This in effect influenced my articulation, dynamics, tempo, register, texture, and tonal direction. For example, when I heard Maria softly moaning and sensed that she needed soothing, I shifted my dynamics and texture and played more delicately, with a more sparse texture rather than continue to match her dynamics, even as I continued to play with dissonant tones. My tonal choices kept the tension in the music which I felt was necessary for Maria to continue her process, while I changed the touch of how I was playing in order to comfort her in the moment. There are other examples when my tones reflected my sense of what Maria needed energetically. When I sensed she needed to feel my supportive presence more directly, I played thirds moving in parallel motion to create a sense of being close to her and being present with her as she continued her process. When I sensed Maria needed to relax as she sang this lyric, my hands became relaxed and this changed my articulation as I played. If I sensed that Maria needed to be awakened, I changed my touch to play with a crisper articulation. This can be heard in “There, There”‖ when Maria used a kind of numb zombie-like voice in creating despairing lyric content (“I’m bleeding”) and I played a cluster with a sharp attack. Listening for the Message in Words and Tone While I listened, I sorted out the messages that I received, with the most vibrant one—a descriptive word, or a tonal direction—coming to the forefront for my response. When I heard a quality in Maria‘s voice that suggested she was becoming more animated or emotional, I shifted my focus from tones to assessing what her emotional state was, and this informed the music I played. An internal dialogue took place which brought the content of the lyric, the quality of how the lyric was sung, or the musical quality of the lyric to the forefront. At times all of these components were perceived as a single entity. At other times they were perceived as separate elements. I listened for musical potentials while trying to comprehend the meaning of the lyric, and the significance of the lyric in terms of my understanding of Maria and her challenges. I sorted out whether the lyric called for more attention or the way/the quality of how the lyric was sung the most prominent factor. Repetitive lyrics, which occurred often in the material under study allowed me to shift from concentrating on the lyric content to the quality of how the lyric was sung. Listening for Psychological Discovery This was an area that was made explicit during the research process as I listened recursively in the listening stance as therapist. I attempted to understand the meaning of the

lyric content and its significance. I considered whether there was more that Maria was not revealing. I tried to understand her motivations, the latent content of what she was singing, and what perspective she was utilizing as she sang. Was it the “angry critic” persona heard for instance in “There, There”?‖ I considered how emotionally connected she was to the content. I wondered what the lyric content revealed about our therapeutic relationship. An important consideration was the congruence between the content of her lyric and the quality of her musical expression. I considered whether her expression was more emotionally driven or more driven by aesthetic considerations. All of these psychological considerations fed into my musical choices, sometimes consciously, more often than not unconsciously. Perceiving Maria’s Vocal Quality One of the areas of my listening and perception was in discerning the wide variety of emotional qualities Maria utilized in singing. That entailed attempting to hear the quality, the underlying perspective, and the form of how she was singing. The following categories list the different ways that I heard Maria sing. They are not conclusions regarding what Maria experienced, but are descriptions of what I perceived to help the reader understand my listening process. Perceived Emotional Quality. Emotions could be heard in the quality of the voice as Maria sang. Her breathing, phrasing, volume and pitch variance revealed emotional intensity. Emotion was often heard in the bending of or length of tones. At times the pitch of her tone would waver and this was an indication of strong emotion, though not always. There were times when she sang with a gradual increase of emotion as she repeated one note or one particular phrase. There were also times when her emotion fueled melodic direction and the interval between notes. There were times that as she was singing, Maria began to cry and she stopped singing. The music I played at the piano helped her to reenter into the music. Yet reenter can be misleading because often during those times that she was crying she would be responding to the music in some way. At other times Maria continued to sing even as she began to cry. This can be heard in several of the songs. Though these occurred in the same way, the quality was different. In the improvised song “Woman Why are you Weeping,”‖ Maria‘s crying related to her resignation that she could not find her voice. In “There, There,”‖ her crying related to allowing her compassion towards herself to emerge. For organizational purposes, Table 2 lists the varied emotional qualities as single occurrences. Many times there were blends of emotion in the way Robinson (2005) describes as one emotion became more prominent than another as the improvisation evolved. Even as I list them separately I acknowledge that some took place at the same time. Perceived Musical Quality. Maria often sang on one tone which could be variable in terms of pitch. If she did not sing but spoke, I listened to the inflection, rhythm, and pacing of what she said, hearing it as potential music. If she sang only one tone, I listened to the length and volume as well as the implied pulse in order to form the phrase. When Maria started to move her tones, I listened for where she was headed, listening for the next note and the implied harmony that the note implied. At times, Maria created patterns and I anticipated what tones she would repeat or head for. At other times, my harmony led her to start and move to particular tones.

Perceived Intention in Creating Lyric and Melody. I sensed during each of the improvisations that Maria had a purpose. Though this purpose may not have been explicit to either of us at the time, upon reflection as it occurred or upon retrospective analysis I have been able to list the intentions that I perceived Maria had as she created her lyrics. One of the guiding principles behind my findings was to understand her intention by closely examining what she actually did. I believe that her intentions shifted as her involvement in the music changed and her psychological defenses became less or more rigid. At times, the feelings triggered by the music may have occurred before she was ready to handle it. Often she could not start off ready to experience fully the feelings that were triggered by the musical experience. The evolution of the improvisation led her to be able to experience them. Many times the music itself became more intense as the improvisation unfolded. This was something I tried to gauge and respond to, sometimes with explicit changes in the music, but mostly with an implicit reaction based on my intuition at the time. Perceived Intention in Creating Lyric and Melody. I sensed during each of the improvisations that Maria had a purpose. Though this purpose may not have been explicit to either of us at the time, upon reflection as it occurred or upon retrospective analysis I have been able to list the intentions that I perceived Maria had as she created her lyrics. One of the guiding principles behind my findings was to understand her intention by closely examining what she actually did. I believe that her intentions shifted as her involvement in the music changed and her psychological defenses became less or more rigid. At times, the feelings triggered by the music may have occurred before she was ready to handle it. Often she could not start off ready to experience fully the feelings that were triggered by the musical experience. The evolution of the improvisation led her to be able to experience them. Many times the music itself became more intense as the improvisation unfolded. This was something I tried to gauge and respond to, sometimes with explicit changes in the music, but mostly with an implicit reaction based on my intuition at the time. Table 1: How the Therapist Listened: Perceptions regarding Client‘s Vocal Quality Please note: These columns are not linked together EMOTIONAL QUALITY

MUSICAL QUALITY

INTENTION PERCEIVED BY THERAPIST

Disdainful

Monotone

Hopeful Fearful Disbelieving Desperate Contrasting earlier emotion Nurturing

Speaking voice with inflection One tone that is fluid One tone that is solid One tone that is repeating Moving tones

To experience feelings that are not present To establish a melody that has words To lessen painful feelings To avoid feelings that may surface To question whether content is true To question the impact of the content

Searching

Moving tones in relation to the harmony Moving tones implying a new harmony

To convince herself that the content is true To feel playful

Enthusiastic Desiring Yearning

Wishing the expeirence would last longer Mournful Forgiving Ironic Mocking Sad

Assertive Angry Congruent Incongruent Bubbly Silly

Singing a new tone in response to a new harmony Creating a brief melodic statement Responding to her previous melodic statement to create a longer melodic phrase Creating a melodic idea

To resolve a conflict

Repeating a previous melodic idea Creating a melodic sequence Searching for a new tone Searching for tones that help to convey the intention of her lyric Searching for a tone or phrase that will complete the musical phrase/experience Rhythmic Holding one tone for an entire breath Implying a musical style (bluesy operatic) Head voice Chest voice Weak breath support Strong breath support Close to whispering Close to screaming Narrow tone Open tone Sharp Flat Wavering Precisely on Pitch

To be heard

To debate contrasting positions To find an answer to a question

To understand a diffuse feeling

Perceived Underlying Stance of the Client: Personae. Maria could use the same phrase, intervallic distance and direction yet create a different emotional quality in her melody depending on how she was singing, from what perspective she was singing from, or to whom she seemed to be singing to. For instance, there were times when she was singing about her father and her entire demeanor changed such that she sounded like a child. At other times, she might sound as if she was singing from the perspective of a wise and knowing persona, particularly when she sang from God‘s perspective. Sometimes the content of her lyrics and the emotional quality of how she sang them were congruent as I heard them. At other times they

seemed to combine to create a more complex quality, and at times they were in opposition, creating a paradoxical quality. “There, There”‖ contains examples of these qualities. Maria‘s immersion in music produced a very fluid mental and emotional state in which she was able to evoke and give voice to different—sometimes contrasting— selfpersonifications. Just as different characters may emerge in dreams, all of whom are ultimately recognized as representing elements of the attitudes, feelings, and character of one dreamer, so Maria gave musical expression to different internal aspects and perspectives that I came to call “personae.”‖ These personae were musically distinct, and appeared to arise from deepseated personality traits, articulating long-held underlying stances relating to issues, situations, and personalities. In her state of musical involvement, she was able to access several different personae as she sang, moving from one to another during the course of a single improvisation. A vivid example of this process is heard in “There, There.”‖ The significance of these personae, their emergence in conjunction with the music being created, and their reciprocal influence on subsequent shifts and changes during the course of an improvisation will be discussed in the next section. Musical Forms. The musical form Maria utilized was related to the emotional quality of how she sang and the persona that Maria tapped into as she sang. Many times this was associated with the actual content of the lyrics. For instance, she could sing about God in a chant like prayer form, or sing about God in a blues style. She often had dialogues with herself and this fueled her to continue her process when it became difficult. The dialogue form was one she utilized particularly when she hesitated and the music from the piano encouraged her to continue. Maria had a wide variety of resources to tap into. She was familiar with many of the classic operas and often referenced storylines from particular ones that moved her. She knew the Bible very well and at times in the session recalled specific sentences from the Bible and sang them with her own original melodies. Her connection to religion and her experiences with music from church contributed to the forms she created in the session. Her prayer-like singing often had a chant-like quality, particularly when her melody repeated a single tone. Maria had an eclectic music collection including recordings of jazz vocalists and classical singers as well. This was a collection that she intrinsically tapped into during this creative process. She did not bring in specific melodies, but she might snap her fingers and move in a way that suggested a particular musical form. Maria often had a conversation with herself, asking a question through a melody and lyric and then searching for an answer. This is heard in “There, There.”‖Her lyrics and melody also unfolded as if she was telling a story. Maria developed confidence in searching for and finding the particular form she needed as she created her ideas, and this helped her to keep going even when the material she was singing about was difficult and challenging. The song form itself functioned to anchor a new emotion or attitude, support it, reinforce it, establish it, and bring it to fruition. At other times the song worked as a vehicle to bring various polarities together, holding together seemingly paradoxical qualities and combining them to enhance the overall quality. To Whom was Maria Singing? Maria often sang to sing, not to sing to a particular person either in her present or past. But as her investment in the music became more complete and her personae started to emerge, it would seem as if she was singing to a particular

audience or person. At times, it was just a general group of people from whom she might want approval. This would occur when she might be stating her case and waiting for judgment. So in a way she was testifying for a jury. At other times, she seemed to be singing to God or trying to capture God‘s perspective. Of course, since I was always present as Maria sang and listened to what she sang, it could be argued that everything Maria sang she sang to me, or for me to hear, or had to do with the dynamics of our relationship. This was something I regularly considered when listening to her music. Many times I sensed that she was singing to me, to herself, and to another unseen person. In this way, there was a blending of who Maria was singing to. Maria often felt bolstered when she felt that I was listening to the content and formulating the same questions and reactions that she was. At times, she would ask a question to herself and then look at me and ask if I also wanted to know the answer. It was a way for her to validate her direction and reassure herself that I was with her in her unfolding process. Usually she heard my response in the music itself and this was enough for her to continue. Table 3: How the Therapist Listened: Perceptions regarding Stance, Form and Direction Please note: These columns are not linked together. MARIA's UNDERLYING STANCE (PERSONA)

FORM OF MARIA'S SINGING

TO WHOM MARIA WAS SINGING

Playful Child Vulnerable Child Playful Woman Inner Critic Faithful Disciple Sympathetic Judge Sarcastic Adult

Prayer Hymn Statement Plea Conversation Soliloquy Performance

Unseen audience Her father Herself God From God's perspective to herself Her mother A particular person she created and then to another to take different perspectives within the same improvisation

Vengeful Judge Frightened Child Wise Guide Hopeful Child

Story Telling

How Did the Therapist Respond? This section focuses on what I actually did musically. To illustrate the connections between how I listened, what I listened for and how I responded, I have created a pastiche. The structural outline of the pastiche depicts an improvised song as it emerges, establishes, and comes to completion, and cites particular examples where these developments can be found in the archived material.

How did the Therapist listen? What Did the Therapist Listen For? How Did The Therapist Respond? I listened for the shape and quality of Maria’s breathing to inform the development of my music. The process begins. Sensing the energy. I listened for any cues or sounds that imply a rhythmic form or tone in order to inform the development of my music. Simultaneous shaping as my music influences the sounds that Maria is making. This can come from her series of moans that determine the pulse or a verbal statement that has an implied melodic and rhythmic contour which I play. I listened for the pitch of the tone Maria is singing and the harmonic implications of the emerging melody. The potential for an improvised song emerges. I can choose to determine a tonal center and overall tonality or keep the tonal organization more ambiguous, depending on what I sense Maria needs and/or what the music needs. I listened for the quality of Maria’s tone—strong or weak, detached or connected, thin or thick, soft or hard, hollow or full—and the content of the lyric in order to determine the emotional quality of my music. The tensions and resolutions of the music determine the emotional quality. How I play—touch volume and tempo—and what I play— consonance or dissonance—contributes to the qualities in my music and the overall music that Maria and I are creating together. Her vocal quality influences my choices. The mood of the music emerges. I listened for the quality of Maria’s tone and the content of the lyric in order to form the structure and style of the music. Organum structure combined with dissonance to match Maria’s religious contemplation and sadness? A blues with a swing feel implied by her sliding tone? The Lydian mode to encourage more imagery? The Dorian mode to convey warmth and tension in response to her turmoil? I listened for the volume of Maria’s tone and the content of the lyric in order to determine the volume, register and texture of my music. Setting the stage for mutuality by making sure we both can be heard I listened for the pulse and phrasing of Maria’s expression in order to determine the tempo and metric implications of our music. Sharing in the development of tempo and how it changes, stops and starts again is an important component to making the experience a shared, co-active one. It also helps to organize the different sections within the overall song form. I listened for the rhythm of Maria’s melody and how she phrased it in order to form a bar structure that allowed the two of us to create with a sense of the ongoing structure of the music with regard to measures and sections of the music Creating a meter and measures are key factors in creating forward momentum and shaping the structure of the improvisation into a song form. I listened for the harmonic implications of Maria’s emerging melody not only to place her current note within a harmony but to anticipate what the next harmony could be.

This determined not only the changing chords as a whole but how the tones within each chord could change. The more harmonic options I can hear the more I can choose from. The more choices I have, the more options I have to make musical choices that have clinical intention. Will it be major or minor, or a chord with more ambiguity? Inversion or root position? Closed or open voicings? I listened for the potential motion of Maria’s melody and the lyric content to determine the motion of my harmonic progression If Maria is singing one tone, I can create harmonic motion in ways to move the song form forward. It can be the bass tone, an inner voice of the chord, or the chord as a whole. If Maria is singing a sequence, I can anticipate the next set of tones and the implications for the harmonic progression become clear. I listened for the notes of Maria’s melody to determine the mode or scale she is utilizing and the implications for my harmonic choices. If she is singing tones of the pentatonic, I have many options with regard to harmonic accompaniment. I can stay in the pentatonic, choose a mode, create a diatonic progression, since all of these contain the notes of the pentatonic. I can choose to play tones in contrast to the tones of her melody. Discerning her tones is not a conscious determination but a response by ear to what I am hearing. I listened for both the melodic rhythm and the lyric content in order to shape a potential countermelody. My musical commentary often comes directly from my melodic rhythm. The rhythm often is the same as a lyric that Maria has just sung, or an answering lyric that I hold in my thoughts while playing. My melodic rhythm often has an interval that moves in parallel motion. The parallel motion makes the melodic rhythm more noticeable, and the relationship between the tones of the interval can reveal some aspect oft the relationship between Maria and me. I listened for the relationship between the meaning of the words and Maria’s current quality of musical expression in order to develop clinical context and direction. When she is unable to deal with the emotions related to the lyric content, what can I do with my music to help her? Infuse the music with dissonance and dynamics? Change my touch to trigger a shift in her perspective? I listened for the emerging meaning of the words in relation to the client’s general issues and development. How did what she sang fit into my understanding of what her current issues were? Is there a kind of music or musical quality from our past collaborations that could help now? I listened for clues in developing an understanding of the perspective Maria was taking When she sings from the persona of “the wounded child” I often play soft arpeggiated minor music in ¾ time in a high register to both manifest the persona and comfort Maria. “The critic” usually gets low pitches with angular intervals and a harsh articulation, which can lead to earthy music and a way to transform the energy of the persona that Maria is living in. Sometimes my music leads to the development of the persona, sometimes the persona leads to the development of my music, and sometimes the music and the persona emerge together. I listened to the melody and lyrics in order to determine whether to match it, enhance it, create music that depicted the imagery of the lyric, or respond and musically comment on the lyric with my own melody.

This is a process that could be based on my musical countertransference, on purely musical considerations and or specific clinical intentions, or a combination of all of these. I may react to a word or words that Maria sings and respond to it, or try and create a musical description of it. Intuition plays a part in my musical choices. I listened for the relationship between Maria’s pitch and the pitch of the piano. As Maria’s pitch places in between two notes that are a half step apart, I can play both of those notes and accentuate the tension of being “out of tune.” Bringing out these tones can help in moving Maria’s psychological process forward by helping her live in the tension of the interval and utilize the tension to go on, and at the same time help her to become grounded in the musical experience by choosing one or the other of the tones to sing. I listened for the emotional expression or dynamic intensity Maria was utilizing in singing lyrics. This plays an important part in determining the third of a harmony that I play—whether it is major and minor, or left out completely-and the tones included in the harmony—tritones, sixths, sevenths, ninths, elevenths, thirteenths, that together determine the emotional color of a harmony. I listened for Maria’s shifting emotional state to determine how much support to provide in the music Creating a definitive tonal center helps to provide organization and safety. Singing with her is a way to provide support more directly. She feels the sound of my presence as we have a defined melody and lyric to join in together. I listened for the quality of the words and music and the form of the song to determine when to end. A sense of wholeness and completeness often accompanies the ending of an improvised song. Sometimes bringing the music to a close allows for a new perspective and a continuation of some kind in a new musical form. This depends in part on when the song is occurring within the overall session. Embracing Tensions: Creating Blends of Qualities. During moments of lyrical content describing hopeless imagery or during moments where Maria‘s vocal expression revealed turmoil or conflict, the music that I played at the piano included the melody notes and melodic phrase of the lyric statement. This music that held a quality of turmoil or tension was then combined with harmony and a harmonic rhythm that sounds like a beginning, an introduction, or an opening to a new song form and creates a strong sense that the music could continue. This could happen by changing the key or by creating a progression that sounded as if leading to a new key. One common harmonic device I used in creating a sense of beginning was to play a suspended dominant seventh chord and then play a second inversion chord built on the same bass tone in order to establish a new key and a song form beginning. So with this combination of past qualities and current qualities there was forward momentum to continue in the musical experience. Through the use of dissonance coupled with Maria‘s original melodic expression of her turmoil, the music from the piano maintained some quality of the tension that was expressed previously. This was a way that musical elements combined to create the emotional qualities of turmoil and hopefulness at the same time. There was hope for a new direction and a resolution in the music even as the music continued to

acknowledge the turmoil. When Maria reentered the collaboration, and suggested a possible more hopeful lyric, the music offered the experience of less tension, of resolution. Unexpected Discoveries. I had thought that I would find a developmental process through the period under study for Maria in creating melodies. I had held the idea that as she became less constricted psychologically, her melodies would become more expansive. What I found was that even early on in the process Maria was moving from her single tone melodies and creating melodies that were wider in terms of tonal range. What did change were her intervallic paths. She became more able to skip, leap, and change direction. Also what changed and developed through time was Maria‘s vocal quality with regards to flow of breath support and accuracy of pitch. Her quality became more robust and her sound more sustained. Another development during the period under study was her precision and accuracy of pitch. In general there was less sliding into notes. Another surprise was how the vocal quality of Maria changed and how that played upon my response. In listening to the archived material I realized how her constriction and the tension in her voice played a part in my emotional response to the material. Early on, I played with more pedal, used more arpeggiation and legato, and this was done in part in response to Maria‘s overall vocal quality. It was a way to soothe and relax her and me as well. As I listened to the archived material created later in the process, I noticed a slight reduction in the use of the pedal on my part and in the amount of notes used in arpeggiation. I was surprised at the blends of emotional qualities I found when I listened. During the sessions, I had a sense that a particular mood or quality was at the forefront. But as the analysis unfolded I could hear several blends of emotional qualities as they emerged, shifted, transformed, and combined. There were times when Maria‘s exasperation or even desperation as she sang also contained elements of insistence and assertiveness that gave her the energy to continue even during moments where the lyric content suggested she was giving up. She attributed her ability to continue during those moments to listening to the continuing music. In retrospect, it may have been that the music accessed those parts of her that were barely present, incipient, but that could come to the forefront when the music could support them. I was surprised when I learned who initiated a particular musical idea. Closer and repeated listening triggered new understandings as to how things emerged. Whereas previously I thought I began something, it was really based on something that happened much earlier in the improvisation; things I attributed to Maria were things she was actually responding to that I had already done. .‖I had thought that the first time I played the tritone was in response to Maria‘s lyric “Everything’s fine.”‖ I discovered that I had actually played it in the harmony earlier, and this was heard by Maria and influenced the way she stated her lyric, which then influenced my playing the tritone as a countermelody. Rather than the tritone being an isolated response to a particular quality in Maria‘s lyric statement, it was already present in the music, although not as apparent as it would eventually become. I was surprised to discover a harmonic relationship between “There, There,”‖ and another improvised song under study “Do I Dare Imagine?”‖ In both examples, there is a harmonic shift during the improvisation from Bb minor to Db major. In “There, There,”‖ this occurs from section to section, when the music shifts from the main lyric theme “There, There”‖ which is in Bb minor, to the gospel section, which moves to Db major, an uplifting key change that fuses with the uplifting style of music. In “Do I Dare Imagine?” the shift between Bb

minor and Db major occurs within a section in which Maria was singing about a psychological struggle she was having. The fact that both improvisations had the same harmonies probably had more to do with Maria‘s vocal range then my personal musical tendencies, as these were not keys I found myself improvising in often. Conclusions The songs improvised in music psychotherapy are not merely musical creations; they are musical/psychological creations that emanate from and are intimately connected to the client‘s intrapsychic states. Music combined with words and given form and structure in the improvisational process has a special ability to evoke the emergence, and subsequent integration and transformation of, different parts of the self—different contrasting personae— that live within the individual. Because of the qualities that music holds it can make this happen in a smooth, seamless and connected fashion. In fusing words and music, creating melody and lyrics, a coordination takes place that enables the client to think, describe, and express both emotionally and intellectually. The client can think and feel fully during moments of the improvisation by tapping into previously dormant potentials to connect thought with feeling, music with words. The implication from this study is that this ability to express by fusing words and music, to integrate thought and feeling is not an ability that one consciously practices. Rather, it arises spontaneously with the deep immersion into the experience. The flow and form of the music, the dynamic forces inherent in the music, are vital forces in allowing this to happen. The process of creating an improvised song allows the client in music psychotherapy not only to express in a way that integrates thoughts and emotions; it allows the client to try on a psychological attitude that would not be possible without the musical experience. The music of the therapist provides the safe environment to encourage risk-taking and suggests the direction and quality of the risk. The path of the unfolding music can suggest entering into challenge or taking on a helpful quality like strength or courage. Because music contains blends of qualities, the music can have both the emotional qualities that the client is experiencing and the emotional qualities that the client is seeking. The fact that the client is not merely passively listening, but actively creating makes the experience more related to core personality constructs and thus the potential for more lasting psychological change is possible. The client can experience a sense of initiative even while the therapist makes a significant contribution to the immediate emotional tone and the future musical development of the song by shaping the musical elements. By improvising songs the music psychotherapist can work to bring out personae that are in contrast to each other in order to facilitate dialogue and integration of those personae. Clients who are drawn to music therapy and have issues regarding self-criticism and overbearing judgment can become engaged successfully in music psychotherapy because they have a sense that they can be more spontaneous and playful. There can be a positive relationship that people hold with regard to musical expression, particularly when the client is not a trained musician. Yet the issues regarding self-criticism can arise even within musical interaction for the non-musician because music is so closely related to the core of the person.

Combining music and words is an ideal vehicle to work on bringing a playful and creative attitude to long-held critical positions within the client. Zuckerkandl (1973) theorized that the act of singing was “an enhancement of the self”‖ (p.23) that breaks down the separation between subject and object. Words that are sung “build a living bridge”‖ (p.29) between the singer and the topic being sung about. In this way, the singer can “without losing his[her] identity, be with what he[she] is not” (p30). Rather than singing to communicate to others, the singer is singing to become more vital, to become more connected to the subject of the song. Here, Maria breaks down the separation between her various selves to enhance her overall self. She seeks to be with the consoling and accepting qualities she often cannot be with in everyday life. References Brescia, T. (2004). A qualitative study of Intuition as Experienced and used by music therapists. Unpublished doctoral dissertation, New York University, New York. Robinson, J. (2005). Deeper than reason: Emotion and its role in literature, music, and art. Oxford: Oxford University Press. Turry, A. (1998). Transference and countertransference in Nordoff-Robbins music therapy. In K. E. Bruscia (Ed.), The dynamics of music psychotherapy, (pp. 161-212). Gilsum, NH: Barcelona Publishers. Turry, A. (2002). Don’t let the fear prevent the grief: Working with traumatic reactions through improvisation. In J. Loewy & A. Frisch Hara (Eds.), Caring for the Caregiver: The Use of Music and Music Therapy in Grief and Trauma, (pp. 44-53). Silver Springs, MD: American Music Therapy Association. Turry, A. (2007). The connection between words and music in music therapy improvisation: An examination of a therapist’s method. Unpublished doctoral dissertation, New York University, New York, 3247771. Turry, A. (2010). Integrating musical and psychotherapeutic thinking: Research on the relationship between words and music in clinically improvised song. Qualitative Inquiries in Music Therapy, 5(4), 116–172. Turry, A. & Marcus, D. (2003). Using the Nordoff-Robbins approach to music therapy with adults diagnosed with autism. In D. Weiner, D & L. Oxford (Eds.), Action Therapy with Families and Groups: Using Creative Arts Improvisation in Clinical Practice (pp. 197-228). Washington, DC: American Psychological Association. Turry, A., & Turry, A. E. (1999). The use of improvised songs with children and adults with cancer. In C. Dileo (Ed.), Music therapy and medicine (pp. 167-178). Silver Spring, MD: American Music Therapy Association. Zuckerkandl, V. (1973). Man the musician: Sound and symbol (Vol. 2). Princeton, NJ: Princeton University Press.

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

CASE TWENTY TWO Reclaiming a Positive Identity: Music Therapy in the Aftermath of a Stroke Nancy McMaster Abstract This study describes how music therapy helped a forty-year old woman cope with the effects of a stroke. Through improvising, composing and singing, Vera grieved and protested what life had brought her, while also finding a way of validating the ability and strength that still lived inside her debilitated body. Background Information This is the story of Vera, a married woman in her early forties, and the mother of four children. Her life as a bright, vivacious, socially-active, ambitious, and philosophically-minded woman was cut short three years ago by a stroke or cerebrovascular accident (CVA). The CVA was precipitated by the rupture of an unsuspected tumor in her heart. She was left without the use of her right arm, dragging her right leg, drooling, with no speech, virtually no sight, and an undetermined cognitive impairment which affects her memory and body awareness. Extensive assessment indicated that little value would result from therapeutic intervention. A year after the accident, she was placed in a residence for seniors, where she had the support of a personal attendant and frequent contact with her children. This residence provided social, activity, and religious programs but no rehabilitation beyond maintenance of functioning. Vera’s husband arranged for her to have a daily personal attendant and frequent contact with her children. Visits from her husband were very stressful, as Vera did not understand why she could not live at home. Visits from friends decreased as they found it very difficult to accept Vera’s condition and also very difficult to communicate with her. Vera’s parents made daily phone calls and several trips each year from hundreds of miles away to offer their love, support and sympathy. Vera’s emotional response to this set of circumstances moved through a wide range: from devastation, hope and determination to despair, apathy, grief, and later to frustration and anger. Her movements have tended to be slow; her neck, shoulders and spine drooping; and her face almost blank, except for slightly raised eyebrows. Vera was generally preoccupied with the losses in her life, which she indicated by the frequent use of signs which she had created to refer to each one. Vera tended to remain uninvolved in her day-to-day life, neither seeking nor responding with interest to anything except eating, listening to music, religious services and studies, and conversations which might contain solutions to her dilemma. When her interest was stirred by

any one of these events: her spine and neck would straighten, she would cock her head, raise her eyebrows, make vocal sounds of interest; she would move quickly and confidently, even taking several steps unassisted; she would even strain, if necessary, to get a better access to what was interesting her, and then demand help, forcefully, if she could not get such access. But generally this keen interest would last no more than five minutes and then be forgotten, at which point her body would settle back into her more typical state. Three years after Vera’s CVA, her husband requested music therapy for her on a private contractual basis, outside of the residence. His hope was that music therapy would alleviate some of the bleakness in Vera’s life. The background information I was given about Vera gave me the impression that Vera and all of the people in her life viewed her situation as completely tragic and debilitating. Without having met her, I anticipated that Vera would have a need to mourn and protest her situation, and a need to develop a positive sense of her identity. I was prepared to encourage equally, expressions of distress and enjoyment; to acknowledge and appreciate equally her limitations, challenges, abilities and efforts; and to give Vera many opportunities for choice and initiative so that her personality could shine through and be clearly acknowledged. I did not know what Vera would initiate, comprehend, remember, or respond to musically. I was ready to design musical experiences according to her abilities, as they emerged—making some readily available to her, and others that would require some effort, as both types of experience can provide a sense of accomplishment. My assessment of her abilities and needs was ongoing, as was my evaluation of her progress and the relevance of musical and non-musical approaches. Treatment Process First Meeting As Vera entered the room and I greeted her, she left her attendant to walk over to me. She reached out to feel my face, then readily took my hand to go to the piano. When we were seated, Vera gestured to her attendant to tell me the details of Vera’s situation. Vera listened attentively, nodding frequently. When Vera sobbed at one point, the attendant discouraged her, saying it did her no good to cry about it. When I turned to begin to present to Vera how she and I could make music together, Vera did not understand and suddenly interrupted with a few loud smacks on the keyboard. I laughed in surprise and jumped in to join her on the bass with equal strength, setting a tonality and adding a bit of swing. Vera immediately started to stomp her foot and grin, continuing to play apparently random clusters of the white piano keys. (2 min.) When asked if she would like more of the same or something different, Vera indicated a desire for something different, yet in the next few beginnings, Vera played the same types of clusters and stopped after a few seconds each time. When I moved into a very different sound—full, slow bass chords—Vera began to sob deeply. I put one hand on Vera’s back, shifted into a gently rocking bass and began to improvise a lullaby without words, at which Vera instantly stopped crying, her face blank.

At my invitation, Vera joined in singing, her voice strong, very quick to sense where the improvised melody was going. After several minutes of that music, I shifted into an improvised waltz. Vera sang along with gusto and confidence, as if she knew the waltz. The attendant applauded enthusiastically when the waltz finished. Vera grinned. The attendant was surprised to see such a normal musical interaction between Vera and me. Vera’s disability had slipped into the background. The attendant also witnessed a different way of responding to Vera’s grief. Phase One: Musical Explorations We set up a schedule so that I would see Vera for thirty-minute sessions every two weeks. In this phase, Vera and I began to discover her musical interests and abilities. Vera learned the pentatonic scale (on the raised/black piano keys) very quickly, needing only one verbal reminder after a hand-over-hand introduction. She started with a short, somewhat cautious exploration. Later, this progressed to longer explorations of about two minutes. Vera was attentive, quiet, sometimes repeating one cluster for a while, sensing good ending places. For this work, I matched her timing and volume, adding no musical direction beyond whatever Vera initiated. Vera tended to be moderate in both speed and volume. I invited Vera to switch places with me to play the bass, suggesting she might like to play loudly. She spontaneously altered her hand position to play more strongly. During her first improvisation on the bass, Vera initiated an accelerando as well as a slow strong section. When asked if she likes to be loud, sometimes, Vera nodded affirmatively and giggled. Her second improvisation on the bass lasted for four minutes; it had a gentle quality. She initiated singing to the improvisation, although it had no constant tonality. Her third bass improvisation began very fast and loud, slowed and stopped abruptly, followed by a strong vocalization. When asked whether it was exciting, Vera shook her head to disagree. She nodded when I asked if it was scary. I suggested she could try playing more slowly, at which she began again, choosing her notes more deliberately, apparently seeking more preferable sounds, although still without any consistent tonality. Throughout, I continued to complement whatever she did, following her lead. Vera agreed when I commented that the bass seemed to move her. I introduced some percussion instruments in this phase. Vera played a two-beat pattern (quarter-half) on the conga drum, when I played the waltz from our first session, and she held her own beat when I added more complex rhythms and syncopation on a second drum. Vera’s drumming tended to be soft, even after verbal and hand-over-hand suggestions as to how to play more loudly. Together we did slide into some dynamic changes in speed and tempo, however. She frequently chose and/or welcomed the drum in the first phase of working together. The sound of the temple blocks (a pitched series of hollow wooden bowls) evoked grins and laughter. After attentive exploration, Vera discovered where to place her mallet to hit each block, and we had an intense, syncopated rhythmic duo. The attendant reported that Vera’s absorption and responsiveness during the last three sessions had far exceeded that evoked by any other stimulus in Vera’s life at this time. Phase Two: Developing Musical Language

Thirty minute sessions became inadequate, and we started to go on for 45 minutes. Vera’s improvisations were becoming increasingly tonal, more deliberately shaped. I was watching the pitches she played and choosing notes which would create chords, whenever I could. This resulted in a constantly changing tonality, and both Vera and I were always adjusting to try to fit together tonally. Vera tended to use parallel 4ths, 5ths or 6ths, interspersed with clusters, occasionally repeating one interval 5 to 10 times before moving on. She often sang spontaneously with these improvisations. When I reinforced this new level of awareness and purpose with comments such as, “You were really listening, weren’t you? You were choosing,” Vera agreed emphatically, pleased. While this work marked a significant development in Vera’s concentration, it also tended to inhibit the flow of dynamic, emotional expression and enjoyment she had demonstrated in her first session. To facilitate access to that freer expression, I introduced several different ethnic idioms (Spanish, Middle Eastern and Eastern European) chosen for their combination of vitality, intensity and touch of melancholy. The harmonic accompaniment was provided in a variety of ways: by myself on guitar or piano, by Vera strumming as I chorded the guitar, or by Vera holding a simple bass pattern on the piano as I filled in the other harmonies. We would always sing improvised melodies as we played. These idioms often evoked whole-hearted singing, but not reliably. Vera usually continued with an idiom for several minutes before stopping. I also began to explore a way for Vera and I to play a dance form of some kind. We evolved a polka, with me using a traditional bass pattern, and Vera in the treble playing parallel 6ths. This developed into a set composition with 2 sections: the first section going up to the first half of the C scale (to F) and returning to C: the second going down the entire scale. As soon as the form was set, Vera concentrated fully for over 10 minutes, sitting straighter and being much more vocally involved in response to my directions and comments. Any time I suggested that maybe she had worked hard enough, Vera disagreed strongly and gestured for more. Several times she laughed in a breathless, excited sort of sound, as we started yet another repetition of this very challenging work. For several sessions, sustained work on one section would obliterate her memory of the other section, even if she had just worked on it previously. Vera laughed when she realized this, but could not retain both sections at the same time. The approach I used in this work seemed to follow a fairly regular sequence: reminding Vera to listen carefully and then playing the sound of the section we were going to work on; moving her hand through the sequence, giving the verbal cues I would be using later; giving her verbal cues, with a slight touch when needed; giving her no cue, every once in a while, to notice her tendencies; calling out and stopping her at any mistake and beginning the whole sequence again; calling out a caution and a verbal cue, any time I saw her about to make a mistake; and later, calling out a caution with no verbal cue, for her to correct herself. This was accompanied by very active, enthusiastic encouragement and bit of clowning. Towards the end of this phase, Vera’s attendant started to talk about songs Vera used to know and like before her CVA. After listening for a few minutes, Vera suddenly sat very still, her hand to her mouth, obviously trying to remember a song so she could sing it. After about 20 seconds, I suggested we sing one of the songs, “Let It Be” by the Beatles, and we sang it

together. Vera reached out her hand, wanting to play the song. I said I would try to work out an arrangement that she and I could play. The attendant reported that Vera’s concentration outside of the sessions was markedly improved. She could now stay awake and alert for up to one hour in situations of interest to her. Phase Three: Music Reaching the Heart Work on the polka continued well into this third phase. Vera was able to play both sections and, with practice, could play the whole piece through without any mistakes. Work on this piece usually lasted 10 minutes at a time. Vera also worked on the arrangement I made of “Let It Be,” involving only 2 parallel 6ths (C/E and B/D) for Vera and an octave bass for myself. I used the same basic approach outlined in Phase Two. Vera had to remember at each point in the song whether it was time to move her hand up or down the keyboard or to repeat the chord she was on. She would work eagerly on the song for 20 minutes at a stretch. With some persuasion, she would stop when her concentration began to fade. Later on in this phase, Vera started to work on “Hey Jude,” another song by the Beatles, suddenly singing it in response to being asked what she would like to do next. Vera sang along patiently as I worked out an arrangement on the spot, giggling whenever I got stuck and had to find a different voicing. In “Hey Jude,” Vera had to move stepwise between 3 parallel 6ths. Vera’s improvisations in this phase tended to be much more extensive than previously, often lasting for 5 minutes. They included a lot of simple scales, repeating each note in the scale using various rhythmic patterns (e.g., 2 sets of triplets; combinations of 4 eighths and a quarter). Once in this session, when her mother had come to the session, Vera was obviously dissatisfied with a long improvisation she had done. When I asked if she was trying to make it beautiful, Vera nodded yes. I encouraged her to work at that challenge, given how good she felt when she succeeded. She tried again for several minutes, with similar results. She burst out laughing when I said I could see that she wanted to be a composer. When I said how ambitious I thought that was, she laughed again, pleased, and went at it again. She persisted for about 12 minutes, all together, before being ready to move on. I told her that one of the things about composing was that she might not like everything she tries. Vera received that with a “Hm.” Vera’s mother, meanwhile, had been enthusiastically appreciative of both Vera’s music and her work, this being the first time she had seen Vera absorbed and creative since her CVA. This phase was marked by several very emotional outbursts, as Vera’s husband had recently arranged for a divorce. In one session, Vera stopped playing and gestured toward her eyes, crying. Her attendant called out, “Come on now, get on with it, that’s a waste of time. Tell Nancy about your birthday party.” After a rather labored conversation about the party, Vera gestured to her right arm, crying again. I began to sing a lament in the Middle Eastern idiom, using its minor, ornamented melodic style. Vera reached out to strum the guitar as I sang, tears running down her face. At a natural ending point, I asked Vera if she wanted more. She nodded. I shifted slightly into a slow Flamenco strum with a similar melodic line, at which Vera began to stomp her foot and grin, but as soon as I began to sing, Vera began to sob deeply. I kept singing but stopped playing, to touch Vera’s face and hold her hand. At the end of that session, after talking with the attendant, I told Vera that her crying was fine with me, though I

might at times suggest that she move on into making music again. When I checked if that felt alright to her, Vera nodded and reached out to hold my hand for a moment. Soon after, when it was time to leave, Vera was not ready to go and remained sitting, her back turned to us, grinning widely. In the same period, during a subsequent session, the attendant encouraged Vera to start playing, knowing that Vera was upset. Vera played one chord once, then stopped, turned to me and proceeded to vocalize and gesture, quite urgently, for about 2 minutes. When the attendant saw that Vera was making a sign referring to her husband, she called out “Don’t worry about that.” Vera persisted, wanting to “tell” me, somehow, about what was on her mind and heart. I listened and watched, silent except for some small sounds to let her know I was paying attention, and finally said “You have a lot of woes don’t you?”. Vera nodded, still trying to communicate. Then I said, “Well, given all of that, what would you like to do now with our time together?” Vera laughed and immediately reached out to the piano, playing a beautiful simple scale pattern of 6ths. At the end of the session, Vera returned to the subject of her sight. It turned out that she wanted to know how long she would have to wait until she could see again. I gathered that the doctors involved in Vera’s assessments thought that she would never regain any sight, and I told Vera so. She slumped a bit and simply said “Hm.” I acknowledged the challenge it was for Vera to live her life without regaining her sight. Then I played some well-known classical pieces for Vera (Brahms’ “Lullaby” and Beethoven’s “Moonlight Sonata”). She sang along, breaking down in the middle of the sonata and then singing again, through to the end. Vera’s mother had now seen glimpses of Vera’s abilities, motivation and pleasure, and Vera’s husband had been informed of her progress through monthly reports. The attendant, far from being unsympathetic to Vera’s distress, had witnessed hours of Vera’s crying with no stopping or resolution. In music therapy, she was witnessing a new ability in Vera to express her grief deeply, and then move out of it into a lighter state. She had begun to actively encourage Vera’s emotional expression through the music. Phase Four: A Quiet Period There was a relatively quiet period, emotionally, when Vera worked on her song repertoire and the polka. She also learned to play a waltz pattern. We had a few sessions where we sang a lullaby together, swaying side-by-side, with our shoulders touching. Phase Five: Going Deeper with Music We began to meet weekly for 45 minutes. Work on the song material continued. Vera added two new songs spontaneously. She was becoming more vocal, taking much more initiative in directing the flow of the sessions. Vera’s improvisations had more freedom and flavor, sometimes jumping lightly over twothirds of the keyboard with a laugh when it was over, sometimes more song-like, using only fragments of scales, sometimes dancelike, with Vera’s leg jigging to her own music. This was another very upsetting time in Vera’s life, when her husband remarried. In one session, Vera was looking particularly sad. Her attendant encouraged her to get her feelings out

on the piano, but Vera was not ready to do anything. I began to play the lullaby we had swayed to in an earlier session and just kept repeating it for over five minutes, with Vera alternately singing and crying. At the end of the music, Vera sobbed, sounding heartbroken. I gave an audible sigh and asked, “Does it feel hard today?” Vera nodded. “Some days are harder than others,” I added. Vera responded, “Mm!” Then I asked if she wanted to continue singing. She did. I shifted into a new improvised waltz and we sang together. One particular session best demonstrates this period. When asked how she would like to begin, Vera played a burst of clusters very fast and forcefully, then slowed to a scale, using 6ths. I simply said, “Hm!” and Vera launched into another short improvisation similar to the first. I sensed an emotional charge in Vera which was not yet released through the music and asked, “More?”. Vera laughed. She nodded when I asked if I should join her. The sound was still somehow held back. When we stopped, Vera pointed to her stomach, nodding when asked if she had pain there. She nodded again when I asked if there were any other feelings in there, nodding and vocalizing loudly when I asked if it was jealousy. I said, sympathetically, “Yuck! That’s my least favorite emotion. You know why?” Vera gestured that she wanted to know. “Because it can be so consuming!” Vera responded, “Hm!” I then suggested that Vera feel right down in that part of her body. With no further prompt, Vera immediately reached out and pounded the keyboard for about 4 seconds, began to sob and stopped a second, pounded again for a few seconds and stopped, racked by very deep sobbing. I put my hand on her back, encouraging her for a few moments and then began to play a deep octave bass, very slowly, and sang a heavy lament with a Slavic flavor. Vera started to sing with it, her voice wavering. At its end, Vera reached out and landed on a chord which was the major version of the tonic. I immediately changed to the major and between us, Vera and I found a simple sequence of chords, using parallel 6ths, which suggested a feeling of comfort, and we proceeded to sing several variations of that music. This ended in a long held note, initiated by Vera and a downward vocal slide, initiated by me, which resulted in both of us laughing. I then moved into teaching Vera a new waltz pattern which required her full concentration. After working on that for 5 minutes, Vera chose to practice her song material, working hard for another 30 minutes. At the end of that session, Vera’s face was alert and glowing and she walked very erect. She thanked me enthusiastically when she said goodbye. At the end of a later session, the attendant noticed Vera referring to her husband’s marriage and said, “We’re not talking about that any more”. Vera looked blank. “What’s past is past.” Vera nodded emphatically in agreement with the attendant. Towards the end of this phase, Vera had separate meetings with her ex-husband and with his new wife and seemed to feel deeply at peace with them and with her situation. This feeling was corroborated by Vera, when the attendant reported it to me. Anger and sadness came back several times, later, but not with the same gut-wrenching intensity: expressed more often through a growl or a symbolic kick, sometimes with a laugh and/or a dismissive wave and a choice to move into her more structured musical work. Vera’s husband decided to increase the amount of music therapy in each week in response to Vera’s expressed desired, the attendant’s recommendations and my reports. Sessions were increased to 90 minutes each week.

Phase Six: Developing a Musical Identity Sessions in this period often began with solo improvisations by Vera in response to the invitation to play how she felt. These tended to begin very forcefully and atonally, with a freedom of emotional expression which would either lead into sobbing or shift into a more tonal framework. I would wait a moment as an improvisation ended, to see whether the impulse was really finished. When it didn’t seem quite complete, I would only need to say “Hm” or “More?” for Vera to begin again, often with a laugh. At other times, she would pause to check if she wanted to play more and then give a dismissing wave of her hand, again often laughing. When the impulse had truly ended, Vera would often grin or settle back with a thoughtful “Hm”. In this phase, Vera’s attendant often encouraged her to play what she felt, to get it off her chest, as soon as Vera got to the piano, when she knew that Vera was upset. The attendant would call out, “That was good”, when Vera had been particularly energetic and would chuckle, sometimes, when Vera indicated there was more to express. Vera’s major focus in this phase was on structured keyboard work. She was a very vocal, active and increasingly independent participant in this work. She had somehow, on her own, discovered how to go back to a place in a song which came just before an area she found difficult. She would catch her own mistakes and either correct them herself or take my reminders and then go over the trouble spot many times until she felt confident that she had learned it. This was rote learning, and often would not be retained when she started back at the beginning of the song. I coached her on the difference between endless repetition and memorization. I began to see a noticeable difference in Vera’s face and posture between when she was simply working hard and when she was focusing in a highly concentrated way. When I pointed out this difference to Vera, she could sometimes feel the difference. The call for yet another repetition of a whole song or a fragment fell about equally between Vera and me. If she played a song perfectly but with hesitation, Vera would repeat it. If she played a song perfectly with no audible hesitation but did not feel confident, Vera would not be satisfied and would want to repeat it. If she played it perfectly, she would be thrilled, raising her fist in the air and squealing in triumph. Sometimes this would change into sobbing, after which Vera would stop and laugh, as if a bit surprised. I would comment on how exciting it was to see that her mind was working so well and she would agree strongly. And then she would want to play it perfectly again. As she could rarely sustain that much concentration, this often led to her desire to work longer at the same song. After one or two repetitions, I would suggest that it was time to move on and wait until the next session to work on that song. Vera would agree, reluctantly, and then move on to work on the next song with the same singleminded concentration. In this phase, Vera and I began to have conversations about how we know things. When she would play a piece perfectly, I would ask, exclaiming, “How did you do that?!” Vera would laugh—as if so pleased with herself—and then shrug. She would disagree if I suggested that she knew the piece. So I would ask her who had just played the piece perfectly. Vera would hesitate, looking blank and then point to her chest. We had some moments of hilarity when I would say, “Someone in there knows this song and someone doesn’t.” Vera burst out laughing at that statement. The suggestion that she

might be wise to pay attention to the side of her that knows a song brought another gale of laughter. Gradually she came to acknowledge that she might know a song and even to recognize, sometimes, the feeling of knowing a piece. During a few sessions in this period, Vera “talked” to me urgently (with the help of her attendant) about wanting to practice her songs at her residence, in between her sessions. She also worked hard one day to let me know that she was bored, in her week, and wanted to be learning things. The attendant said Vera had been thinking about it all week, and wanted the attendant to organize some solution. Shortly after, the attendant arranged for Vera to audit classes at a local college. The attendant began to report that Vera was no longer so angry or preoccupied with her losses. Her facial expression, though still predominantly flat, was no longer so blank. While Vera continued to feel that her life was very hard (which in fact it was!), she would confirm at times that she felt happy or peaceful. Her readiness to express distress and then to let it go increased. She would laugh often and occasionally show that she was excited or even thrilled. She began to express appreciation for people more often than previously. It was now common for friends, family and staff to hear stories of Vera’s accomplishments and pleasure in music therapy sessions. In a case conference on Vera, the team agreed that everyone involved with Vera should come to terms with limitations in her situation and help her to focus on the positive aspects as well as the challenges of her life. Music therapy was identified as a major area of communication and satisfaction in Vera’s life, and everyone recommended that it continue. Discussion and Conclusions Vera responded strongly to music therapy in the areas of emotional expression, selfimage, and her ability to be absorbed by and appreciative of her environment. Emotionally, Vera found the laments and lullabies to be both evocative and supportive of her grief. Occasionally, Vera and I were both taken by surprise when the music evoked a sudden shift from pleasure or a more neutral state into sobbing. More often, Vera’s expressions of grief grew out of her preoccupations with the numerous losses in her life. The laments and lullabies provided her with tangible evidence that her grief was being accepted, understood, and honored by others. Vera’s protest found its expression in the free improvisation. She showed considerable abandonment in releasing her feelings through this medium, taking full advantage of my open invitations to play however she felt. Her discernment of whether she needed to continue became very acute. There was also a non-musical benefit within the music therapy relationship. The fact that I was not identified by either Vera or myself as having responsibility for altering the structure of her everyday life freed her emotional expression of any agenda other than to experience and deal with her feelings. Vera’s sense of a positive identity gradually blossomed over the course of these sessions. She invested an increasing attentiveness and care in her creative improvisational work. Much more dramatically, her absorption persistence, excitement and eventual exhilaration with the structured musical compositions gave rise to her sense of ability and pride.

Initially, Vera responded positively to my appreciation of her abilities and accomplishments, and agreed whenever I commented that she was working well or that her music was beautiful. As her excitement emerged, I increased the enthusiasm with which I encouraged and acknowledged her. As well as applauding the quality of her work, I actively reinforced Vera’s sense of herself by giving her many opportunities for choice, by finding ways to join in with her impulses and by telling her what I saw of her responses, tendencies and interests in a way that called for her to acknowledge them actively herself. I believe that Vera’s increased absorption in and appreciation of her world grew organically out of the validation she received in these sessions: validation of her emotional responses to her situation, validation of her ableness and perserverance, and validation of her ability to be seen and enjoyed in a deep exchange with another human being. The music contributed a flexibility of structure, a natural meeting ground, an absorbing challenge and focus, and most importantly, the richness of its own beauty.

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

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

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

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

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

trying to instruct me what notes to play, and also becoming quite animated in a drum improvisation and a chordal, more structured guitar improvisation. Brian showed interest in who might be attending the group, and what he might gain from it. The decision to accept him for group therapy was based on a notion that if he was to work on increasing his ability/wish to socialize in the world, it would be through music. I also felt strongly that a very regular therapy group with firm boundaries may help Brian feel able to interact with others, and realize something of his effect on others. It was therefore worth a period of assessment in the group. In our initial contact, Brian presented as an angry, rather sulky man, with a capacity for being challenging and argumentative, juxtaposed with a sensitive musical expressive side that seemed to represent his wish for contact and togetherness. He was very reticent about acknowledging anything about his life and difficulties, but his energy to challenge, abuse and debate gave me some optimism for his beginning group music therapy Treatment Brian has been attending the music therapy group for two years. After an initial settlingin period, when he attended alternate sessions, Brian made a commitment to coming regularly on a weekly basis, and when unable to attend, letting the group know the reason. Throughout his involvement in the music therapy group, Brian was not involved in any other formal therapy. He occasionally attended activity groups (e.g., creative writing), and he saw a psychiatrist regularly for consultation regarding his medication. The two year period can be divided into three main phases. The first two were six months each in length, and the final was twelve months. Looking back, these periods seem to reflect different developments for Brian. The main features in Brian’s therapy during each phase will be described, with some detailed examples of sessions. Phase One: Testing and Establishing Himself Brian presented a challenge to me from the very beginning: he constantly criticized the group, its members, and me. In the first few weeks, he was often monosyllabic, and seemed confused and sometimes thought-disordered. I felt that it was important to constantly interpret some of his behaviour, whilst remaining receptive and nonjudgmental. He was often angry, and this meant that I had to constantly reflect upon the feelings this conjured up in me, in order to understand him without driving him away or letting him abuse the group. During the first six months of his attendance, the group itself was beginning, and Brian was part of this beginning process. Its membership included Dorothy, Brian, Peter, and three other individuals who attended sporadically, and were eventually discharged. Thus, the group was small, with a core of four members most of the time. An important feature during this phase was the difference in Brian’s behaviors when the group was larger, and when he and Dorothy were the only members present (which happened on occasion). On one occasion, he acknowledged that he preferred a smaller group, and on another, he stated that he would like to “have me to himself.”

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

In the improvisations, Brian played rich piano chords and also used drums and metallophone in an expressive way with Dorothy. It was significant that he did not need my support to do so. Session 15. This was one of the sessions leading up to a summer break, during which Brian was going on a holiday for the first time with people in the sheltered house where he lived. This itself reflected a change in that he could contemplate being in a close-knit situation with others for an entire week. Brian entered very interested in getting started. He seemed less angry and gentler, yet able to express how he was feeling. He became very frustrated that my music was not exactly what he wanted. Several times he challenged me: “Can you play octaves? Your music is a bit thin.” I purposely did not want to influence or intrude. Then Brian began his questioning of the value of the group: “We’ve had ten minutes and not done anything!” Then later, when I was trying to explore silence, he said: “Silence is noise.” Brian started drumming and then stopped to write down some dates in his diary concerning cancellations of the group. Dorothy accompanied throughout, and he paid little attention to her. Eventually, Brian was very willing to express himself and let go—after the awkward silence at the beginning, and after challenging me further: “What about taping some records and having a proper music therapy group?” After the first improvisation (Brian on drums, Dorothy on xylophone, myself on piano), he said “it was fun, but still not quite good enough—your hands are too small.” Dorothy, however, commented on how pleased she was that Brian was very involved in the improvising. Near the end of the session, Brian asked Dorothy for the first time what was “wrong” with her arm. Dorothy replied that she had stuck nails in it. Brian seemed shocked and said in a thoughtful way: “You must have been very angry.” In this session, Brian showed more involvement than ever before, albeit in a challenging way: continually trying out pieces, wanting me to play in a certain way, etc. He agreed that he worried about not knowing what might happen next in the group. He seemed much more open. When I suggested that the group was feeling more in touch with each other, Brian agreed, but then added: “It’s monotonous, and I’m trying to change things.” His music was much more fluid and flexible, often within a structured rhythmic framework, but towards the end, he used drums and cymbals in a free dialogue improvisation with me. Six Month Summary. During this period, Brian was able to gradually make a commitment, and attend more regularly. After three months, he attended every week, and would always let the group know if he could not come. This is of major importance, as Brian’s previous history showed a difficulty in making relationships and keeping commitments. At first, he found it very difficult to take into account anyone else’s needs. He did not even talk directly to other members of the group, apart from to me as the leader. He was very keen to control others, and his initial interactions with members of the group were commands or derogatory comments, such as “Your music sounds abominable!” Part of his wish to control others seemed to be manifest in a need to keep him in control. He often became angry with me because I did not tell everyone exactly what to do. Often, when things became difficult, Brian would express a dire need to smoke, and because the group had established the boundary of not smoking, he would have to leave the group to do so. Gradually, with help, Brian began to acknowledge his

need to challenge authority. He also became better able to relax and to allow himself to get to know others and even understand their needs. He began to stay for the entire hour. As these changes occurred, they showed in his music. He became able to improvise more freely and to follow others–in addition to expressing himself through music which often had very loud, structured beating as its main feature. Previously, Brian had been dominant to the point of being often abusive to others, but as this became less frequent, he began to notice and listen to others more, allowing them the time to talk and play their own music. A turning point was when, in addition to feedback from others, Brian listened to a tape of the group improvising, and heard he was “drowning” other people’s music. When he was angry, he often benefitted from being able to release some tension and aggression by playing loudly and freely in improvisations. It also seemed useful for Brian to receive feedback from others about how he made them feel when he was organizing or criticizing them. He also benefitted from positive feedback from others about his musical skills on piano and percussion. By the end of this period, the group had helped Brian integrate with others in a more positive way than before his referral. He was more sensitive and trusting of others. He seemed to feel more confident and “good” about himself, better able to organise his time, and more amenable to spending time with others. He seemed to benefit from the regular support and insight possible in the group, and had begun to make links for himself regarding his personal difficulties and how he might change. His psychotic traits seemed to be disappearing and his mental state seemed more settled. Phase Two: Trusting or Not - In or Out This phase showed Brian really grappling with whether or not he wanted to be close to others in the group and explore things further for himself. He had his only admission to hospital in the middle of this phase. It did not last very long, and was more for the purpose of the psychiatrist monitoring him more closely rather than because everything in his life was breaking down. In fact, he continued to attend the group during his admission, coming to the clinic from the ward in a taxi. His group therapy seemed quite central to his fairly quick discharge. After his discharge, he moved to a smaller sheltered housing situation run like a therapeutic community where his case manager and other team members felt he would fit in better. He is still settled there, and has remained more stable ever since this move. Leading up to his admission, Brian did stop taking his medication and generally because confused. However he also used the group to deal with some of his feelings concerning relating closely to others. He went through a pattern of sitting in silence for whole sessions at a time when five members were present. He acknowledged that it was easier for him to relate to one or two people at once. Twice, when only he and Stephen were present, Brian said he wanted me to himself. During this phase, he began to explore his relationships in more depth, and asked me more personal questions, such as: “What do you do on the weekends?”, and “Can you come for a drink afterwards?” However, he did not seem ready to try to understand some of these desires, and would either play music in order to avoid talking, or not attend the group after a particularly insight-oriented session. It seemed difficult for him to acknowledge his wish for

contact, and he appeared to run away whenever he moved nearer to understanding something. However, the fact that he continued to attend the group throughout this phase is significant, and following many weeks of angry silence, he began using the instruments expressively again towards his discharge time. He desperately wanted me to help him be discharged, and we agreed together that I would give my opinion in ward rounds, after discussing it with him beforehand. My opinion was that if he moved to the new housing, where there was more psychiatric follow-up, he was well enough to go at any time. In fact, I had not really felt his admission to the hospital was essential in the first place, although in some ways he seemed to benefit from the overall attention he received. His admission also convinced him that he did not want to identify too much with longterm, institutionalized clients. All of these issues were examined in the group towards the end of this six-month phase, as he was settling into the new community house. At this time, his music became more adventurous and expressive. Phases Three: Hard Work During this one-year phase, there were three new members in the group making six regular attendees. Brian’s music because much more complex and intense, and he really became involved in the group. He began to mention people by name, show concern if they did not attend, and acknowledge how he hurt others by his criticisms. This seemed to be particularly possible with two new members, Stephen and Anthea, with whom he was constantly supporting or criticizing. The following two examples illustrate how Brian tried to deal with his competitive feelings towards others through interactions with Stephen and Anthea. He also tried to come to terms with the consequences of his criticisms towards women particularly. Overall, these examples show how much Brian was changing, now being able to consider his “place” in the group rather than angrily deny his involvement as he did in the past. Example 1. Near the end of this session, a fifth improvisation took place, with Brian very much leading on piano with strong chordal, rhythm patterns, and Stephen beating loudly on drums as if competing with Brian. Peter and Anthea were rather lost in directionless playing. A dialogue followed: Stephen: I thought the last piece was OK. Brian: I thought it came off quite well, but it carried on after I had finished. Stephen: I stopped when you stopped. Brian: Oh well, somebody didn’t. Can’t remember who was making the best accompaniment. Me: It seemed quite important to you that people stopped when you did, Brian. I thought Stephen that you wanted to let Brian know that you think of him as a leader. Stephen: Brian had finished his piece, so I stopped playing the drums. Me: (Sensing much underlying anger between Stephen and Brian). It seemed, Stephen, that earlier in the group you felt at home in coming to your first group and being a

leader too. (I later suggested that there was some competitive tension between them, which they both seemed to acknowledge). Example 2. This session was four months later, and the first session after Brian and Peter had been on holiday together with a group from their house. They both seemed able to discuss it in the group, which was a new development. They also improvised a gentle melodic duet during which some intense listening and “give-and-take” took place. The mood changed during the last improvisation, when all members played feely (Brian on piano, Peter on metallophone, Stephen on xylophone, Anthea on glockenspiel, Melissa on gato drum and Dorothy on maracas). Brian suddenly shouted: “It would help if you told Anthea what notes to play!” The women all immediately stopped playing, and Anthea left the room. For the next 30 minutes, I tried to help the group understand what was happening. Brian’s comment, and this session, was significant in that, by the end, Brian had actually regretted pushing Anthea out. For the first time, I found my countertransference towards him had been useful in that somehow we were able to recognise together that he needs to be destructive and abusive. I tried to help him see something I had been feeling for a long time-that he needed to be this way to avoid the fear of being hurt himself, and that he desperately wanted to be looked after, too. Since that time, a main focus of his work in the group has been to contain his rage, criticisms, and denial of the benefits of therapy. It became clearer that his fear of being hurt and avoidance of what others are feeling manifested themselves in Brian’s attempts to squash many improvisations by the group. He did this by being critical of others, by suggesting or playing complex harmonies that others could not follow, and by denying the value of any music other than the precomposed pieces of his own choice. I am still convinced that at some level Brian has been hurt and needs repairing, but we have not explored this yet in any depth. Discussion and Conclusions Brian’s history, and rather fixed schizophrenic disposition, may lead everyone connected with him to feel despair. He has not held down a job for 20 years, yet is intelligent and talented. He does not now exhibit particularly bizarre, psychotic behaviour (which was seen mostly while he was in hospital), but rather maintains a constant disposition of hatred towards the world and other people. He could be experienced as quite passive-aggressive at times. In the entire two years, he has admitted only twice that he has any problems, and often states that he is forced into attending the group. The reality is that he has the ultimate choice, and has often brought himself along to insult me and others, week after week. So, of what value is the music therapy? Why are we all still meeting? The reasons are complex, but to summarize finally, I will briefly mention some essential points. Brian’s only motivation to relate to others in the last three years has appeared to have been through the group. Before attending it, he was reported never to speak to anyone in his home or at the clinic; likewise, he did not even venture into the drop-in room. He now interacts with others in the drop-in room, and joins in community life more in his house. I cannot be sure that this is related to his music therapy, but what I have experienced is Brian gradually realizing

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

Schizophrenia: A severe mental disorder thought to have a strong genetic component, but which can be brought on by stress. Characteristics include psychotic traits - loss of contact with reality, a disintegration of the process of thinking at times, delusions, and hallucinations. Social withdrawal can occur, and the patient often feels that his/her thoughts and actions are controlled or shared by others. Transference: In analytic therapy, this involves the patient’s unconscious wishes. Within the relationship with the therapist, “infantile prototypes re-emerge and are experienced with a strong sensation of immediacy” (Laplanche & Pontalis, 1973). References DeMare, P. & Kreeger, L. (1974). Introduction to Group Treatment in Psychiatry. London: Butterworth and Company Ltd. Laplanche, J., & Pontalis, J. (1973). The Language of Psychoanalysis. London: Hogarth Press. Lieberman, M., Yalom, I., & Miles, M. (1973). Encounter Groups: First Facts. New York: Basic Books. Odell, H. (1988). A music therapy approach in mental health. Psychology of Music, 16, 52-61.

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

CASE TWENTY-FOUR The Revival of the Frozen Sea Urchin: Music Therapy with a Psychiatric Patient Inge Nygaard Pedersen Abstract In this case study I will share some very positive results in music therapy with an adult psychiatric male patient with personality disorders. I am working with improvisational music therapy based on a psychodynamic understanding of the process. I have chosen to frame the case study by dividing the case retrospectively into six significant phases in the therapeutic process. For each phase I will describe the most important verbal metaphors and statements the patient brings into the process, as these are used as guidelines for the aim and direction of the therapy process. I will also provide vignettes to illustrate methodology and techniques applied in the musical relationship we built up together during the treatment. Introduction I was primarily trained as an analytical music therapist by Mary Priestley (London) and by Johannes Eschen, Colleen Purdon, and Ole Teichmann (Herdecke, Germany) from 1978-1980. For the last twenty years I have been deeply involved in music therapy as an educator, a clinician, and a researcher. I have tried to follow the advice that Mary Priestley repeated over and over again during our training: “Take from me what you can use and transfer it into your own approach.” Today, I have also almost completed my training in Guided Imagery in Music (GIM), with Ken Bruscia as my primary trainer. In my everyday work I simply call my treatment approach music therapy. I work in a context of psychotherapy treatment at the Music Therapy Clinic in Aalborg Psychiatric Hospital, where music therapy can be offered to a patient instead of verbal psychotherapy. In the following case, I only use active improvisational methods. In each session I alternate between verbal and musical interventions. In the case I will present in this chapter, the patient was referred to the Music Therapy Clinic as an outpatient, and he refused the offer of supplemental medical treatment. So, music therapy was his primary and only treatment as a psychiatric patient during the two years (57 sessions) I worked with him. This is a rather unique phenomenon in psychiatric hospital treatment. Also, this patient allowed me to use his material (of course in an anonymous form) for whatever purpose might support the profession of music therapy. As a consequence, I asked the patient to write his own report/account of the music therapy treatment three years after the treatment was finished. The report was requested by a national medical journal that

wanted to publish an article on music therapy in general that included a report from a patient’s perspective. I am ending this case study by quoting the last bit of this report, as I consider the patient’s perspective of treatment as very important when documenting the process and outcome of music therapy. So, I am very aware, that what I am writing here could be called a “success story” or “successful case,” usually referred to in Danish as a “sunshine story” (as the sun does not shine that often in Denmark!). Not all my clinical work results in “successful cases,” and I have learned just as much from what could be called “disastrous cases.” During the treatment, I had regular supervision with a psychiatrist in a small group consisting of music therapists. Background Information The patient (here called H.) was forty-one-years-old when he started the music therapy treatment. He was referred for psychiatric treatment, in the form of psychotherapy, as an outpatient on the basis of the following diagnosis: F60.8 from the World Health Organization’s International Classification of Diseases tenth revision (1993): Personality Disorders with specific anhedonic and obsessive compulsive features — very intellectualizing in verbal contact with other people. H. had been tested using the Wechsler Adult Intelligence Scale, and the Luria and Rorschach tests before referral to music therapy. Music therapy was suggested as a suitable treatment instead of verbal psychotherapy because of H.’s intellectualizing use of words (he knew all the psychological/analytical theories, but it did not help him) and because of his anhedonic features. He himself defined his problem as primarily being afraid of relating to others, especially women. Biographically, H. was the second of two children. His older sister died two weeks after birth. His father suffered from manic-depressive disorder and was pensioned when H. was seven years old. H. described him as partly violent, an alcoholic, unpredictable, and often spending long hours lying in bed. H. had no experience of a father/son relationship. H. was very close to his mother as a child and his mother gave up her career to look after him. H. described her as overprotective and dependent. H. was hospitalized at the age of eighteen months for six weeks because of an eating disorder. He did not see his parents during this period, due to hospital practices and regulations at that time. He could hardly recognize them after this period and he more or less refused any intimate contact with them after this time. His parents divorced when he was eighteen, and H. stayed in contact with both of them. His father committed suicide two years ago. H. felt extremely insecure, diffuse, and compulsive during his teenage period. He managed to obtain a high school degree and started studying mathematics at the university, which he subsequently abandoned. Later, he completed training as a school teacher and also as a social pedagogue,1 but he could not cope with being in contact with either children or adolescents. H. experienced himself being pushed by his mother to take these courses and to succeed in examinations, and was often reminded that she gave up her career because of him. He reported that he was aware from the beginning of his enrollment as a student that he would

never be able to use his training as a teacher because of his symptoms. He could not communicate with children on an emotional or associative level. He had had only one long-term relationship with a girlfriend, but this ended two years before the start of therapy. He suffered deeply at that time and simultaneously ended contact with most of his friends. He himself did not connect these events with the suicide of his father around the same time. He tried out drugs (LSD and others) between the ages of sixteen and eighteen, and experienced some very bad trips. In the preparatory discussion before therapy started, H. was very formal in the contact, and clear in spatial orientation. He could not remember episodes and times. He himself saw his primary problem as a lack of ability to function in contact with other people. H. described that he felt like he was disappearing when in contact with others, almost phobically — and he could not think clearly. H. could not set clear boundaries and felt like withdrawing very quickly. He could not handle intimacy or closeness, from which he often had the feeling of being exposed. He reported compulsive symptoms, where he had to control opening and closing windows and doors many times on a daily basis. He only remembered one period of happiness and freedom in his whole life, during a vacation in Greece some years before the start of therapy. We agreed that an aim for the music therapy work at the beginning would be to work on developing better contact with himself, and with others — especially women. This aim included working on establishing boundaries, and also valuing himself as a person worthy of being in a relationship with others. Treatment I will describe the treatment process, dividing it into six phases integrated with vignettes describing the methodology and techniques used. I have retrospectively named the six phases: “Into concentration”: Sessions 1-10 “Beginning of self-manifestation”: Sessions 11-19 “Emotional fluctuations and openings”: Sessions 20-32 “Searching for resources”: Sessions 32-42 “Sexuality” Sessions: 42-46 “Stabilization and dialogue”: Sessions 46-57 During the first four phases H. formulated problems in the form of identification of the self in polarities. I will use the patient’s own words in defining the core polarities for each phase. Phase 1: Into Concentration: Sessions 1-10 In this phase the patient formulated the following polarities in his perceptions and experiences: Being distant, restless, not present in reality Experiencing explosive energy, acting out, not present in reality.

During this phase, together, we defined my role as being his center point, both in talking (keeping us to the point) and in the musical dialogues (keeping a stable pulse). Vignette A: From the very first session. H. had never played music before starting therapy. I asked him to choose an instrument. He chose the piano, which I have noticed is very often chosen by intellectualizing patients. They consider the piano as a “grown up, “challenging instrument. I asked him to try to express “his experience of his personal space in the music” as the playing rule for the music. I instructed him to start to play by striking a key and listening to that sound and to let this sound lead him to the next sound, listen to it and so on — and if possible play with closed eyes. He started exploring how to express himself on an unknown instrument and he gradually followed my instructions. He played single sounds either in the lower or the upper part of the piano. The sounds were single sounds in the beginning, not interrelated, and he created a fragmented soundscape. I listened very carefully to his music to sense how I could be a part of this “sound picture” and I, playing on a second piano, intuitively placed myself as a kind of center in the picture — repeating one sound in a heartbeat rhythm, but with contrasting dynamics in my way of playing, as if coming closer and then being more distant through the sound. I chose this position, but I could not know for sure if it was meaningful for H. Gradually, in this first thirteen-minute improvisation, H. played more related sounds — at one point playing a melody with a strong drive in its rhythm and direction. But he constantly rushed back to a more fragmented way of playing the sounds. At certain moments his differentiated sounds and my repeated pulsed sound created beautiful harmonies. After the music finished, I was unsure whether he noticed my part in the music. He was sitting at the piano for a couple of minutes without talking and then suddenly said: “I have no words. “After a long pause he continued with the comment: “But I heard some quite melancholic moods there.” I considered these brief and isolated statements as very important for a person that normally talks a lot and over-intellectualizes in his way of speaking. As I felt in rather close contact with H. during some of the music parts, I asked him if he had heard my part in the music and he said: “Barely, but I had a sense of some kind of a center somewhere to which I came a little closer to and from which I also moved away.” I also asked if I had disturbed him and he responded that I had not. We reflected verbally together that he probably needed a center point from outside, and we decided that this role should be my part in the music-making over the next sessions — acting as the center point, holding things together, and trying to give him a free space to explore himself through sounds. During Phase 1, the patient developed in the way that he played. At first, he often played rather predictably and in a programmatic way — associating the light sounds (upper part of the piano) as the distant, restless part of him and the darker sounds (lower part of the piano) as the explosive energy and acting out part of himself. Subsequently, he found he could move into a state of letting himself go and flow along a little more using both musical sounds. In verbal reflection he used phrases like “unknown perception,” “unknown feelings,” “I am wondering,” “being touched,” “empty in my head,” “replacing my crowd of thoughts.”

Phase 2: Beginning of Self-Manifestation: Sessions 11-19 as:

In this phase, he formulated his experiences in the polarized symptoms of his problems • •

a need to choke all sounds around him, the experience of being constantly disturbed from outside; and a beginning of listening to and keeping self-expressions in the music.

At the beginning of this phase, the patient allowed himself to act out chaotically on the piano (see Vignette B) and he associated these experiences with having been on drugs at the age of eighteen. He noticed that he had not had any access to such perceptions or experiences since he had had bad drug experiences. He also noticed that these acting-out experiences in the music left him full of energy and not as empty and anxious as he remembered having been after he had taken drugs earlier. I constantly encouraged his need for acting out in the music and kept my role of being a center point by sustaining a stable pulse in my left-hand ground rhythm, while, at the same time, following him into chaos with my right hand and with vocal sounds. We defined an intermediate aim for the next phase as trying to build a bridge between the maelstrom and verbalization. Vignette B: From Session 14. In this example, H. played the piano and I played the congas and used my voice. The playing rule was that the patient should try to allow himself to express an experience of power. I facilitated him in my playing, still keeping the center point through my stable pulse-playing. H. was acting out in this musical selection, playing loudly, chaotically, and energetically on the piano. His pulse, in the playing, was unstable. He was alternating playing very loud sounds and repeating clusters. I tried to follow his dynamic and level of energy on the drum and through my voice. At the same time, I tried to keep a stable pulse. At the conclusion of the music, we matched shortly in a soft sound and slow tempo for a few seconds, but H. immediately stopped the music as if he had burned his fingers. He told me that this energetic way of playing reminded him of taking drugs, which he did when he was younger. But here he did not feel that empty after playing the music. Taking drugs made him feel very empty and lonesome afterward. During this phase, the patient developed a need to be creative. His experiences while playing the music moved from feeling disturbed by every sound from outside (including my music part) to being able to shut out other sounds and being totally engaged in his own musical expressions. He could now keep his concentration for a longer period and had the feeling of filling out his personal space in the music. During this period he contacted strong feelings of rage and sorrow. During this time, he started dreaming again, which he had not been doing for years, and he recalled many childhood memories of loss and trauma, which he could now also express in the music. He started to write a diary, of his own accord, about this therapy process. He expressed constantly that he now experienced the music-making as a maelstrom (whirlpool) — but still not connected to verbalization.

Phase 3: Emotional Fluctuations and Openings: Sessions 20-32 In this phase, the patient experienced himself as rather unpredictable. He experienced large emotional fluctuations. The polarization from the first phase, where he associated light sounds with distance and restlessness and darker sounds with explosive energy, was transcended and he created another polarization where he experienced: • •

A pinned-down side, being an audience to the world An unsuspecting, simpleminded side newly awakened and identified.

Many new openings to childhood memories took place and words for his musical experiences were mostly connected to “new” sensations and perceptions. He was also “better able to flow in the swing of the music.” We defined the next intermediate aim as moving the inner dialogue from taking place between parental representations (concretized through light sounds being mother qualities and darker sounds being father qualities) to a dialogue between the following “inner child” representations: • •

A terrified, paralyzed inner child, and A naive, but safe inner child.

H. gained and expressed more insight into the effect of his childhood trauma, and the influence that it had on him later in terms of being fragmented and basically insecure in terms of perceiving his surroundings. At the same time, he seemed to be more open to lively and playful qualities in terms of expressing himself in our joint music improvisations. I still kept my position of being a center point, but simultaneously went with him on playful ideas and movements in the musical improvisations. Phase 4: Searching for Resources: Sessions 32-42 In this phase, the patient started to bring some of the dreams from his newly revived dream activity into the music therapy work. Vignette C: From Session 32. The patient brought a specific dream to the music therapy session which he described as follows: “I was running along — searching — climbing a fence of barbed wire and finding myself on a frozen water hole. Just under the ice I saw a fossilized sea urchin, which I recognized as a part of myself.” I encouraged him to use his voice to express the quality of the fossilized sea urchin and we improvised together for the first time with unaccompanied voices. I tried to match him and our voices sounded very thin, metallic, insecure, and icy. We both experienced this as being very naked in the quality of our expressions, using a high-pitched pianissimo. Gradually, both voices grew in intensity and created more vibrations and sound waves, which can be understood as the performers becoming more and more present and related in the joint sound space. I felt almost overwhelmed by insecurity, and tried to resonate with the icy, fragile, and insecure expressions from the patient. At the same time, I tried to be encouraging with my voice by taking the lead in terms of intensity and in creating more sound waves. We were improvising standing side by side with closed eyes — sharing the

atmosphere in the room. The patient was very touched by the music and, most important; he was able to show it to me afterward. This experience created the opportunity for us to work solely with vocal improvisations, and using these improvisations to search for inner resources and to recognize how to fill oneself up from the inside using vocal sounds. H. very basically explored: “I feel myself — I am allowed to be in the world.” At that point the patient started to paint watercolor paintings between the music therapy sessions. He brought two to four paintings to each session. Each session I asked him to choose one painting that he felt was most important to him and to explain to me what it meant for him, symbolically. In the beginning an ongoing theme in the paintings was a “mask in the water” — there was something under the waterline on the paintings while at the same time the picture was full of distorted human beings and animal figures above the waterline. The mask in the water transformed into a face and his focus developed into the polarities of: • •

An alive eye A glazed eye.

Generally the patient verbalized that he felt in greater contact with his feelings, and that he had very high dream activity, with themes of destruction, death, and new beginnings. His vocal expression developed from being thin and icy to becoming much more intense and careful, with increasingly powerful sound. During this period, the patient allowed primitive energies and emotions, like hate and rage, to be expressed. It led to a new aim for the work — the aim of sexuality and the polarities of being a boy/man. Phase 5: Sexuality: Sessions 42-46 The aim formed in Phase 4 continued here and a new ongoing dream symbol of a black panther emerged. The patient dared to express the power of that panther, with his voice now sounding very deep and full of colors — alternating with sounds that I associated with Tibetan monks. I gradually felt free to challenge him more and our vocal improvisations grew into rather dramatic expressions. At this time, the patient also dared to express himself in the form of vocal improvisation solos without support or countermelodies from me. He talked about experiences of filling himself out from these vocal sounds, now more in the basic understanding of: “I am not only allowed to be in the world — I am proud of myself and my sounding self.” This phase was not identified by polarities by the patient, but rather through insight into his progression. H. was now able to move from being afraid of his own strength, to realizing his need for support from his surroundings, to allowing himself to integrate more primitive energies and, thus, to develop more containment. Finally, he dared not only to express the black panther, but to identify with the power of this symbol. The patient talked about an experience of a new and totally unknown energy which he could now express through a powerful and vibrating-sounding voice — as if he was developing, for the first time, a real “core sound” of his voice. The anxiety was transformed to strength and this transformation was realized, and could be expressed, through vocal improvisations.

Phase 6: Stabilization and Dialogue: Sessions 46-57 During Phase 5, and especially in Phase 6, I could begin to leave my supporting roles and also my challenging roles as a therapist. He could now both support and challenge himself. He still needed me as a careful listener and a mirror. The patient often experienced traumatic situations being repeated, and of being locked up/stuck by frustrations or anxieties, or by making decisions he could not yet handle. The important thing was that he could now contain these feelings and he did not panic by being locked up/stuck. He knew things would change. Through these experiences, much insight about his former repressive tendencies (being out of contact with emotions and fantasies — the whirlpool) and use of defense mechanisms (the need to control the surroundings) became clear and conscious, and he worked consciously on breaking through the defense mechanisms he wanted to get rid of. He repeated some of the former themes of the therapy process in our joint improvisations and I gradually felt more like an equal partner having no more countertransference feelings of “having to” hold a ground or “having to” reinforce his expressions anymore. In his daily life he now acted out a lot, setting up new boundaries for his mother and for friends. He broke ties with friends that he felt kept him locked up/stuck and he found new friends, including female friends. In session fifty-five, he told me that he now felt ready to leave the music therapy and to continue to exercise in real life by himself. We decided to continue for another two sessions to bring closure to our relationship. Vignette D: From Session 57. In the very last session he wanted mostly to play — not so much to talk. He suggested that we played together on the two pianos on the topic of “leaving and future.” We both used piano and voice. We played for about thirty minutes in a baroquelike style, floating rhythmically in a modal harmony, and I totally forgot that I was playing with a patient. I could as well have been playing with a colleague. I felt totally free to put myself spontaneously in the music; we took turns in introducing new musical ideas and floated with the ideas from one another. After the music stopped the patient said: “I now feel much younger, more vulnerable, and much better integrated. “ After the therapy stopped he went into rehabilitation, began studying at an art college, and today he makes his living by selling his paintings. He did not know he was that skilled. Discussion and Conclusions I have tried to write this case study paying close attention to defining important phases in the patient’s development, and the process involved, and by illustrating in vignettes the methodology and techniques used. This patient was very motivated to delve into the process, and was ready to dive into his repressed whirlpool of creativity, which he had repressed since his bad experiences with drugs between the ages of sixteen and eighteen. His inability to relate to other people, and his need to control by intellectualization, was connected to many traumatic periods and experiences in his life, but probably seeded by the age of one and a half when he was hospitalized and not able to see his parents. During the therapy process, he came

to verbalize several episodes from childhood and adolescence, where he felt emotionally abused, especially by his father and also by other adults. He also realized how he had felt almost choked by his mother’s care for him while, at the same time, he was aware that she wanted to control him totally in his adult life. I think in the case here, as in most cases of pathology, the patient’s symptoms were the result of him being very vulnerable and, at the same time, being part of a traumatic life story. He did not have the resources to cope as a child and adolescent with the problems. In the music therapy treatment, he used the music to contact and express emotions and dream symbols, and he used the music and me to be held, supported, expanded, and challenged in his attempts to live out these emotions and fantasies. He also used the music to gradually build up a more stable self-identity and to better integrate male and female parts of himself. His obvious artistic creativity, which was unknown to him prior to therapy, helped him to very quickly dive into a deep concentration and intensity in the musical improvisations, and our use of vocal improvisation obviously gave him a tool for self-exploration, and later, selfregulation. I want to end this case study by providing an excerpt of the patient report that I mentioned at the beginning of this case study. Through this report, I will let the patient end the story with his own words: Patient Report (Excerpt): “More than three years have passed since the music stopped. Things have happened. I feel like I have partly changed and still, part of me remains the same. But I have a clear feeling of being able to ‘fill up’ myself much better than before the music therapy. “Earlier, I often felt like a sad, lonely, and misunderstood ‘steppe wolf’ (an archetype of human loneliness) sitting in a waiting room, and when with other people I felt like the ‘spy coming in from the cold’: I am still a ‘steppe wolf’ but now a far more free, unpredictable, amused, and acting one. Instead of being tacit and speculating, I am now a ‘wolf’ who enjoys howling with the others. I am much better at taking care of myself and I am not that scared of hurting other people. My former morning crisis — a crisis which could last for the whole day — where I felt like a catastrophe was waiting just around the corner, has almost disappeared. Even if the music therapy has officially ended, I feel as if it is still working in me. All the experiments, sounds, and motifs I created in the music, I am now using in interaction with other people and this gives me a greater feeling of freedom; freedom understood as me having more strings to play on — many more possibilities of handling different life situations. I still make sound improvisation with my voice, just to sense how I feel at certain moments deep inside myself. This gives me a useful tool to loosen up the psychological knots and tensions building up.” References Bonde, L. O., Pedersen, I. N., & Wigram, T. (2001). Musikterapi: Når ord ikke slår til. En håndbog i musikterapiens teori og praksis i Danmark. [Music Therapy: When Words Are Not

Enough. A Handbook on Theory and Praxis of Music Therapy in Denmark]. Aarhus. Denmark: Klim. Bruscia, K. E. (1998). The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona Publishers. Pedersen, I. N. (1998). Indføring i musikterapi som en selvstœndig behandlings-form. [Introduction to Music Therapy as a Primary Treatment Form]. Musikterapiklinikken. [The Music Therapy Clinic]. Aalborg University/Aalborg Psychiatric Hospital. Pedersen, I. N. (2002). Analytical Music Therapy (AMT) with Adults in Mental Health and in Counseling Work. In Johannes Th. Eschen (ed.), Analytical Music Therapy. London: Jessica Kingsley Publishers. Priestley, M. (1975). Music Therapy in Action. London: Constable. Priestley, M. (1994). Essays on Analytical Music Therapy. Gilsum, NH: Barcelona Publishers. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. (1993). Geneva: World Health Organization.

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

CASE TWENTY-FIVE Analytical Music Therapy and the “Detour Through Fantasy” (The Case of Curtis) Mary Priestley This essay is based on a talk originally given at the 1979 Conference of the British Society for Projective Psychology and Personality Study. Its title contains a phrase, “The Detour through Fantasy,” which captured me as I was reading Heinz Hartmann’s Ego Psychology and the Problem of Adaptation (1958). Here is the complete quotation: “Taking our point of departure from pathology, from the psychology of neuroses and psychoses, we come to overestimate the positive developmental significance of the shortest pathways to reality, and it is only when we set out from the problem of reality adaptation that we recognise the positive value of the detour through fantasy.”(Hartmann, 1958) A phrase like that tends to capture us when we have a body of experience which cries out to be neatly clothed in its verbal skin. The body of experience was, in this case, some work in my private analytical music therapy practice which constituted a detour---in fact several detours---through fantasy. We, the patients and I, took these detours without any conscious knowledge that this might be the best way as regards reality-adaptation; we took them because they seemed to be the only routes open to us at the time. In the case that follows it was necessary for me to enter the patient’s fantasy world because she was unable, at that time, to enter the challenging world of more generally accepted reality. I wondered what it would be like to make this detour purposively, and decided to call on a colleague to make an improvisation with me to the title of this chapter. As the therapist, she sat at the hospital Steinway grand piano and I sat, as the patients do, behind a battery of instruments comprising an alto chromatic xylophone, a 16” tom-tom, a gong and a cymbal. There were other smaller instruments nearby: a melodica, double naqqaras, a chordal dulcimer - that sort of thing. (At home I also have a home-made bell-tree with bells from all over the world). We started playing, and immediately I found myself in a leafy jungle running for my life with a horde of angry psychologists after me. I was thudding along on the xylophone and annihilating the strident sounds of my colleague’s pianistic cacophony with the drum and cymbal. It was a slightly paranoid impression of my talk to the Projective Psychologists and a timely warning to me not to get too defensive at question time. My colleague felt that the title gave her carte blanche to pull out all the stops of musical creativity and fantasy. Having made this experiment with myself as patient, I felt confident to try it out on my patient. Curtis (as I will call him) was referred to me by a consultant psychotherapist with the words: “It is either music therapy or nothing!” Curtis was a tall, pleasant but anxious-faced 32

year-old man of medium build. He had recently been hospitalized with schizophrenia and was still falling into catatonic states and finding speech difficult. He lived then with his parents, being recently divorced but without children. His father, with whom he had a poor relationship, was a professional man and Curtis had been studying for the same profession until he cut loose, left this country, married a dancer from the Continent, taught English, and studied singing, only to be told that he had insufficient talent to become a professional musician. At the time therapy commenced, he was working behind the scenes with people in a commercial concern, a job that his mother had helped him to obtain. (How he coped I could not imagine. Certainly there had been a very poor report on his work just before we started therapy). He had a sister some years older who was married and had five children, and Curtis had a good relationship with that family. He was quite cut off from any of his former friends and led a restricted life working, chatting sparsely to his parents, watching television, and retiring to bed early. Here he listened to the radio (what else he did he did not say); certainly he was unable to read at that time. Curtis came for treatment in early spring. I had comprehensive notes on his case from his consultant psychiatrist and the referring consultant psychotherapist, but I always like to have the patient’s own version of his story to see how it has been edited for me and how it felt from the inside. I wrote in my notes that he seemed dim and faint; his hold on reality seemed as fragile as a soap bubble. He could not initiate speech but answered monosyllabically when asked a question, seemingly in some distress. After a brief history-taking we moved quickly on to the instruments. We played together for 10 timed minutes. He played quietly but with interest, mostly on the xylophone. Afterwards I explained that we were going to record the next improvisation and the microphone would not pick up such quiet playing. We then improvised on his imagined “Mountain Climb.” He made a quiet start, and then came rain and thunder on the drums, the sun coming out with cymbal and glissandi on the xylophone, climbing up and crossing the stream, and resting under a tree. I thought that this symbolized this stage of his life when he was protected by his family. Then he went on and climbed to the top but imagined no view. When he told me about his visualization he spoke clearly, his face flushed and his eyes much brighter. There was a countertransference of sadness. The “Mountain Climb” theme was an exercise used by Dr. R. Assagioli (1965) to discover a patient’s life aspiration. I decided not to discuss the possible meaning of Curtis’ fantasy in reality terms. I felt that he was too frail to make such connections for the moment, just as in our talk, I had to be the model for a fluently communicating person rather than subjecting him to the stress of long, tense silences when his words would not form themselves. Fifteen months later, I was sometimes empty and silent to receive his verbal flow, and sometimes responding and amplifying, too, like a good musical instrument. For the first eleven sessions (once-weekly for an hour), we vacillated between fantasy and reality in our titles. There were, in fact, five fantasy titles and six reality titles. The fantasy titles were: “Mountain Climb” (he chose to do this title three times, each time differently), “The Castle of the Self,” and “The Dream at Work.” These titles were fruitful in that they seemed to cause a release of energy and expression in music and more especially in words. But, possibly because I thought we ought to be exploring the shortest pathways to reality, they were interspersed with titles of: “The Artist versus the Professional,” “Mother,” “Holiday,” “Father,”

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

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

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

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

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

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

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

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

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

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

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

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

When Curtis began sessions with Priestley, he had difficulty communicating; his speech was flat and monosyllabic, and he could not initiate dialogue (1:3-17-78; 2: p. 200). He stated that he had no thoughts about the past or the future; Curtis' world was an eternal present in which his memories and hopes, if he entertained them, were not expressed (1:5-12-78). As the images in his fantasy improvisations allowed him greater access to his inner life, he began to interact more with the world and his speech became more expressive and spontaneous (1:7- 478; 7-13-78). The tasks of manhood that Curtis mastered symbolically in his myth gave him more confidence in work and relationships (2: p. 205). Previously, he had received a poor work report (2: p. 200), but after a few months of therapy he began to recount positive personal changes at work; he conversed with his colleagues more and perceived himself able to stand up for himself when needed (1:6-16-78; 2: p. 202). He continued to live at home with his parents. He had no social engagements, was unable to read, and he passed his time watching television. Music: Emergent Musical Dialogue Priestley stated that the music of this early period consisted of "taut, tonal, repetitive rhythmic phrases which every now and then he would alter by changing into another rhythm" (2: p. 128). Priestley also noted an emerging musical dialogue as Curtis began to relate to her as someone with whom he could play, as opposed to relating to her as a part of his larger self (2: p. 204). Two improvisations in this period have been selected for analysis using the IAPs: a) Conversation at work, and b) After getting the sword. A) Conversation at Work: Reality Improvisation Conversation at work was recorded in Curtis' fourth session, April 21, 1978 (1). According to Priestley, her piano part in this improvisation represented "the room and other people," while Curtis played the wooden xylophone to represent his "conversation." Priestley felt that her playing expressed Curtis' unconscious, which she experienced through countertransference as being "very remote and dreamy"(1). Audio File: Conversation at Work Based on the IAP analysis, the salient musical elements were the fusion of the rhythmic figure to its rhythmic ground and the fusion of the melodic figure to its tonal ground. Curtis' playing was characterized by perseverative single tones repeated in groups of three or six with occasional forays into duple groupings. Melodic movement consisted of ascending and descending scale patterns in a narrow diatonic range. The subdivisions of the beat created tension resulting from the unpredictable instability of the meter which was affected by an occasional change from a triple to a duple figure; instability also resulted from the sporadic addition of a single note that was added to a metrical grouping which slightly distorted the pulse. Phrasing, timbre, and volume were rigid and did not vary. As a musical partner, Curtis resisted Priestley in changes in volume, tonality, and rhythm. In the second segment there were slight tempo changes, minor rhythmic figure variations, and slight volume changes that resulted in more flexibility. In addition, Curtis

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

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

Throughout this improvisation, Curtis was over-reliant on structure and was embedded in it, both physically and emotionally. This was demonstrated in his rhythmic perseveration on the subdivision of the beat and in his sequencing of the three-note descending melody by which he provided himself with his own holding environment. However, by exploring different timbres, Curtis began to establish his own identity separate from Priestley (mother) while modeling it closely on hers. Clinically speaking, the way for Curtis to make progress with his dependent identity issue would be through the timbre, because when the timbre changed, he also began to play more responsively with regards to volume and rhythm. By following Priestley's changes in volume, Curtis was beginning to experiment with his own power. The subtle changes in rhythm indicated he was also discovering the energy available in his impulses. However, when he returned to playing the xylophone in segment two, his rhythmic perseveration indicated that he still felt physically and emotionally unsafe, causing him to be extremely dependent on creating a stable holding environment for himself. Curtis' short excursion into the exploration of his own identity with the drum timbre had an effect on the music that followed in segment three. When Priestley became bolder in her melody and accompaniment, Curtis became responsive to her on the cymbal, as if he was waiting for his mother to lead so that he might get out of his own world. He became more responsive to Priestley's volume changes that allowed him, by imitation, to play with his own power. This reflected a positive transference. At this time he could not maintain this psychological dynamic of responsiveness for long, so he reverted to the safety of his repetitious rhythmic melodic figure on the xylophone. Perhaps Curtis' inability to tolerate intimacy and power, as he demonstrated when he stopped playing the cymbal and reverted to the xylophone, was a manifestation of his organic problems which caused him to become overwhelmed and to seek retreat to defend himself against mental or neurological overstimulation and chaos. Throughout, Curtis continued to hold himself rhythmically, as though he could not trust anyone to hold the rhythm for him. This might suggest that his early holding environment was so chaotic that he could not surrender control even though he reached out desperately to Priestley for intimacy by following her and imitating her musical expression. Priestley found that Curtis' improvisations that were based on fantasy titles caused a release of energy and expression in his music as well as in words (2: p. 201). It is interesting that in the two examples analyzed here, the fantasy improvisation indicated a direction that would help to break through his transference of dependence and enmeshment that was entrenched in the reality improvisation. The fantasy improvisation revealed a glimpse of a musical partnership with Priestley as Curtis allowed himself to follow her lead and explore the musical elements with greater flexibility. Period II: August 25 1978 to November 06, 1978 (11 sessions) Images: Self is Explored Through Reality and Fantasy

Having concluded the myth based on fantasy that he created in period one, Curtis indirectly explored issues in his life that he wished to work on using titles such as Dependence/independence (1:8-31-78); Love (1:9-15-78); Hate (1:9-18-78); Gateway (1:9-2578); and What sort of person I am (1:10-9-78). Following these improvisations, he developed a narrative based on images related to a boat trip. He explored his illness symbolically by entering a cave mouth and finding a bear, and he attended to his feelings when he found a horse after going through a gateway. The White Lady made an appearance in one of his trips down the river, and he engaged in creativity through play with porpoises when he dove under the water (1:10-9-78 to10-23-78). A more profound exploration of his psyche, symbolized by the image of a deep dive into the water in Down under the sea (1:10-23-78) was a continuation of the previous river theme. His last improvisation in this period explored a deserted room in a house that included the images of a harp that he played, fruit that he ate, and a window through which he saw a garden. Priestley interpreted these symbols as an indication of the feelings that he had been neglecting. In order to be able to do more in the world, he needed to be able to comfort himself more, which she felt he was doing in the images, in his life, and in the music (1:11-6-78). Life: Reaching Out to Others and Rediscovering Interests Curtis’ speech was becoming more spontaneous and expressive, and he was able to carry on dialogue with greater ease. He still found it difficult to concentrate, could not read books, and spent his evenings at home with his parents (1:10-16-78). In therapy, he had resisted talking about anything that was difficult in his life, stating that he could only cope with pleasant things (1:8-11-78), though in this period, he began to symbolically explore biographical material related to his past in a tentative manner through images and music (1:9-18-78; 10-23-78; 11-678). During this period, Curtis increased his awareness of and attention to his feelings as he worked on issues of autonomy versus dependence in the images and in the dyadic improvisations with Priestley (1:8-31-78). He maintained his job in the department store, began to attend a social skills group, and found a mutual interest in betting on horses with one of his work colleagues (1:10-30-78). It is interesting that the image of the horse, a symbol of feelings, had made a few appearances in his improvisations by this time. His new-found excitement of betting on the horses was coincidental with “betting” on his feelings in the imagery and music. Music: Awakening Creativity and Expression According to Priestley, during this period, Curtis' rhythm became somewhat bolder and the melodies were more creative and adventurous, with greater expressed emotion (2: p. 205). Although change was indicated by rhythmic and dynamic alterations within the improvisations, his music played the role of a "synthetic or synthesizing function of carefully balancing and holding together his lately disintegrated psyche" (2: p. 128). Down Under the Sea

This improvisation occurred in the twenty-seventh session that was the penultimate session in period two (1:10-23-78). In her diary, Priestley stated that Curtis engaged in creative play when he dove into the sea where he played with a porpoise, then found a wreck and some old jewelry that he brought up to the surface. She interpreted the porpoise as a representation of herself; as a porpoise, she had come under the water to meet Curtis, but she stated that he had to do the work himself. Priestley saw the wreck as a symbol of his last illness, and the jewelry as a symbol of the values that he possessed, but had not yet used. Priestley's countertransference also took on a symbolic form, that of a huge water snake, which she put into the music (1:10-23-78). Audio File: Down Under the Sea Curtis used the xylophone almost exclusively throughout the improvisation with the exception of two sections where he used the cymbal for approximately fifteen seconds each. Based on an IAP analysis, the rhythmic ground controlled the rhythmic figures in all four segments and the meter subdivision ranged from stable to variable throughout three segments. The variability of the rhythmic figure was closely related to the variability of the melodic figure, both salient elements. Segments two and four introduced a change in the melodic and rhythmic figure, while segment three was notable for the change primarily in the rhythmic figure. The phrasing was stable, and it was congruent with the rhythmic and melodic elements. While the volume was undifferentiated because Curtis did not manipulate this element to create different part relationships, he nevertheless demonstrated greater flexibility in subtle volume changes throughout the four sections. In terms of musical autonomy, Curtis continued to alternate between roles of dependent and resister, but there were moments when he took the initiative and became a partner to Priestley. Psychodynamic Interpretation of the IAPs Throughout this improvisation, Curtis was resolving transference issues related to trust and dependency. At times, his defensive control of his environment through rhythmic and melodic perseveration resulted in him using all his energy trying to provide his own security. He was timidly following his impulses, but he didn't yet trust himself to invest in them. He had a symbiotic relationship with Priestley (mother) in which he depended on her for his feelings in the melody and he resisted her when she tried to get him to venture beyond his known world. It was as if he could still not trust that his environment could hold him if he allowed his attention and impulses to waver from the fixation of holding himself. Priestley created a holding environment for Curtis while encouraging him to explore new experiences she offered in her harmonic, rhythmic and melodic space. Through a positive transference, he was able to begin to internalize the secure, holding environment that Priestley offered and follow her invitation to play with his own power in the volume changes. He began to venture out into new experiences of his identity in the cymbal, which led to an emotion that he held on to in a fixated manner. He freed himself from this fixation by developing his instinctual drives into organized, cohesive goals in the phrasing. The final segment demonstrated that Curtis was beginning to develop his autonomy. Having experienced, to some extent, a secure internal holding environment, and having

resolved some of his unconscious conflicts with Priestley, he was less fused with her and therefore less defended against her, which opened the possibility to following and leading in dynamic play with her in the volume. Thus, he began to liberate himself from having to hold on to his environment and he reduced his dependency on her. This was the meaning of Priestley's statement that though she came to meet him and play with him as a porpoise, he, alone, had to do the work of discovering his unexploited potential symbolized by the jewels he discovered during this improvisation (1). Period III: November 20, 1978 – July 02, 1979 (29 sessions) Images: Fantasy Evokes Memory and Serves Reality The alternation of fantasy and reality images that had been established in the first eight months of work continued throughout this period. The deepening of Curtis’ self-communication and access to his imagery supported his burgeoning engagement with life and vice-versa. During the first part of this period, Curtis' images were closely related to life issues. As a result, many improvisations were reality rehearsals in which he imagined having conversations, meeting new people, and sharing meals with others or going on outings (1:12-18-78). For example, while improvising, he thought about what to say to each person in his social skills group (1:1-15-79) and imagined conversations he might have with an old friend who had contacted him (1:3-5-79 & 3-12-79). Before moving into a hostel, he did a number of improvisations in which he imagined moving there and participating in the chores and routines of daily life (1:11-27 to 12-11-78). After a number of reality rehearsals, Curtis' imagery again became based on fantasy. He imagined a Volcano (1:11-20-78), then improvised a series based on a sea voyage. He sailed to a desert island where there were no inhabitants, which Priestley interpreted as Curtis beginning to unfurl his sails as he visited a new part of himself (1:2-19-79), then he returned to the desert island to discover a spring where natives were eating and feeding fish to the parrots (1:2-2679). In Parrot and turtle he imagined joining the natives to cast nets for fish (1:3-19-79). Priestley interpreted the natives and parrot as the part of him that was searching for a more meaningful and richer life (1:3-19-79), and stated that he possessed both a thick-skinned turtle part and a rarer, but more flamboyant parrot part that was the singing part of himself (1:2-2679; 2: p. 140). Following the sea voyage series, Priestley encouraged an exploration of Curtis' past life events in reality-based improvisations with titles such as Separation and Autobiography (1:5-779 & 6-4-79). These images evoked memories of his early vocal studies (1:5-7-79) and his time spent in France (1:6-4-79), and brought up emotions related to the loss of his wife at the dissolution of their marriage (1:5-14-79). Interestingly, after having explored these memories through reality-based titles, he began for the first time to explore images that integrated life memories with fantasy elements (1:6-11-79 to 7-30-79). In subsequent improvisations, Curtis developed recurring images of the sailboat, water, and the voyage. These images sparked more memories of actual adventures he had had in France. He set off to sea on a moonlit night and arrived in a port where he had a meal (1: 6-1179). He found colorful bales of cloth and perfume that he loaded on board (1:6-18-79) then

sailed back to England where he exchanged the cloth and perfume for fruit (1:6-25-79), and finally, he arranged a feast with dancing (1:7-2-79). Each of these improvisations also evoked memories related to his trips and to the time he spent abroad. Priestley interpreted these images as the colorful part of himself that he had left in France that he was now going back to reclaim (1:6-18-79). She stated that the boat was a symbol of his psyche holding him together as he sailed over the sea of quiet emotion (1:6-11-79). Life: Enacting Major Changes Curtis made enormous changes in his life during this period of treatment in the areas of work, leisure, and interpersonal relationships. The fantasy improvisation entitled Volcano (1:11-2078) brought up sad feelings of how he had lost his sense of spontaneity, and perhaps served the purpose of motivating him to break out of the monotonous patterns that he had established in his life. The first major change he enacted was that he moved out of his parents’ home into a hostel (1:1-2-79). There, he met new people, cultivated a friendship with his roommate, began to cook for himself (1:11-27-78 & 6-25-79) and participated in leisure activities such as going to movies (1:1-8-79). He enjoyed doing the shared tasks of community living at the hostel and took on a part-time job as a volunteer for an elderly lady who was handicapped (1:5-7-79). Priestley noticed that he had more expression and spontaneity in his speech and body language (1:1-8-79). Although at first he found it difficult to keep up conversations with others, he used the musical dialogue he created with Priestley and the imagined conversations during reality rehearsal improvisations to practice connecting to others emotionally and verbally (1:1-22-79). These social skills helped him to become reacquainted with an old school friend who was now a doctor, and the old friend was able to feel comfortable enough with him to maintain this relationship (1:3-12-79). His new-found confidence motivated him to go to the cinema, dinners, concerts, and art galleries both alone and with new friends from the hostel (1:4-23-79). He stated that he was once again enjoying reading (1:4-2-79). He began to renew his relationship with his niece and nephew (1:12-4-78 &12-18-78) and experienced satisfaction in his ability to enjoy visits and a holiday with his family (1:1-2-79). With increased awareness of his feelings, Curtis was able to articulate the aspects of his life that were unsatisfactory. He stated that he felt anxious in the morning, and often had a sense of indistinctness or “not being definite” and that he was not able to remember things, though this was much better than it had been previously (1:4-23-79). The fantasy images that followed helped Curtis to rediscover memories through association. He recounted his youthful experiences at a boarding school (1:12-4-78) and followed his memories back to his first interest in studying singing at the age of 13 (1:5-7-79). He explored images and emotions related to the loss of his wife and briefly reminisced about the time they spent together in France during his vocal studies (1:6-4-79). In these images, he began to come to terms with the unraveling of his life at the onset of his illness. It seems that the process of revisiting the difficult memories of his time spent in France through imagery based on fantasy allowed him to recover happier memories and the excitement that also belonged to that time in his life. Music: Deepening Creativity and Expression

During this period, Curtis explored his musical ability to express his feelings about internal and external events. He became more inventive with his use of musical elements; for example, his rhythms became adventurous (1:1- 8-79) and he developed greater autonomy in his playing (1:1-15-79). He continued to use improvisations to rehearse events that would occur in his life (1:2-12-79) and also used the improvisations to re-experience the success he felt after having engaged in these life events (1:3-12-79). He created desires and goals by imagining what he wanted, for example, his "ideal home" (1:4-2 & 4-9-79). Curtis accessed the deeper regions of his psyche with fantasy improvisations that were based on his memories of life events and on an imaginative elaboration of these events (1:6-1179 to 7-19-79). Rather than being divorced from reality, these fantasy improvisations served the purpose of reclaiming the energy and emotions associated with his pre-morbid functioning, which stimulated his desire and awoke emotions related to his life in the present. An example of the vivid expression of emotions he experienced in the present occurred in the improvisation, The fracas. The Fracas This improvisation occurred in the thirty-seventh session (1:1-29-79). During an evening meal, Curtis and his roommate witnessed a violent exchange at the hostel that involved threats and a knife, though no one was physically harmed. Curtis chose to replay this event in an improvisation in which he and Priestley described the thematic sections as: 1) quiet eating music, 2) music depicting the argument, 3) tense eating as if nothing had happened music, 4) music that portrayed the conversation with his roommate afterwards, and 5) music depicting the conversation that took place a few days later with one of the persons involved in the fracas. The entire improvisation lasted nine minutes. Audio File: The Fracas The five sections can be identified by shifts in instrumentation and playing style. Although the xylophone was predominant for all sections and was used exclusively in sections three and five, Curtis also used the drum and cymbal at various moments in the improvisation. The eating music consisted of cymbal and xylophone; in the argument scene, Curtis used the drum almost exclusively apart from two beats of cymbal crashes. In the eating as if nothing had happened music, he used only the xylophone, while music that depicted the conversation with his roommate after the event used the xylophone, the drum, and the cymbal and drum together in three balanced segments, and in the final section, conversation a few days later, Curtis again used the xylophone exclusively. Priestley wrote in her diary, "it was the most expressive improvisation he’d ever done and he put much more expression into the music than into his words" (1). The animated use of the drum and cymbal with the xylophone added the dimension of timbre to the music in a dramatic way which indicated a new development in Curtis' playing. Summarizing the improvisation in IAP terminology, the timbre and tension were the salient elements and they contributed to other musical elements with varying degrees of

prominence, depending on the segment. This variability in timbre, that was used cyclically from section to section, contributed to the tension. Tension was also derived from changes in volume that created variability in the drum and cymbal timbres. The meter, subdivisions, and tempos were also all variable among sections, and programmatic changes were identified by shifts in timbre, tempo, meter, and the rhythmic or melodic figure. In the sections that used the xylophone exclusively, Curtis used his characteristic melodic figure based on six ascending steps in a scale, but he varied the melodic figure by changing its direction or by introducing short motives based upon the main theme. He also employed variations in the tempo as well as greater variability in the rhythmic figure. The rhythmic ground was stable throughout the improvisation. In addition, Curtis developed more autonomy and became a musical partner with Priestley, both following and initiating changes in volume, tempo, phrasing, and in the rhythmic and melodic figure. Psychodynamic Interpretation of the IAPs Based on images emanating from a real-life event, this improvisation provided Curtis with the opportunity to explore his own character from different vantage points. Old identities and old ways of being were juxtaposed with new aspects of his character that he was discovering. For example, in the eating as if nothing had happened segment, Curtis played the xylophone in a rigid way reminiscent of his early improvisations to express the denial of feelings (as if nothing had happened), while Priestley played the repressed feelings attached to the event. This suggests that Curtis associated the rigid way he played the xylophone when he began therapy with repression or denial. The difference now was that because of his internalized experience of a secure holding environment, Curtis had the liberty of choosing to play rigidly or not while he remained congruent with Priestley's contrasting music. Curtis' ability to create a stable rhythmic ground for himself without having to devote all his energy to the task of holding allowed him to develop the concept of object permanence and to separate from Priestley. His burgeoning sense of identity resulted in less anxiety and this gave him greater access to his emotions, freeing him to invest his energy in following his instincts in the rhythm, in recognizing his emotions and desires in the melody, and in directing them towards a goal in the phrasing and volume. Using the image of the argument, Curtis projected the more aggressive and powerful parts of his character onto the persona of his housemate, thereby discovering his own untapped potential for commitment, strength, and intensity. He developed his own power through his capacity to recognize, organize, and express his feelings and instinctual energy. His impulses and emotions were organized and congruent with each other and his feelings were consistent with the intensity of his urges. A stronger identity freed Curtis to cultivate greater intimacy in his contacts with others without having to inflexibly maintain his boundaries by blocking others out. This nascent responsiveness can be heard in the last two segments of the fracas. In the music, Curtis was able to leave space, listen to, support, and follow Priestley, and to respond to her spontaneously. Curtis' increased capacity for intimacy was possible because of the crystallization of his core identity through his experience of having had a secure holding environment in the musical transference. The reconstruction of Curtis' psyche fortified his ego, dissipated some of his anxiety that had been attached to defenses of repression, and freed him

to become more connected to himself in the moment. The process of establishing intimacy with others and the recognition and expression of his emotions and drives continued in his work with Priestley throughout the last period of his treatment. Period IV: July 09, 1979 to April 27, 1981 (63 sessions) Images: Fantasy and Reality are Integrated The last part of the treatment was a period of consolidation of gains for Curtis as he continued to integrate fantasy and reality images. Reality-based images were imbued with the richness that he formerly reserved for his fantasy improvisations and he consciously used these images to help him to concretize his wishes, to reclaim the excitement he had felt in his past, and to prepare himself psychologically to embrace a more challenging future. For example, Curtis used reality rehearsal techniques to prepare himself for a move into an apartment by improvising on images of preparing dinners (1:8-13-79); chatting with his roommate (1:8-2079); decorating his new home (1:2-11-80); inviting guests (1:8-13-80); and putting in a garden in his new flat or apartment (1:2-18-80). He also used imagery to prepare himself for the role of being best man at his friend's wedding (1:1-7-80). Curtis’ images not only prepared him for the future, but also acknowledged the transient joys of his recent past. At the beginning of his treatment, he used fantasy to bring meaning to his life which he found uninteresting. Now, pleasant, everyday experiences, such as a walk in a public garden with a friend (1:9-3-79) or an evening at the cinema (1:1-8-79), theatre (1:10-29-79), or concerts (1:12-31-79) became a theme in improvisations that permitted him to savor the memory through the images and the music. He imagined visiting France again; this led to more memories of his previous time in France (1:1-14-80 & 1-21-80). In a reciprocal manner, new discoveries in life sometimes served as a catalyst for images, such as the improvisation on the theme of Starry night that was inspired by his new interest in astronomy (1:12-1-80). As opposed to the purely concrete images or the fantasy magical thinking that typified the first period of treatment, Curtis was developing his ability to use metaphor consciously in his images. For example, a physical injury to his legs prompted improvisations based on themes of exploration of where his legs would take him (1:10-15-79 & 10-22-79). Another example of the use of images as metaphor occurred in an improvisation after Curtis saw the film Les enfants du paradis. He improvised on a beggar character in the movie who pretended to be disabled though he was actually a gold expert. Priestley wondered if Curtis was communicating that he was hiding behind his illness, and brought his attention to the fact that he was now finding his identity in being a well man, which was represented by the beggar’s gold treasure (1: 6-9-80). Similarly, after attending the musicals Sleeping Beauty (1:10-29-79) and Cinderella (1:118-81), Curtis improvised on images associated with these personas that were related to awakening and transformation, a process that he was undergoing in his life. In the last year of therapy, Curtis consciously used images as symbols to intensify intra and interpersonal communication. In an improvisation on Pandora’s box, he heard Hope’s voice after he let out the bad objects, and decided to keep Hope in the box, which Priestley interpreted as an attempt to control his persecutory objects (1:3-31-80). After an improvisation

on the image of a Cross journey, Curtis said that the cross was his illness; this was one of the few times that he directly expressed feelings about his illness (1:12-10-79). He also used the image of Renoir’s Girl in blue watering a plant to express the feelings he had about his relationship with his niece (1:1-5-81). Finally, Curtis communicated that he was beginning to think about leaving therapy through an image of an uneaten meal for two people (1:10-27-80). Five months later, he expressed this more directly in an improvisation entitled Nightscene print, based on an image of a print he had purchased depicting a prince leaving at night (1:3-23-81). Thus, in the final stage of therapy, Curtis used his images to increase his quality of life and to meet new challenges through reality rehearsals; he used his memory to relive pleasant daily experiences, thereby reinforcing his motivation to continue to grow; and he used images to evoke past memories that helped him to make sense of his experience, to reconnect to the qualities possessed by his pre-morbid self, and to integrate them with his present self. Curtis' psychological functioning became more abstract. He used metaphors to explore his unconscious and he used symbols to communicate with others and to intensify his intrapersonal communication. Life: Consolidating Gains and Ending Therapy In his life during this period, Curtis made major changes that demonstrated his growing ease with people and his increased autonomy. The reality rehearsal improvisations that he used as preparation to move into a flat with his roommate were qualitatively different from those he played in the earlier stages of therapy. For example, when Curtis was first preparing to move out of his parents' house (period three), the function of the reality rehearsals was to quell his fears and help him view the move to the hostel as an attainable goal, whereas now, his images were ego-driven with the emphasis on his desire and the confident creation of a pleasurable future (1:8-18-80). Curtis communicated more easily and established a mature, autonomous relationship with his family, taking a vacation with them (1:8- 4-80); visiting them (1:10-15-79 & 3-31-80); and cultivating an avuncular relationship with his niece and nephew (1:3-17-80 & 10- 6-80). He reached out to people to widen his circle of friends (1:12-79; 9-22-80 & 9-29-80), and his confidence in his social skills increased to the point that he accepted weekend invitations with his old school friend, participated in joint ventures with his friend and his friend’s fiancée (1:24-80), and efficiently carried out all the duties of best man at their wedding (1:4-28-80). Weekends became a time for creative adventure, whereas at the beginning of treatment, they were a time of anxiously trying to fill up the hours (1:9-15-80). He continued to work at the department store, but took on a more challenging volunteer job reading and helping to mark papers for a blind professor of French (1:5-14-80). Memories of his previous time in France revealed to him some of the things that he presently missed in his life, such as cultivating his interest in art (1:1-21-80). He wanted to have a greater knowledge of painting and he craved more clarity of thought (1:11-26-79). His memories of France (1:1-14-80) incited him to join the French Institute (1:6-16-80) and to enthusiastically pursue his interest in art with visits to galleries and purchases of prints and books on painting (1:12-31-79; 2-11-80 & 8-4-80).

Although Curtis reclaimed his memories of the years he spent in France, he resisted exploring the difficult memories both verbally and in the music (1:10-1-79 & 12-10-79). Priestley felt that Curtis could not get to a depressive position about his losses (1:4-28-80 & 514-80), though she noticed more fleeting expressions of both sadness and joy in his music (1:24-80; 3-31-80 & 10-20-80). As he prepared for separation from Priestley and faced the end of his music-making with her, his musical pursuits became focused on attending concerts (1:1-21-80; 2-18-80 & 3-3-80) and learning to play the guitar (1:9-1-80). He used this newly acquired skill for musical expression and social interaction as he accompanied himself while singing popular songs (1:106-80; 1-13-80 & 1-5-81). Curtis stated that he felt he was becoming more thoughtful, better at planning, and had a “wider attitude towards life” (1:4-14-80). In summary, during the last 22 months of therapy, Curtis worked on consolidating his gains by defining his goals, developing his creativity, and cultivating interests that would bring him a greater quality of life. Psychologically, the overall theme was that of awakening to life after illness. He gained greater access to past memories, and as he did so, he identified with his healthy, functional, and creative capacities that made it easier for him to focus on living in the present and to prepare for realistic goals in the near future. Achievement of goals and new interests gave him a sense of competence in the world. Finally, he successfully completed the tasks of separation and transition from the therapeutic relationship by finding fulfillment in the development and maintenance of his life relationships, and by bringing his music-making into a developmentally appropriate, functional sphere of life. Music: Becoming a Musical Partner and Creating Meaning The three recorded improvisations of this period reveal that Curtis' music became more expressive and creative. He was also acting as a musical partner with Priestley. This was evident in his autonomy and leadership in proposing musical ideas, and in the quality of his listening and sensitivity to Priestley in following her musical ideas. Nightscene Print This improvisation occurred in session 118 on March 23, 1981 (1). This was the third last session Curtis had with Priestley. The theme was based on a Japanese print that Curtis had bought depicting a young prince leaving at night. Priestley wondered in her diary if Curtis was thinking of leaving therapy at that time. She also stated that this improvisation was very mysterious and unusual and that his playing was more creative (1). Audio File: Nightscene Print An IAP analysis revealed that all the musical elements in this improvisation were salient. The timbre was salient in the opening of the improvisation when Curtis used the cymbal. However, after the first segment, he played the xylophone exclusively for the remainder of the improvisation. In the xylophone playing, Curtis began with his usual melodic figure of five ascending notes, then he proceeded to vary this theme rhythmically and melodically

throughout the improvisation, creating a form of theme and variations. Curtis' expressivity was evident in all the musical elements: volume, timbre, phrasing, rhythm, and melody, which were all variable. Curtis initiated changes in tempo, volume, meter, and musical character. He was also sensitive to changes that Priestley made and complemented them, taking on a balanced role of both leader and partner. This improvisation demonstrated a significant development in sensitivity and creativity in Curtis' playing, particularly as compared to the rigid improvisations he did in period one. The rhythmic figure, which was integrated with its ground, was variable and was more developed in character and more flexible than in previous improvisations. Tempo changes and volume changes as well as beat subdivisions and metric changes were used in a variable way for expressive ends with frequent use of rubato, accelerandos and ritardandos. The phrasing was variable as it conformed to the changes that occurred in the rhythmic ground and in the rhythmic and melodic figures. The melodic figure, which was integrated with its ground, was variable, because Curtis employed changes in melodic direction, some intervallic leaps, and melodic motives of different character and length. Accents and phrasing conformed to the variability in the rhythmic and melodic figures. Psychodynamic Interpretation of the IAPs It is difficult to listen to this improvisation without feeling awe at the changes in Curtis' music that had occurred since his first improvisations. The core of his identity as it was expressed in his first sessions was still heard in the ascending repetitions on a five note scale, but the rigid and perseverative theme of the early improvisations had become enriched with rhythmic and melodic variations as well as fluidly-changing dynamics. The positive transference with Priestley freed Curtis to be adventurous and to interact with her spontaneously; he was able to move both towards himself and towards her in the music. The dyadic musical relationship with Priestley had the quality of equals exchanging intimate feelings and tenderly supporting each other. Psychologically, Curtis was now able to establish intimate, authentic relationships with others, and to act in the world in a way that would fulfill his desires and advance his goals towards accomplishments. Secure in the knowledge that his instinctual forces would not become overwhelming to him, he could organize and direct his impulses towards the achievement of personal goals and desires. Unconscious conflicts that had kept him rigidly defended and fixated were no longer blocking the energy and creativity in his life. He was able to experience the flow of energy in his body, recognize the many emotions that were carried by this flow, and express these feelings in his music. Connection to his inner life gave him a stronger sense of his identity and freed him from needing to maintain his psychological integrity by creating rigid boundaries between himself and others. He was able to play with his own power, experimenting with using his energy to lead and create, or using it to be sensitive and responsive, while leaving space in which he could dialogue with others. It is interesting that Curtis chose an image from a print that he had bought as the theme of this improvisation. One of the aspects of his life that had changed over the course of therapy was his renewed interest in art and music; both were passions that he had abandoned when he became ill. At the beginning of therapy, Curtis used the fantasy myth of the maiden and the

romantic quest to gain access to his psychic energy and his emotions, whereas now, he gravitated towards an object which he found in the world that reflected a psychological problem that he was grappling with. Curtis used the image with its message of stealing away to help him deal with the separation from Priestley that he knew was inevitable, and also used it to communicate to Priestley that he was thinking about termination of treatment. Thus, Curtis was able to use both abstract and concrete thinking, and fantasy and reality in the service of his imagination, feelings, desires and will, with the goal of self-expression and communication in order to achieve his objective of continued growth. Discussion Personal Bias Influencing my Approach to this Study The purpose of this study was to determine if it was possible to see changes in Curtis' imagery and life and to hear changes in his improvised music over the course of his therapy. This purpose determined my approach to the study and it was influenced by a personal bias that changes in music or imagery should facilitate and reflect positive life changes. This bias stems from my clinical work with persons with chronic mental illness. Therefore, I was particularly interested to discover if there were parallels among the changes in Curtis' music, images, and life over time, and if so, what meaning these changes had and whether they altered Curtis' quality of life significantly. Changes related to Curtis' life and images were recorded in Priestley's diaries; however, deriving meaning from the music improvisations necessitated a method of analysis that would consistently reveal not only changes in the musical elements, but also, the symbolic significance and meaning of these changes. In the music therapy literature, the most common approach to deriving meaning from the client's improvisations is to describe what one hears in the music in a phenomenological way and relate this to the salient aspect of the treatment that is being discussed. Because I had no direct contact with Curtis as a client, I did not have an intimate sense of his process throughout his therapy from which to draw upon. Thus, in this historical reconstruction, Curtis' recorded improvisations took on a primordial importance as the most direct link that I had with him that could help me to better understand him and his process in AMT. The written sources that I had access to – Priestley's diary entries (1) and her published chapter (2) clearly demonstrated the changes in Curtis' life events and his images, and I wondered if a systematic way of analyzing the music would yield similar detailed results. Structural analyses used to understand the formal aspects of occidental music, whether the music is in a classical, jazz, or popular style, are useful in comprehending the composer's construction of phrase, harmony, rhythm, melody, and form. However, subjective meaning is not usually extrapolated from such analyses. For this study, in which the personal significance of the music is a vital component, I considered a using a phenomenological approach that would allow me to infer meaning from Curtis' music. I was wary that without having had direct contact with Curtis, I might be unaware of a bias in my listening. Furthermore, I could not fully comprehend the context surrounding Curtis' creation of the music. In the IAPs, each musical element is presented with a number of scales within each profile and they include clear definitions related to the quality of each musical element. Further

meaning can then be derived from the application of an interpretive frame of psychodynamic concepts as applied to the musical elements. I therefore decided to use the IAPs, which provided me with a more objective structured and systematic approach with which to analyze each musical element. I had expected that it would take considerable effort to become adept at using the IAPs and I was concerned at the interpretive skill involved in making psychodynamic interpretations. I discovered that in order to manipulate the many elements in the analytic tool of the IAPs, it was necessary for me to make subjective decisions to determine the salience of musical elements. Initially, I also found it difficult to avoid integrating a descriptive, phenomenological language into the IAP analysis, which seemed at the time to render the analysis more meaningful and therefore, more useful to me. I wondered what the structured IAP language could possibly yield in terms of making meaning of the changes in the musical elements that were brought to light by the IAP analyses of Curtis' improvisations. Once I began to work on the psychodynamic interpretations, I discovered that I was afforded considerable clarity in grasping the essential meaning of the musical elements by virtue of having avoided phenomenological descriptions of the music. In contrast, the focused language of the profiles and scales of the IAPs as applied to the salience of each musical element revealed aspects of Curtis' music that I would not have been aware of in a more open listening approach. The psychodynamic application of the IAPs included guidelines with which to interpret each musical element within the profiles, thereby uncovering the meaning which lay at the heart of Curtis' music. Thus, with Priestley's diaries and audiotapes and the psychodynamic interpretation of the IAPs, it was possible to discover how Curtis made changes in his images, life, and music over the course of three years of therapy with Priestley. Implications for Use of IAPs Beyond this Study One result of having become more adept at using the IAPs during the course of this study is that they have also provided me with a new way of listening to my clients' improvised music. In turn, this has engendered a new means of understanding and making meaning of the way that a particular client uses or avoids each musical element. The acquisition of this analytical tool has provided me with an answer to a question that had long plagued me – how to listen to and analyze the clients' improvisations in a way that would provide me with some insight into their process and character and personal issues, and how to better guide the client to work out therapeutic issues in the music-making. I have found that similar themes have been raised frequently by students in improvisation class, for example: what is the significance that making music has for the client, and how can the therapist make meaning of the client's improvisations and gain insight from them. I now find that I am teaching in a different way, calling my students' attention to a close listening to the musical elements and their meaning within the psychodynamic interpretation of the IAPs. Ultimately, each music therapist will find his or her own answers to the question of how to make meaning of the client's music and each researcher will discover his or her unique language to present the music improvisations in a way that is significant to his or her research. Because of the discoveries I made in this study, I believe that the IAPs are an analytical tool that

has the potential to provide much insight for clinicians and researchers alike. Thus, while the IAPs are not the only way to derive meaning from or to understand a client's music, they offer a structured, systematic method of analysis that goes beyond both phenomenological description and formal analysis. This implies that an introduction of the IAPs to the graduate music therapy curriculum would be useful in applications to research and clinical work by providing a systematic way to gain insight into clients' improvised music. Changes in Images, Life, and Music in the Case Study of Curtis The results of this study revealed that changes in all three areas did occur and that these changes were interrelated; changes heard in the music and seen in Curtis' imagery were congruent with changes that he enacted in his life. In the music, Curtis became more creative and expressive, demonstrating greater flexibility over time; he created a strong rhythmic pulse, became rhythmically inventive, and he created melodic phrases. He explored new timbres and developed greater autonomy along with an ability to interact musically with Priestley in creative ways as an equal partner. One of the limitations of this study was the lack of recorded improvisations from session 35 (February 05, 1979) to session 115 (March 02, 1981). Clearly, there was an extended period of time during which there was no documentation of music. It was fortuitous that Priestley continued to document improvisation titles, images, and life changes in her diary entries during this time, and that she recorded the last three improvisations. These improvisations clearly demonstrated the musical changes that had taken place in the interim, and the seven extant audiotapes showed the process of gradual change that had begun in Curtis' music. Concurrently with the musical changes, Curtis made life changes that demanded greater autonomy and that were linked to his desires and to his creativity. These changes served to motivate Curtis to make more demanding life changes. Life changes included moving into more autonomous living situations, making new friends, rekindling an old friendship, taking on new responsibilities, and renewing his relationship with family members. As Curtis developed a stronger sense of self, he pursued interests and desires that were based on aspects of his identity that he reclaimed and developed during his work with Priestley. He embarked on creative ventures such as going to concerts and galleries, taking trips abroad, learning to play the guitar, joining the French Institute, and taking on volunteer work that he found to be interesting and fulfilling. When Priestley wrote the chapter, "Analytical music therapy and the 'detour through phantasy'" (2: pp. 199-206), she had been struck by the difference in Curtis' music when he improvised on reality as opposed to fantasy themes. Based on her reading of Heinz Hartmann's theories on ego psychology, Priestley stated that the use of fantasy in improvisations was often the only way to help her clients adapt to reality (2: p. 199). She theorized that in order for Curtis to have access to his internal drives and creativity, he first had to have greater access to his capacity for fantasy, for it was in the fantasy improvisations that Curtis was most easily able to release his energy in musical and verbal expression (2: p. 201). The use of fantasy and reality in Curtis' imagery and improvisation titles underwent a process of change during his therapy that paralleled his psychological changes and growth.

Throughout the three years of therapy, Curtis used fantasy and reality improvisations differently. At the beginning, fantasy and reality were opposed to each other; the fantasy improvisations were based on unconscious and primary process material that Curtis could not consciously interpret, while the reality improvisations were more lacking in expression than the fantasy-based improvisations. Later, Curtis consciously explored his identity through reality improvisations, while he was able to use the fantasy improvisations to make connections between his inner life and desires and his images. In the third period, fantasy was intertwined with reality in his improvisations; the fantasy contained aspects of reality and served to evoke memory and increase his sense of self and reclaim aspects of his identity rooted in the past. Finally, in the last period of treatment, fantasy and reality became fully integrated; Curtis was able to use abstract thinking; he used symbols to deepen his understanding of himself and to communicate with others. Thus, this study led to a discovery of how images, music, and life were related for Curtis throughout his course of AMT for three years, and how the changes in Curtis' improvisations reflected the changes he made in his imagery and in his life.

References for Priestley Sources Cited in the Study 1) Priestley, Mary. (March 17, 1978 to April 27, 1981). Personal Diaries. Temple University Archives, Paley Library. 2) Priestley, M. (1994). Essays on analytical music therapy. Phoenixville: Barcelona Publishers. 3) Priestley, M. (1975). Music therapy in action. London: Constable. References Bruscia, K. (1987). Improvisational models of music therapy. Springfield, Illinois: Charles C. Thomas. Langenberg, M. (1995). From isolation to bonding: A music therapy case study of a patient with chronic migraines. The Arts in Psychotherapy, 22(2), pp. 87-101. Mahns, W. (2003). Speaking without talking: Fifty analytical music therapy sessions with a boy with selective mutism. In S. Hadley (Ed.), Psychodynamic music therapy: Case studies (pp. 5372). Gilsum, NH: Barcelona Publishers. Pederson, I. (2002). Analytical music therapy with adults in mental health and in counselling work. In J. Eschen (Ed.), Analytical Music Therapy (pp. 64-84). London: Jessica Kingsley Publishers. Pederson, I. (2003). The revival of the frozen sea urchin: Music therapy with a psychiatric patient. In S. Hadley (Ed.), Psychodynamic music therapy: Case studies (pp. 375-388). Gilsum, NH: Barcelona Publishers. Purdon, C. (2002). The role of music in analytical music therapy: music as a carrier of stories. In J. Eschen (Ed.), Analytical music therapy (pp. 104-115). London: Jessica Kingsley Publishers.

Scheiby, B. (1991). Mia's fourteenth — the symphony of fate: Psychodynamic improvisation therapy with a music therapy student in training. In K. Bruscia (Ed.), Case studies in music therapy (pp. 271-290). Phoenixville, PA: Barcelona Publishers. Scheiby, B. (1998). The role of musical countertransference in analytical music therapy. In K. Bruscia (Ed.), The dynamics of music psychotherapy (pp. 213-248). Gilsum, NH: Barcelona Publishers. Wigram, T., Pedersen, I., & Bonde, L. (2002). A comprehensive guide to music therapy: Theory, clinical practice, research and training. London: Jessica Kingsley Publishers.

Appendix: Definition of Terms Used in IAPS Types of Relationships •

•

Figure-Ground Relationships: The ground is the basic matrix, environment, material, context, or underlying structure out which a figure is formed; the figure is the pattern, design, or entity that is created out of the ground. The figure is created to be heard against its background; it emerges from embeddedness as an independent entity to be attended. Figure-ground relationships are always simultaneous, and are most relevant to the rhythmic elements and the tonal elements. The integration profile is used to analyze figure-ground relationships. Part-whole relationships: A part is any independent voice, strand, or configuration in the music that makes up part of the whole texture of the piece, because it plays a “role” in the music such as solo or accompaniment. For example: 2+ simultaneous rhythmic parts, or melodies, or instruments, or players, or any accompaniment pattern. Simultaneous part-whole relationships form the “texture” of the piece, and are analyzed according to the various integration scales. Successive part-whole relationships constitute the “form” of the piece, and are analyzed according to the variability profile.

Levels of Relationship in Improvisation •

Intramusical relationships: how the elements and components within one person’s music are related to one another. Includes only within-music-within-individual relationships. • Intermusical relationships: how the elements and components of one person’s music relate to the elements and components of another person’s music. Includes only between-music-between-individual relationships. • Intrapersonal relationships: how parts of the self relate to one another, for example, how the musical and nonmusical selves are related, how emotions are related to behavior, etc. • Interpersonal relationships: how musical and nonmusical parts of each person’s self are related to one another. Rhythmic Elements • Rhythmic Grounds: pulse, subdivision, tempo, meter • Rhythmic Figure: rhythm pattern or theme • Pulse: a division of time into equal, recurring segments that are marked off by equally significant events. • Subdivision: equal divisions of the pulse into shorter temporal units. • Tempo: the speed of the pulse. • Meter: the organization of pulse into numerical units • Rhythm: a sequence of sounds and silences of varying durations and emphases that relate in some way to one another and/or the rhythmic ground. Tonal Elements • Tonal Grounds: Modality, Tonality, Harmony. • Tonal Figure: Melody. • Modality: a delimitation of pitches that can be used horizontally (melodically) or vertically (harmonically). Also called “scale.” • Tonality: the means by which pitches are organized around a tonal center or resting point. • Harmony: A sequence of simultaneous combination of pitches (chords), which may or may not be organized according to intervals between the pitches (tertian, quartal, quintal), a modality, and/or tonality. • Melody: a sequential arrangement of pitches that move in different directions at different intervals from one another to form a contour.

Sound Elements • •

Timbre: Identity or character of music-maker. Volume: Power, strength, intensity, size of commitment.

Structural Elements

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• •

Phrase: The syntactical and prosodic structure for melody; the physical or motoric structure for rhythm; the element which unites the physical, emotional and cognitive. The temporal-physical boundaries for feelings and ideas. Texture: Fabric: role relationships of the various musical parts, along with organizational strategies and hierarchies. Register and voicing: where parts are in relation to one another; degree of intimacy. Spatial-physical relationships between psychological parts.

The Six Profiles •

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• • • •

Integration: Reflex organization, sensorimotor coordination, physical boundaries, figure-ground and partwhole perception, perceptual illusions, impulsivity, field-dependence, emotional individuation, role boundaries. The basic well-formedness of the individual. Variability: Control issues; need for sameness or change, regression or progression, retention or invention; conservativism versus liberalism; preferred time zone; fear; ability to integrate past, present, and future. The openness of the person to the birth-death-rebirth cycle. Tension: The origin, direction, aim and impact of both psychic and physical energy; location of conflicts and methods of resolution; reveals stress and anxiety in relation to the elements and profiles. Salience: The need for attention, recognition, power, or control; the person's agenda; differentiates conscious and unconscious; hierarchy of concerns and values. Congruence: Reveals latent or unconscious conflicts. Autonomy: Awareness of self and other; identity issues, role boundaries, tolerance, aggression, need for control. Interpersonal stances are: toward self and other, toward self and away from other, toward self and against other, toward other and away from self, and toward other and against self.

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

CASE TWENTY-SEVEN Mia’s Fourteenth - The Symphony of Fate: Psychodynamic Improvisation Therapy with a Music Therapy Student in Training Benedikte Barth Scheiby Abstract This psychodynamically based case study describes 22 individual music therapy sessions with Mia, a 27-year-old music therapy student in training. Free improvisations were used to facilitate her personal development while also imparting essential clinical skills. Mia’s experience of the process is conveyed through excerpts from her diary, comments during sessions, and the therapist’s notes. Introduction This case study is unique because the client was a music therapy student in training, and because the therapy was provided as an integral part of her training program. The purposes of this kind of training-therapy are many: to enable the student to experience the deepest potential of music therapy in addressing childhood traumas and other formative experiences crucial to the development of the personality, as well as more current personal issues; to provide the student with a deep understanding of the meaning of a client-therapist relationship in music therapy; to help the student discover the different ways music can be used as a tool in therapy; to reveal “blind spots” in the students self-awareness; and to help the student develop his/her own musical language, along with a framework for making musical and verbal interventions. This mode of training--practiced since 1982 at the four-year Master’s program at Aalborg University in Denmark--is intended to provide an experience for the student that is as near as possible to the clinical reality outside the university. In the first year of training, students are offered sixteen sessions of music therapy in groups of five. Here they encounter self-experiential work in a music therapy group for the first time, and gain the preparation they need for the deeper work that follows. During the second year, all students are required to take a minimum of 20 individual, weekly sessions, and if they choose, they may extend the therapy for a longer period. I have seen over 80 students in the eight years that I have been offering individual music therapy as part of academic training. I chose to write about Mia for several reasons. We both considered our work together successful; she was willing to share her notes on the experience,

which are in the form of a diary; and the process that she underwent in therapy was fairly typical of music therapy students in training. Having access to Mia’s diary was important because I believe that what a client expresses verbally about the nature of their experience in therapy must have the highest priority in providing an adequate account of the therapeutic process. In the music therapy literature, we are usually only offered the therapist’s interpretations, experiences and evaluations. This allows us to get only a glimpse at the therapeutic process and the music--and only through the therapist’s eyes and ears. As a clinician, I have often noticed that the client’s experience differs from mine, particularly with respect to how the music functions as a therapeutic agent. I therefore encourage all of my clients to write a diary after each session. Upon termination, they have the choice of whether or not to share it with me. Mia decided to share her diary with me, and she also gave me permission to use the tapes from her sessions. I have purposely changed some of the biographical material to maintain her anonymity. Since both Mia and I considered her therapy successful, I was most interested in analyzing how the work unfolded, and what implications I could gather for training purposes. I have deliberately used the word “unfold,” as I noticed that the sessions unfolded like a lotus flower, each session leading to a new layer of Mia’s inner life. This particular work made a deep impression on me because of the manner in which the music: stimulated memories, images, and emotions related to her parents; tapped Mia’s unconscious use of current relationships for continued parenting; and released a transformative process in her life. Method My clinical work is consonant with psychodynamic/psychoanalytic and humanistic theories, which reflects my own personal experiences in training-therapy. I am in debt to the inventor of Analytical Music Therapy, Mary Priestley (1980), with whom I trained and by whom my work is deeply influenced. The form of music therapy that I practice involves the symbolic use of improvised and composed music by the client and the therapist for the purpose of transformation, integration, enhanced self-awareness and self-exploration. In my verbal processing, I attempt to relate the music to the client’s present intrapersonal and interpersonal dynamic, to their emotional history, and to the reality outside the therapy room. I also believe that working with the music of the client’s “inner child” (its traumas and resources) is essential. In addition, when desired or needed by the client and only because I have the necessary training, I may also combine music therapy with bioenergetic body work. Many of my private clients, including adults and children with a wide variety of psychiatric diagnoses, demonstrate very little or no verbal abilities in the beginning of their therapy. By developing ways of communicating with them on a pre-verbal level, I have extended Priestley’s approach further so that the musical and body communication can stand alone without the medium of words, if necessary. I mention this aspect because Mia and I both felt that her transformations and deepest realizations tended to happen in those sessions characterized by an exclusive reliance on

improvised musical communication. In one of those sessions (the 14th), Mia named the music “Mia’s Symphony of Fate,” from which the title of this case study is derived. Her music was often based on programs such as this, and interestingly, I came to perceive every improvisation as separate movements in Mia’s “Life Symphony.” Mia’s weekly sessions lasted 50 minutes. The session room contained a large variety of instruments including: two pianos; gongs of different sizes and sound quality; orchestral string, wind, and percussion instruments; ethnic instruments from various cultures; and electric keyboards and guitars. Background Information Mia is a 27-year-old woman, the youngest of three children. Her father committed suicide when she was five years old. Her mother is alive, and in describing their relationship Mia says: “She is a mystery to me.” Mia lives with a boyfriend, Peter, with whom she became pregnant and then miscarried. She is currently under observation for cell changes in the uterus. Mia has been in massage therapy for two years before beginning her music therapy training. She experimented with different types of drugs when she was 21 years-old, but she is now trying to live a healthy life by meditating each day. She is often able to remember her nightly dreams. Mia is functioning well in the academic milieu and is content with her life, except for problems in her relationship with Peter. When given a choice of which music therapist to have, Mia selected me because of the trust she had developed in me during our academic contacts prior to therapy. Treatment Process In my approach, assessment and evaluation are not differentiated procedurally, but are an ongoing part of the treatment process. The sources of data include the client’s improvisations, compositions, body language and verbalizations. My experience has shown that the content of a client’s first session anticipates important themes and emotions that will be encountered later in the process. Therefore I have chosen to elaborate on Mia’s first session as the first source of assessment data, and as the first step in the treatment process. Afterwards, I will describe (in similar detail) subsequent sessions leading to Mia’s Symphony of Fate--a significant turning point in her process prior to termination. 1st Session: Warmth in My Sexual Organs The session consists of a therapeutic interview that leads to a mutual improvisation. From the therapeutic interview--which consists of open-ended questions like: “What would you like me to know?”--I gathered all the information contained in the previous section, except for Mia’s father’s suicide, a fact which Mia chose not to mention at that time. In this session, Mia states that her goal in therapy is to work with her sexuality, as it is a real problem for her in the relationship with her boyfriend. She feels that she cannot live out her sexuality, as he rejects her when she expresses her needs. Sometimes Mia feels like a

nuclear bomb, whose impact her boyfriend is being forced to absorb. She would like to be able to contain her sexual feelings better and avoid pressuring him so much. She also would like to be able to cope with his rejection of her sexual overtures. When she tells me this, I get an image of a little girl crying while her father walks away from her. I recognize this as a possible indication of my own countertransference. Mia would like to integrate body and dream work in the music therapy, when it is relevant. When she says that, I notice that Mia has a fair amount of awareness of her body, some difficulties in maintaining eye contact, and a habit of sitting with one foot near her sexual organs. Her diary describes her feelings during the interview: I gradually felt safer with B and was happy that she asked why I had chosen her, so I could say that I felt confident about her. It is good to be asked about things, to be questioned. In the beginning, I became afraid/nervous when I talked about my problems with a therapist. I recognize that. It is getting close to me. I am looking forward to the “work!” I also noticed that I become nervous, when B makes it clear that what happens is up to me. MY RESPONSIBILITY!! I will determine what I am going to do with my own therapy. She doesn’t want to be the mother that fixes and decides everything! Is never saying “good” or “bad!’ Gives me room to finish my talking, and asks if I have something to ask about. Towards the end of the session, Mia says: “I would like to play together with you. I can feel warmth in my sexual organs. I would like to let that be the theme for our improvisation.” Mia chooses the following instruments: wind chimes, marimba, shaker, big Tibetan bowl, a metal rattle and her voice. I choose the grand piano, a Chinese bell tree and my voice. The latter two make it possible for me to acknowledge Mia by choosing instruments of the same sound quality as hers. I chose the piano because of its variety of timbres (keys, strings, wood, pedal echo), and overall versatility as a percussive, harmonic and melodic instrument. I let Mia start the music, and she plays gentle sounds on the wind chimes, accompanied by breathy, pianissimo singing that contains an ascending and descending fourth from G to C and returning to G. While still singing, Mia changes to the marimba and plays a fast, running rhythm in C major. I join Mia with my voice on the C below hers, forming an octave accompaniment. On the piano I match her marimba rhythm. My intent is to create a holding environment that is not too intrusive. Through the quiet dynamic of the music, I get a feeling of withdrawn emotions. Images emerge for me from the music: of running water in a little stream, the wind blowing in the trees, and two people meeting and touching each other very gently and loving for the first time. Mia writes in her diary: 7 chose metal sounds-tones, a little like water.” Now the music changes as Mia loudly and clearly introduces the following motif on the marimba in C minor:

We begin to play together around this gestalt. In my right hand, I play the motif in different variations while providing a holding octave with my left hand. This continues for a long time and my image changes to a little girl who is all alone and sad, crying to be cared for. Mia leaves the marimba after a while and plays the metal rattle and the big Tibetan bowl, howling like a wolf in the high register of her voice. Here, I sense an intensification in the sound quality of her voice, and I accompany Mia with dramatic tremolos in the bass. After this passage, Mia finishes by playing fine delicate sounds with the metal rattle and breathing aloud. When I look at her after a while she seems very relaxed in her whole body, and she breathes rhythmically. Mia says, “I feel all quiet now. Thank you!” Later, Mia writes this in her diary about the music: I relaxed in the end, when we were finished - we ended in silence. I breathed!! And I felt relaxed in my neck and jaw. [Later] I am back home and I feel extremely well. Am enjoying the cat, the sunshine, the peace, the food. Thinking of B’s responsibility as being good. When I later heard the tape of the music, I again got the warm feeling in the sexual organs. The music is carrying it in itself. B chooses instruments made of metal just like mine. She lets me start and finish the improvisation, and waits a long time before she looks at me again. I will let Mia’s diary speak for itself and make just a few comments. Obviously, there is quite a lot of synchronicity between us, both in and outside the music. I think this is one of the reasons why the first session worked out so well. I have often experienced that the shared improvisation bears many of the same qualities involved in different aspects of love, with the music offering sound patterns that phenomenologically resemble this human expression. In this improvisational meeting, at least four different aspects of love were present. First was the genital love of lovers, which is one of the biggest transformative forces in life. The music produced a warm feeling in Mia’s sexual organs, and I had the image during the improvisation of two people making love to each other for the first time. Second, I noticed that most of the music in the section beginning with the motif in Example 1 had the quality of oral music--music that has the fusion and mutuality characteristic of the first phase of breast-feeding. I see this as a healthy element for Mia, and one that many clients experience at some point in their therapy. Third, the music seemed to help Mia love herself. Recall in Mia’s diary how she feels extremely well back at home enjoying everything around her. A fourth and very essential aspect of love that was evoked by the musical and verbal interaction was Mia’s transference love for me, expressed in her very positive perception of me and the loving quality of Mia’s music when we played together. This provided a basis for a strong therapeutic alliance.

The image of the little girl who is alone, sad, and cries to be taken care of, and that of the howling wolf, anticipated the manner in which Mia’s feelings regarding her father’s suicide would emerge in several subsequent sessions. The clinical technique that I utilized is one that Mary Priestley (1975) calls “Entering into Somatic Communication.” It is used for exploring material when the client’s emotions are manifested in physical symptoms which provide a means of keeping the underlying emotion outside awareness. 2nd Session: Fear of Losing Contact Mia discusses the conflict with her boyfriend and how it makes her tired and tense in the shoulders and arms. Through bioenergetic body work which involves Mia letting her shoulders and arms “speak” to her, the theme “Fear of Losing Contact” emerges. She decides to explore this theme musically. Mia plays the piano strings, hand cymbals and voice. I accompany her with my voice. She cries profusely while she dramatically and angrily tears the piano strings while holding down the sustaining pedal. I hear the voice of Mia’s “inner child” saying, “I am afraid, alone and angry.” Mia describes this music in her diary: Desperate anger and emptiness--am swimming in a deep, black ocean. MISS MY FATHER. Fall down in a well and it gets dark. Something gets torn to pieces. After the end of the improvisation Mia speaks more about her relationship to her boyfriend, saying: “I don’t want only half a heart.” In her diary she writes: Fear of losing contact–emptiness. I reach out and nobody is there. Fear and anger. But I can’t stand it on the long run. It is weighing me down too much. I chose not to connect the “inner child” feelings to her early relationship to her father, as she does not mention her father in the session, and I feel that the timing is not right. Clearly, Mia seems to be getting in touch with how much she misses her father through the improvised music that evokes her longing and tears. It is interesting that she chose not to discuss these feelings in the session, but rather to write about them in the diary. It is probably too painful for her to speak about yet. However, she realizes what her needs are in the relationship with her boyfriend. 3rd Session: The Unspeakable Mia wants to begin without a title today to see what will develop. She also wants me to play without any specific definition of my role. Mia chooses the following instruments: gongs of various pitches and sound quality, piano, Chinese bell tree and voice. I choose the steel drum, kettledrum, Tibetan bowls, wind chimes, metal rattle and voice. The session falls into three parts.

Part I. Mia begins by fiercely hitting the Chinese bell tree and gongs and vocalizing in a deep and loud voice. This triggers images in me of ritual ceremonies in Bali, especially music that is played at funeral ceremonies. I answer Mia by playing loudly on the Tibetan bowls, drumming in a quick running rhythm held in pianissimo and using my voice in the same, masculine manner. The music comes in big sound waves. Suddenly, Mia screams loudly and hits the biggest gong very hard, as if to punctuate her musical “sentence” with a period and provide a temporary stopping point. After this, there is a very long period of silence. Mia writes in her diary about this part of the session: Music--the unspeakable--the thing that only can be whispered or hissed out with the breathing. DEATH. EMPTINESS, ABANDONED, ALONE. I DON’T WANT TO SPEAK ABOUT IT. I DON’T WANT TO HEAR ABOUT IT EITHER [Her father Tom’s death]. FUNERAL -- Music for the dead -- TIBET-- Climax -- release, after that the sorrow, the silence. AS IF I SMASHED A WINDOW AND ENTERED THE ROOM OF SORROW. In this part of the music B was very supportive. Part II. While Mia cries silently, I breathe loudly and deeply like a blowing wind. She responds with “Shhhh!” I stop my breath sound. Mia moves to the piano and pulls violently on the strings. She writes about this phase: I am shushing B with an S-sound. I want peace. Then I pull the strings-ANGER...DESPERATION. I wanted to get the pain out through the fingers; therefore I pulled the piano strings with the fingers. After this Mia plays atonal, dissonant passages with a melancholy color on the piano. I play in the background on the steel drum, trying to illustrate the tears that are rolling down her cheeks. I allow Mia to finish the improvisation. She ends by playing handfuls of clusters in the deep register of the keys, letting the last cluster hang in the air. Mia writes about this part: Playing the keys - an attempt to do something about the condition - NO! - I DO NOT WANT TO! Nevertheless light sounds are sneaking in the piano improvisation. B. only played very little with me in the end. Perhaps she perceived that this time was about loneliness, emptiness - and therefore consciously stayed away. It had a reinforcing effect on my emotion. At one time I called to her and waited for her in the music and she did not come. Because of this, my situation or emotion became clearer. After the music Mia looks very unhappy, and I offer her my hands. She takes them and holds them very firmly during the whole conversation. She says: “There are some things that one cannot talk about,” and sobs very loud, “Like when people are dying.” There is a long break in the talking. She resumes: “My father died, when I was five years old. He went into psychoanalysis and committed suicide. Then I got a stepfather who hit his dogs.” She speaks about how she misses her father, what he was like, and says that her boyfriend reminds her of her father.

Mia’s voice gets gradually clearer and louder during this talk and she looks as if she is relieved. She writes about this verbal processing: I became a little happy, when I had been speaking with B and told her about the circumstances under Tom’s death. Peter is of course becoming the person that has to fill out the gaps after Tom, and therefore those enormously difficult situations arise, when he doesn’t want to, or isn’t able to fill up the hole. Part III. Mia asks me to play a piece of music for her on the grand piano while she lies on the mattress. I choose to improvise over the main theme from Chopin’s “Nocturne in D Major,” because I feel that it reflects her emotions, and also has a caring, holding quality. Mia looks satisfied when she leaves the room. In her diary, she writes that, in the session, “Time went so fast.” It also went fast for me, and I was very touched both by the intensity and ritual-like music in Part I, and by Mia’s story and tears. She touched my own “inner child’s” hurt and feelings of loss connected to my own father’s suicide, which occurred when I was three months old. I used the technique that Priestley (1975) calls “Subverbal Communication,” where client and therapist improvise together without title, focus, or specific roles. It is used to share feelings, when words fail or become meaningless. It is meant to strengthen the ego. 4th and 5th Sessions: My Resources In the fourth session, Mia makes a drawing that pictures her resources as she sees them. She does not want to improvise over the drawing, however. In the fifth session, Mia focuses on the feeling of not being good enough, and ends up improvising on the piano with the title “I am good!” I see this as a natural extension of the previous session. 6th and 7th Sessions: Mother-Daughter Projections In the sixth session, Mia begins to work on a nightly dream in which she is trying to integrate the mother and the girl in herself, thus allowing her to be her own mother. She decides to compose a song from the little girl to the mother about how the girl feels when the drunken mother leaves the girl alone. As a consequence of Mia coming in contact with her resources and benevolent side, she now has the strength to look at her own mother, take her in, and address the task of taking back the “mother projection” from me. The seventh session begins with Mia singing and playing her composed “Song to Mother” on the piano. I accompany her on the accordion. The plea of the song’s refrain is: “Stay by me, stay by me, because I love you.” Later I use Priestley’s (1975) “Splitting Technique,” which helps to explore experiences or situations that involve the exploration and integration of polarities. Mia improvises over the polarities of being a little girl versus being the mother. The musical sounds that Mia associated

with being a little girl were “little, ugly, angry and hard.” Sounds for being the mother were “big, soft, warm, and accepting.” 8th Session: Interplay Mia expresses a need to explore her interpersonal contact and relationship with me in a mutual improvisation without any title. This represents a progression in Mia’s awareness of the process from an intrapersonal to an interpersonal level. Mia writes about this: “The feeling in my chest area is changing. This hurt child is perhaps letting go, so that I can turn the energy outward.” I sense Mia’s resistance against verbalizing for the first time. I see it as a natural and important phenomenon in the therapeutic process. Here music serves as an excellent container and “waiting-platform,” offering possibilities of intrapersonal and interpersonal dialogues at the same time. Mia expresses it in this way in her diary: I am experiencing that I am losing some of the engagement in the therapy. Perhaps it is because the analyzing part of it doesn’t offer me anything right now. Too much analysis, too little being. I prefer to experiment with the possibilities and depths of the music than dig into my own past. I want to play together with B because that is where something is happening - it is in the INTERPLAY...[Later] As a therapist I, of course, have to be ready to contact on a deep level and stay there. It is my impression that in this session Mia starts the process of taking back her projection onto me as “the good mother.” She now perceives me as a playing partner. I see it as a product of the former session where she worked on containing both the little girl and the mother. Later, Mia also has an important realization regarding the value of this improvisation for her training. 9th and 10th Sessions: Finding the Musical Self We start out improvising together again without a title, and later listen to the taped music. In her diary, Mia describes this music as a crystallization of her needs: (1) to let go and give way to the unstructured, chaotic, and casual; (2) to meddle more directly in B’s music, and be a little more confronting; and (3) to draw her boundaries. I sense, that Mia now is trying out her ability to say YES and NO with force and directness, as a part of integrating “the adult” in her. The tenth session begins with Mia saying that she felt that her music contains many “redundant” tones. From that arose the theme for her solo improvisation: “Play One Tone, Wait and Listen, until You Play the Next Relevant Tone.” This improvisation marks the beginning of a greater focus and concern on Mia’s part for the musical material itself. This occurs naturally at certain stages in music therapy, when musical material takes precedence over emotional issues. I see this as a need to nourish the

creative “composer” of the client, and also as an expression of a need to be on “neutral ground” for a time. It also represents a time when the client is reflecting upon and consolidating what has happened in the therapeutic process. After the improvisation, we used the taped music for a guided imagery. Here is Mia’s description: The gongs were like healing. Their vibrations go deep inside the body. Became warm in stomach and sexual organs - combustion! I felt like under water for a time, while I listened to the music. It was very nice. 11th sessions: Finding the Feminine Part of My Self Mia wants to contact her feminine side through music. I take the role of an active listener. She begins on the piano, and searches for a long time. Mia writes: I didn’t like the keys. Couldn’t use them. All the time I had to force the fingers to go on. The music became abrupt - a hard stroke. All the time an attempt to hit something. I didn’t know if I just should stop it and say that I couldn’t; but then I started playing on the strings, then it began to flow. It was very beautiful. I really liked the sound-board that was there all the time. I didn’t know which tones I hit. I chose ONE TONE, THAT BECAME A BASIS. A very strong dissolution came and, after that, the music became much stronger and clearer. I see that I perhaps should pass old ideas and patterns to arrive at my feminine self. In processing the session, Mia says that she saw different types of female images in the end of the music. Mia realizes that she has to let go of old patterns to be able to truly be herself. The contact with the feminine parts of her Self, I see as a natural product of being in touch with her “inner mother.” I also see this session as a beginning step of integration in that one of Mia’s overall goals is to facilitate a balance between her feminine and masculine qualities. The first step in this process is to become aware of those qualities. 12th Session: Feelings toward Peter Mia speaks about not being able to express herself and her needs to her boyfriend. She wants to work with that. I begin by working with her body, using bio-energetic grounding and centering exercises aimed at helping her to “stand on her own two feet” without being overwhelmed by her emotions--in this case, tremendous anger. I then present a hand drum so that Mia can hit it while vocally expressing what she would like to tell Peter. It seems difficult in the beginning, but with my backing and reinforcing on the drum, she finally manages to hit the drum fiercely, and with conviction in her voice. In the end, I take the role as Peter so that Mia can practice what she wants to say to him. About this session, Mia writes: The doubt makes me weak! I lose myself when I flip out at home. I abandon my centering. I had to discover that! I practiced telling him what I wanted to say, clearly,

unambiguously and convincingly. I have just done that and he said yes at once. I hadn’t expected that. I have to work on staying clear and centered--to be in touch with my strength and sticking to my demands. In this session we used the technique of “Reality Rehearsal” (Priestley, 1975), where the client improvises how to take a needed step in her life, focusing on inner obstacles that are encountered--in this case the anger and fear of being rejected. 13th Session: Do I Want To Be Like My Mother? Mia gives positive feedback on the last session, and recounts a dream from the night following this session. The dream provided her a symbolic representation of what had happened in the session and afterwards. A long pause in the session follows the discussion of Mia’s dream. I notice that Mia looks irritated. She says that she does not feel like doing much today and I sense some resistance in the air. Silence occurs again. She uses the rest of the session to speak about negative feelings about her mother (Anna), and makes one improvisational attempt to find out what she would like to own or take over from her and what not. I take a mirroring role. This exercise does not seem productive. One particular sentence lingers in the air: “I remember when I was little--even when she held me, she smelled badly.” I end the session by telling her that I sense that she is irritated, that she has some resistance towards working with her image of the mother, and that it is OK to feel like that. Mia writes about the session: Bullshit! I was not able to get in touch with myself today. And I do not think that B offered me any help. I talked too much. I talked myself away. When I started thinking of Anna, I disappeared. I cannot use her femininity as a model. But I guess that’s OK too. 14th Session: The Symphony of Fate Mia expresses her need to play with me without any predetermined theme. She chooses the synthesizer and I play the grand piano, kettle drum and cymbal. There is a quality of preparing for something fateful in Mia’s broad, dissonant, and sustained sounds. I just listen. I get associations to programmatic or cinematic film music. Mia describes each part of the improvisation in her diary. Her descriptions are indicated below in italics. Entrance: A door is opened. The chords become louder and have a threatening quality. I accompany Mia gently in the background, drumming on the kettle drum in a quick rhythm making dampened beats, as if a thunderstorm is heard in the distance and is coming nearer. Dissolution: Violence, Anxiety.

Mia makes single tones jumping up and down the keyboard, and I answer them on the kettle drum and cymbal, as an offer to enter a dialogue. I hear that she is not answering me, but instead is self-absorbed in her own playing. I listen for a while without playing. Emptiness: No orientation point. The music consists of detached tones, atonality, and empty chords. Then Mia uses the pitch modulator on the synthesizer to bend single tones. They sound like a little child screaming constantly. Tears are running down her cheeks. Through my atonal playing on the piano, I try to portray feelings of desperation, loneliness and unhappiness, while wailing in tremolo passages to underline the mood. Lament--also angry--No! This last part is about my father’s death. I could not bear that he should have died detested and unwanted by all people. Totally lonely without any love. The music still makes me cry. This leads Mia to improvise a tonal elegy in a minor key that I underline with a simple ostinato bass line. Mia’s melody steps down note for note, like steps down a staircase, and ends on the deepest note of the synthesizer. I finish by allowing the A minor ostinato to slowly die out, repeating it more and more gently, like little sighs. After the improvisation ends, there is a long pause. To further process the music, Mia takes a piece of paper and draws a picture of a long line that points downward, ending in a little spiral. She calls it “Sorrow.” While she draws, I let the improvisation settle down into my consciousness, and I imagine that this music must have been about an important and dramatic part of Mia’s “inner child.” So important that, for now, it could not be expressed in words, but only on a symbolic level in music and drawing. Mia explains in her diary: I could not talk - I just wanted to play. It was good to play. It became long. Mia’s Symphony of Fate had a beginning and an ending with structure and melody. It was good that B was there and played together with me. She was backing up my expression. My teeth chattered. When I had been playing for a long time, I was able to think in mode, rhythm, and form without disappearing from the emotions in the music. Here Mia gets in touch with deeper feelings connected to her father: emptiness, lamenting, anger, sorrow. These feelings were also present as an undercurrent in the music of the first session. The session causes “after-pains” six days later. In her diary, she describes the following image that arose during one of her meditations. It was a big hole. I decided not to go in, but I wanted to light it up (there was a man next to the hole). It was a clammy cave. At the very end, a girl, twelve or thirteen years old, was sitting huddled up and bound. It was me who was being kept as a prisoner. I thought of entering the cave and picking her up, but was afraid of being caught myself. She became smaller and smaller. In the end she was a sack that got closed. The man had

it (my father). That is the truth from that time. The fragile, sensitive girl that is kept as a prisoner, that has to be liberated, but does not know how - with warmth and love. 15th Session: Entering the Cave Mia says that her teeth were chattering in the last session and that she cried over the image just described. She also says that the music was also about her relationship to her mother and step-father, who moved into her home when she was twelve years old. She expresses that it is very difficult for her to share this with anybody. She feels as if she has lost the little girl, as if she has hidden herself in the cave far away. I ask her about the connection to her daily life and Mia says that in her relationship with Peter, she sometimes becomes like the little girl in the cave, and he cannot handle that. It is also connected with a feeling of being unwanted, when she is too pushy and he rejects her. I suggest that we improvise being in the cave together. Mia can then explore being the little girl and contact me if she wants. I encourage her to use her voice and facial sounds (as she had mentioned that her teeth were chattering in the previous session also). She prefers to have me outside the cave at the edge, so that we can communicate with each other, if she needs that. I build a symbolic cave out of two quilts, and Mia takes the glockenspiel and triangle with her into the cave. I portray the cave on the grand piano with big hollow sounds made from pulling on the deep dampened strings while depressing the sustaining pedal. I take long breaks between each sound. I guide Mia into the cave through the music. I then hear Mia’s voice from the distance. It is withdrawn yet wailing: “Oh-ya-ya....Ooohh...Mmmmmmmm.” I now support her voice by playing the same tones as her. When I play louder, Mia’s voice becomes louder and more twisting. She now beats the glockenspiel. It sounds like stamping. I stamp with her on a deep string as a drone. Then she plays the triangle gently while humming with her voice. Her diary describes the improvisation so far: There were tears, but I also discovered other things. It was safe: I had chosen to go in the cave to protect myself. I liked communicating with B, then it became more joyful...I could play “princess music” in the cave and it could be heard outside. I felt like playing with this light music. As the improvisation continues, her voice glides up and down ending in various nasally aspirated sounds combined with facial grimaces. Suddenly, there is a big bang. Mia has thrown her instruments on the floor. I bang one time with the lid of the piano. It is over. After the improvisation, Mia realizes that, today, the “cave part” of her also represents something positive–a place she can chose to go to of her own will. The existence of the playful “princess music” leads her to that realization. Mia can break out of her “inner prison” (the big bang), if that is what she needs to do. Technically in this session, I used Mia’s symbols (i.e., cave, little imprisoned girl) as a starting scene for a guided imagery to improvised music. Instead of guiding verbally, however I guided through my musical expression on the piano. This technique is used to explore

unconscious material, and to find new solutions for persistent inner conflicts. Priestley (1975) states: “Symbols are accumulators and transformers of psychic energy. They have the relationship to ideas and action that an iceberg has to a waterfall. Using them, the therapist is dealing with the transformation of force.” (p. 129) In Mia’s case, her musical exploration of the symbols opened her eyes to the positive aspects of contact with her “cave-part.” It was a place where she could feel safe and protected, and where the playful and joyful side of her “inner child” could come forth. Final Sessions In the 17th session, Mia says that she has had a very positive dream about her father. In it, she was two years old, and he was sitting next to her. She was fascinated by him. She also had met him during a meditation where he had given her his love and held her, and afterwards had said good-bye to her. This experience had felt so real to her that Mia later wondered if it was something she was recalling from her childhood, or if it just came to her as an image. She says she is happy for the experience because it was an entrance–a channel–to get in touch with what she received from her father. I see these phenomena as a result of the music’s ability to establish contact with hidden emotions, memories, and experiences that are an important part of her existential being. The music therapy continued for five more sessions and, interestingly, the music in these sessions did not contain undercurrents of melancholy, loneliness, wailing and solitude that were so characteristic of many of her earlier improvisations. In the very last session, the improvisation theme was “Goodbye,” and it touched upon little sequences from most of the sessions, like a recapitulation or reprise. In the verbal evaluation that took place upon her termination, Mia expressed that she was satisfied with the work because her sexuality was more in balance and the cell changes in her uterus were now minor and declining. However, she felt that she still had some work to do on accepting herself and not feeling compelled to live up to other people’s expectations of her. I noticed that our musical and verbal contact was more of one adult to another, and that Mia was able to maintain eye contact as well as hold her own center. Her mood also seemed to have become more stable with less liability. Discussion and Conclusions How do I evaluate Mia’s progress? First, her diary and her specific comments on the sessions represent clear evidence about what progress she made, and the effectiveness of various techniques and interventions. Certainly, Mia had addressed traumas of “the inner child” as well as more current personal issues, and showed an ability to work in the music with this difficult material. Mia’s growth as a therapist has also provided a testament to the productive nature of the work we did together. As I was Mia’s clinical supervisor during the following half-year, I was able to closely observe her clinical development. She was able to establish therapeutic relationships through music, and one of her strengths was an ability to work effectively in both the verbal and musical realm. Mia was more aware of her own counter-transference and was

thus able to avoid many of the pitfalls common to beginning therapists. She had developed her own musical language, and was able to tune her body as an instrument and use her voice as an important tool--on equal terms with the instruments. She also showed the courage to experiment with her own techniques. Why did the music therapy work as it did? As I have previously discussed my methodological procedures and techniques, here I would like to offer my basic assumption concerning the structure in free improvisation, the technique used most prominently in this case. Any musical structure which a client presents in an improvisation is a mirror of the client’s psychological organization and dominant function. By musical structure I mean melody, rhythm, timbre, pitch, dynamic, mode, pulse and tempo--in short, any parameter or element in music that organizes or is organized. This is a variation of Priestley’s statement: “The musical structure as regards rhythm and pitch (less so timbre and dynamics which are more responsive to the mood of the moment) is governed by that mental institution [structure] or function which rules the patient’s psyche at the time” (1980, p. 120). Thus, when describing each improvisation, I have placed particular emphasis upon those musical structures that seemed to have significance in relation to Mia’s psyche at the time. A second important factor connected with the improvisations is their titles. Each one serves as a focus point for structuring the music, and certainly colors the content of the music. Naturally, our selection of the most relevant title for exploration is of central importance. From this case, we can see that the act of improvising in itself offers possibilities for intrapersonal and interpersonal dialogues--dialogues which, as we have seen in Mia’s case, can provide the basis for self-transformation and growth. The work with Mia also illustrates how music therapy, when used as part of training, can serve not only as a place for personal development but also as an experiential laboratory for gaining the insights and skills essential to becoming an effective music therapist. Glossary Analytical Music Therapy: “The symbolic use of improvised music by the therapist and the client to explore the client’s inner life and provide the proclivity for growth (Priestley, 1980, p. 18). Countertransference: The therapist’s unconscious reactions (in and outside of the music) to the client and his/her transference (Priestley, 1980, pp. 50-57). Mother Projection: The client attributes aspects of her mother to the therapist, other person, or object. Transference: “A process by which a patient attempts to relive with her therapist the unfinished business from former important relationships in her life. It can also be her attempt to come to terms with, or rid herself of, conflicting parts of her psyche by projecting them on to her therapist (Priestley, 1975, p. 238).

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

CASE TWENTY-EIGHT Music Is About Feelings: Music Therapy With A Young Man Suffering From Anorexia Nervosa Gro Trondalen I did never believe I would dare to try the piano ... but I did ... Music describes feelings. At least it does to me ... Music is about movement, rhythm, strength and intensity. (Simon, 19) Introduction This chapter addresses expressive individual music therapy in an outpatient setting with a young man suffering from Anorexia Nervosa (AN/B). The therapeutic approach includes musical improvisations and verbal exchange. A central focus was to empower the client by fostering his creative health resources through musical improvisations, verbal communication and the use of instruments. The theoretical framework is rooted in humanistic ideas (Ruud, 2010), while the clinical theory is informed by developments in relational psychology, highlighting an intersubjective pe rspective (Benjamin, 1990, 2004; Stern, 2000). In this chapter, health is understood as a positive relationship between the dimensions of physical/mental health and existential wellbeing, which may be understood as a way of finding meaning and fulfilment by “being-in-the-world” (Sigurdson, 2008). The relationship between the client and the therapist is of vital importance, and may be termed “Fellow Travelers” (Yalom, 2002). Theoretical Foundations A Talking Body Traditionally, anorexia has been reported with reference to women in the Western world, understood as an internal and external expectation to fulfil images exposed in the media (e.g., Nasser & Di Nicola, 2001). However, men also suffer from eating disorders (Andersen, 2002; Kjelsås & Augestad, 2004). Hsu (1996) suggests a prevalence of 0.5 percent for anorexia in the general population. Similar figures have been described by Fairburn and Harrison (2003), who suggest an incidence of 19 females and two males per 100,000 people. From a psychological point of view, suffering from an eating disorder generally reflects insufficiently reliable self-soothing, tension and mood regulation (Garner & Garfield, 1997; Lask & Bryant-Waugh, 1999). The body is used as an external, concrete tool for promoting internal life (“embodiment”) (Duesund & Skårderud, 2003). Literature on eating disorders also draws

attention to difficulties in connecting body and mind; that is, relating inner feelings to words (alexithymia) (Cochrane et al., 1993). Literature on individual music therapy with people suffering from anorexia suggests that musical improvisation provides a basis for connecting non-verbal senses of self and allows for a recreation of self through active music making (Robarts, 2000; Smeijsters, 1996; Trondalen, 2003). Free movement and improvisation may support creative processes, which in turn challenges rigid patterns of behavior (Trondalen, 2005) and allows for confused and aggressive feelings to be expressed (Eckhoff, 1997; Frederiksen, 1999; Loos, 1994; Parente, 1989). Improvisational experiences may also be processed verbally and subsequently support connectedness between body and mind, which is an important objective for people suffering from anorexia (Lejonclou & Trondalen, 2009; Robarts & Sloboda, 1994). Sounding Relationships: A Music Therapeutic Soundboard The music therapy approach undertaken by the author included free improvisations and verbal exchange. The improvisations and handling of instruments did not require musical skills and were not evaluated according to performance criteria (Alvin, 1966; Bruscia, 1987). Improvisations were usually programmatic and referential in nature. On occasion, the client also listened to recordings of his improvisations after playing, a form of “self-listening” (Bruscia, 1998 p. 125). This music therapy approach was inspired by Alvin’s Free Improvisation model focusing on the use of instruments (Alvin, 1966) and Nordoff and Robbins’ client-centered model concentrating on the development of a musical/therapeutic relationship (Nordoff & Robbins, 1977). The creation of themes followed by a verbal reworking after the improvisation was informed by Priestley’s Analytical Music Therapy (Priestley, 1994). The theme for an improvisation always emerged from whatever the client brought to therapy. The client chose instruments for himself, and then the music therapist made her choice(s). From this sounding relationship emerged a playful exchange of musical ideas and themes. To conclude sessions, the client was often asked to write (i.e., a word, phrase or sentence) or draw to “sum up” the session. This served several different purposes. It allowed for closure, created a concrete image of client’s inner experiences, created a symbol or metaphor for the session and gave coherence and continuity to the music therapy process as a whole (Trondalen, 2006). Examples of such intuitive phrases include “a possibility of peace in mind” and “I am happy – but I hope I am not going to jump that much up and down from joy that I lose even more weight.” A Theoretical Stratum The theoretical framework of this approach is rooted in humanistic ideas (Ruud, 2010) and is inspired by developments in relational psychology (Benjamin, 1990; 2004), while focusing on an intersubjective perspective (Stern, 2000; Bråten 1998; Trevarthen, 1999; Trevarthen & Mallock, 2000).

The basic assumption is that the relating experience itself is the driving force of human development and growth (Stern, 2000). Using music as a relating experience (to oneself and another) is understood as a way of “being-in-the-world” (Trondalen, 2008). Stated in another way, music serves as an expression of performing personal identity (Ruud, 1997). Such a humanistic-existential perspective may be interpreted as self-caring (self-actualization) (Ruud, 2010). From a philosophical point of view, the human being is understood as homo communicans, with an inherent humanity able to share experiences and actions. Such exchange allows for recognition and partaking in one another’s life at an existential level (Trondalen, 2004). In western society today, health is more often linked with quality of life connected to individual, collective and social ways of living, rather than focusing on sanitary conditions and the fight against contagious diseases carried out through history (Sigurdson, 2008). The theologian Sigurdson suggests that health is a relationship; a positive relationship between the dimensions of physical/mental health and existential wellbeing. Physical and mental health are not to be understood in a categorical way, but seen as a continuum wherein bodily functions influence our mental state of being — and vice versa. Together they form a unit. The existential aspect of health is connected to human existence in a broad sense, including cultural, political, reflective, religious and social dimensions. Approaching health in such a broad way provides a context in which our cultures are conditioned by history and given meaning through discourse (Ibid.). Health, a positive relation between the dimensions of physical/mental and existential wellbeing, may be understood as a way of finding meaning and fulfilment by “being-in-theworld.” A central emphasis in this approach to music therapy is to empower the client by fostering his/her creative health resources through musical and verbal dialogue (Trondalen, 2008). Empowering1 is always linked to context. In this music therapy setting, it is connected to psychological empowerment at an individual level (Zimmermann, 2000), which includes changes in behavior, cognition and emotions. Focusing em powerment by supporting creative health resources in such an aesthetic practice in modern society seems to be linked to “an assemblage of activities designed to promote health and prevent sickness” (Aldridge, 2004 p. 37), rather than a focus on personal health management in response to sickness. Health becomes a creative performance linked to personal values and cultural norms. Accordingly, health is understood through experience rather than the objective measurement of bodily functions. This implies that the music therapist downplays pathological aspects of a person’s life in favor of healthy dimensions, in order to allow for self-actualization and the search for meaning within a relational context. Such a humanistic and resource-oriented perspective2 still takes the person’s illness (bio-medical perspective) into consideration, however in a dialogical way by focusing positive creative resources to cope with a variety of constraints. The relationship between the client and the therapist is of vital importance and may be termed “Fellow Travelers” (Yalom, 2002 p. 8). From a philosophical point of view, this indicates a subject-subject position, as opposed to the client being an “object” that is treated in therapy. Being a fellow traveler does not allow the therapist to disclaim responsibility for understanding and monitoring the therapeutic process (at a practical and theoretical level). It does, however, abolish the “distinctions between “them” (the afflicted) and “us” (the healers): “we are all in

this together” (loc.cit.). From this follows an attention toward what emerges between equal human beings, as this relationship is seen as the basis of development and growth. This clinical theory is drawn from developmental psychology, oriented toward clinical research on infants, highlighting an intersubjective perspective (Benjamin, 1990, 2004; Bråten, 1998; Stern, 2000; Trevarthen, 1999). Such theoretical thinking is fundamentally dyadic and understands communication as a process, making a shift from a stage-like to a layered model of development. Core elements are the child’s experience of “senses of self” in relation to oneself and others. These inner experiences of “senses of self” organize the child’s development (Stern, 2000, p. xxv). Being together with another person is seen as a process of “moving along,” which implies implicit knowledge of “how to be intimate with others” at a nonverbal level (Stern, 1998, Lyons-Ruth, 1998). The process of “moving along” includes two consecutive goals. One goal is to explore the theme of the communication; for example, talking about the family situation. The other goal is to participate in the moving along process itself. What is at stake is how the interaction moves along, rather than merely the themes or the concrete actions per se. Transferred to music therapy, such a process of “moving along” simultaneously includes an exchange of musical ideas and gestures (e.g., beat, key and dynamic expression), and an awareness of how it feels to be with the other person at an existential level. Further, it is most important to recognize how the musical interaction moves along, rather than only the themes/phrases in the music or the musical actions as such. From a therapeutic point of view, this allows the client to feel recognized within the musical relationship at an existential level, even if the client does not have any musical skills. From a therapeutic point of view, there may be a need for verbal processing to contextualize, develop, and interpret the musical interaction, not least in the client’s case because he found it hard to connect inner feelings to words (cf. alexithymia). However, such a reworking is not necessary when it comes to the origin of the interaction’s immediate power. The music in these relating experiences was both an agent (nonreferral) and a tool for dialoguing (frame and medium). The aim in music therapy was to maintain immediate mutuality, since sharing musical experiences (intersubjective behavior) was seen as the basis for the development and continuity of the musical relationship. The Client A Traveler Simon, a young man of 19, came to music therapy while attending college. During a stay abroad, it became obvious he was suffering from an eating disorder, namely Anorexia Nervosa, bulimic type (AN/B, American Psychiatric Association, 1994). Simon struggled with concentration, was hardly eating anything and used to vomit after meals. Suffering from anorexia limited his personal development and reduced his quality of life during the previous one and a half years. Simon’s daily activities used to be winter sports, reading and listening to music, but it was difficult for him to keep up with these interests due to his physical condition. He had a

warm sense of humor and wonderful sense of irony. Simon was the youngest of two, with an older sister. He grew up in a small town, belonged to a supportive and wellresourced family and had friends he spoke of highly. Simon had always been connected to music, even though he had never played any instrument before. He loved to listen to music through headphones: “funky music with real lyrics,” he would say. Simon alternated biweekly between music therapy and verbal psychotherapy. The psychiatrist and music therapist talked frequently about their work with Simon, and he was happy with this collaboration. There was also one joint family meeting, in the initial phase of therapy. Simon came to music therapy because he was curious. During the process, he often expressed great pleasure in participating. “After I’ve been to music therapy I don’t have to throw up the half slice of bread I’ve had today,” he said at one occasion. His music therapy lasted for one year and included 19 sessions. Sessions usually lasted for one hour, but the duration had to be adjusted in accordance with Simon’s physical and mental condition. The heating in the room also had to be high, otherwise Simon would start freezing, which reduced his concentration and capacity to engage. Therapeutic Process3 Moving Along Simon had never learned to play any instruments or improvised music before. He often seemed restless, and his arms and legs appeared to be “spread everywhere.” It seemed as if he struggled to connect to himself and others. “I do not know — I do not know anything,” he often said. Throughout the music therapy process, he explored a variety of instruments, from xylophones and maracas to piano and percussion. The music therapist played different instruments and sang, which Simon never did, except for some spontaneous humming. Musically, the improvisations covered pentatonic modes, blues, a Spanish mode, standard scales and atonal expression. When examined as a whole, the music therapy process can be divided into three phases: 1) sessions 1–10, 2) sessions 11–17 and 3) sessions 18–19. The First Phase: Sessions 1–10 In the first phase of therapy, Simon chose the xylophone as his favorite instrument. He said he had a “passion for knocking on objects.” The therapist would sometimes play another xylophone together with Simon, while at other times, piano or djembe. Simon often said he was exhausted after playing, but “enjoyed being tired.” It allowed him “to be absorbed in the music.” In summing up session one, Simon said “improvisation gives energy.” I found this encouraging, since Simon talked a lot about being “limp and tired.”

This first long phase of therapy was characterized by a search for security in the relationship (“I am afraid of trying all these new things”), a period of trying out the instruments (“important to try all these things”) and of “having fun.” He was very fond of “the strange” pentatonic scale. Musically, Simon explored the instruments predominantly through single tones and rhythmic patterns. In the tenth session, he discovered the big tubular bells, which were hung in a frame. From this point on, it seemed as if Simon explored emotional expressions in the music in a broader way than earlier, very different from his first rhythmic expressions. The Second Phase: Sessions 11–17 In the second phase, Simon took a greater interest in bigger instruments like the piano, djembe and drum kit. He seemed to move from small instruments to bigger, while exploring rhythmic and melodic patterns musically. “Playing on a set of drums demands concentration and my concentration is getting better,” he wrote after the eleventh session. In session twelve, Simon told me he had realized his vomiting was related to times when he felt “angry, lost sight and felt overwhelmed.” In the same session, he also recognized his musical progression by saying “I do manage the rhythm better than before.” In the fifteenth session, regulation was a term that emerged after the improvisation. We explored the notion together, relating both to the musical improvisation and how he regulated himself (e.g., in a party, in daily life). Simon said he knew he was going to reflect on “regulation” on his way home. In summing up, he wrote the word “regulation” within a rectangle. Within this phase, the music became more accentuated and ‘groovy,’ and there was a new awareness between Simon and myself in the music. Simon commented on this development in the sessions: “We are adjusting to each other — I do regulate too” and “it does not necessarily sound better, but it feels better … I am fully in the music … I hear you are playing the same tone as I do. Are you teasing me?” (session sixteen). He also related feelings to playing on instruments in a referential way saying “I do not want to play a set of drums because I am not so angry today.” The seventeenth session included an improvisation that Simon said was important. This was due to 1) him daring to play the piano, and 2) what emerged in the music while playing. Before beginning this improvisation, Simon told me he was afraid of improvising on the piano. Nevertheless, he did choose the piano, and the music therapist played a drum kit. The improvisation lasted for nearly fourteen minutes. After this shared improvisation, there were some seconds of condensed awareness. It was as if “I know that you know that I know we’ve been very close to each other” (intersubjectivity). This was observable immediately after the improvisation through a momentary glance at each other, a microsecond of a pause, bursting into a smile, and a deep relaxed breath before a vocalization (i.e., “mmm” with a smile).4 Afterwards, Simon said that “music is about movement and feelings.”5 The Third Phase: Sessions 18–19

The third phase represented the termination of expressive music therapy and consisted of only two sessions. In this closing phase, Simon improvised more freely than earlier. He talked a lot between the improvisations in sessions eighteen and nineteen and expressed a new belief that he could actually manage to learn to play an instrument, if he really wanted to (session eighteen). He also came to understand that “music and feelings are connected … It is something to relate to when I am alone. Music and feeling — the music reflects my feelings.” On his frequent choice of xylophones, Simon said “it is not a nice instrument, but gives me a lot of fun.” The last improvisation was performed on two equally large African drums, one for each of us. Discussion The discussion of Simon’s music therapy has three main foci: 1) a healthy body, 2) the ambiguity of instruments, and 3) musical relating experiences as potential for change. A Healthy Body Simon was very constrained by his anorexia. He struggled with concentration and his arms and legs often seemed to be “spread everywhere.” However, it was obvious he leaned intentionally toward the instruments to perform music. Such a bodily directedness (intentionality) is a functional action in the situation and related to the subjective body. With reference to the French philosopher Merleau-Ponty (1945/1994 p.35ff.), “the living body” is able to grasp (physically) and perceive (mentally) at the same time from an inside perspective (“double-sensing”). In music therapy, Simon used his living (subjective) body to direct awareness and express inner feelings through music. Such a beneficial body focus and mood regulation are the opposite of a rigid and stiffened (inner and outer) body (anorectic), which does not allow for personal feelings (objective body) (“embodiment”; Duesund & Skårderud, 2003). Connecting music to feelings in such a way promoted inner healing resources and contributed to a living bridge between inner and outer reality (Lejonclou & Trondalen, 2009), as Simon started to verbalize how his inner feelings and visible behavior were connected. In music therapy, Simon moved rhythmically to the music. The performance of his subjective body seemed to promote vitality, create energy and the feeling of being alive. He said that “improvisation gives energy … it does not necessarily sound better but it feels better … I am fully in the music … music and feelings are connected.” Such comments imply that Simon was able to recognize his own musical initiative and appreciate the interplay with the therapist (Trondalen & Skårderud, 2007). From a clinical point of view, this is a positive development, as letting go of control and allowing himself to be influenced by another was a constant challenge for Simon. Simon’s musical expression was a way of “being-in-the-world.” Mutual appreciative recognition through musical and verbal dialogue seemed to support Simon’s sense of belonging to time and space. An example is Simon’s comment: “I know I can become well with a little help from you and the psychiatrist. I know. Music therapy is good for me.” Such a statement can be interpreted as psychological empowerment at an individual level (Zimmermann, 2000), where Simon experienced control and understood the music therapy setting in his personal context,

building on his own competencies. Such a psychologically sufficient self-soothing (Garner & Garfield, 1997; Lask & Bryant-Waugh, 1999) and appreciative “self-actualisation” (Ruud, 2010) support a positive self-image. Self-actualization and the ability to take care of oneself is of vital importance to people suffering from an eating disorder, where performing life in a negative way often is the case (Claude-Pierre, 1999). Hence, the music therapy process supported Simon’s positive bonding between the dimensions of physical/mental and existential well-being (Sigurdson, 2008). The Ambiguity of Instruments Playing instruments had different functions for Simon. They were a concrete means of expression, a referent of an affect, an extension of his body and a symbol (Trondalen, 2006). Other elements influencing Simon’s experience of music-making on instruments seemed to be the instrument’s material, size, visual appearance, texture and sound. He favored the xylophones, but throughout the therapy process, he selected a variety of instruments, which he connected to his own feelings and bodily affects. An example was when he firmly decided not to play the drum kit because he was “not so angry today.” Instead, he chose the big tubular bells to express softer emotions. Simon seemed to be empowered through his personal choices to speak, remain silent, play/not play music, choose an instrument, along with the personal meta-reflection he developed within the context of music therapy. This was observable in his own deliberate awareness of changes in his emotions, which followed his actions. It was obvious he felt he had the right to personal choices, a position connected to individual empowerment (Zimmermann, 2000; Rolvsjord, 2004). Simon also used instruments as a way of “projecting” physical, mental and existential dimensions of himself into the instruments in the musical relationship (Alvin, 1966), while experiencing neither loss of control nor destruction of the relationship. This was evident in the last improvisation performed on two equally large African drums, an improvisation that Simon enjoyed very much. The musical relationship seemed to function as a relating space, allowing for regulation of inner tension and social interaction (Frederiksen, 1999; Robarts, 2000; Stern, 1985/2000). Simon explored dynamic and rhythmic patterns, which created an illusion of moving toward controlled “spreading out” and controlled “holding back,” from a psychological point of view. “I am not so afraid any more,” he said in session ten. This statement was observable in his life outside therapy as well: little by little he returned to college, found a girlfriend and slowly decreased his sessions in psychotherapy and music therapy. He seemed to acquire renewed self-esteem, believing he could manage his life in a normal way again. One important experience for Simon was connected to performing on the piano (session seventeen), an instrument that may be interpreted as a transformative social symbol. On the one hand, the piano is a powerful solo instrument. On the other hand, it belongs to a group of instruments (e.g., an orchestra). Perhaps unconsciously, Simon wanted to try out a social practice; an experience of participating in a socially normal relationship both at a personal and relational level. A sense of belonging, in addition to a personal pleasure of music making, are important elements for developing musical identity (Ruud, 1997).

Musical Relating Experiences as Potentials for Change In his daily life, Simon struggled to connect to himself and others. “I do not know — I do not know anything,” he often said. Nevertheless, in music therapy Simon decided to make personal choices of action by selecting instruments and participating in the musical improvisation. From a theoretical point of view, such an experience of being able to influence at a concrete and interpersonal level supports the development of a “core self” (Stern, 2000 p. 69ff.). At a practical level, Simon was empowered through personal choices, observable through a change in behavior and a new awareness of his personal emotions. Playing music together allowed for joint experiences of processes of “moving along.” Sometimes the musical actions were in the foreground, at other times the most important thing was how it felt to be together in the music (implicit knowledge) (Lyons-Ruth, 1998; Stern, 1998). “It does not necessarily sound better, but it feels better,” Simon said after one improvisation. Another example of shared experience (i.e., intersubjectivity) is the event including the condensed awareness and a smile after the long improvisation in session seventeen. Such joint experiences, although not identical, seemed to support appreciative recognition at an existential level, and supported Simon’s ability to share inner feeling states. Accordingly, he seemed to benefit from such an interpersonal tension and mood exploration in the musical relationship (Lask & Bryant-Waugh, 1999; Robarts & Sloboda, 1994). In the therapy process, Simon and the therapist also explored these musical experiences through verbal exchange. Such dialogues, where both have been actively involved in the music, allowed for a verbal exchange rooted in a shared — but individually informed — form of vitality. Such a sharing of non-verbal experiences, of “dynamic forms of vitality”6 at a non-verbal level, is connected to any temporally based human activity that evokes a felt experience of another. Following, dynamic forms of vitality concern “how” something is done and not the “what” or “why” (Stern, 2009). To Simon, the musical sharing really seemed to support dynamic forms of vitality from an ‘inside perspective’ and was related to his feeling of being alive: “Improvisation gives energy” and “the music reflects my feelings.” The verbal dialogues where lived experiences were explored in a relating context seemed to support Simon’s connection between inner and outer life. From a therapeutic point of view, this may mean a closer connection between lived experiences and experiences that are verbally narrated. Such a combination of the client’s personal inner and outer stories may challenge and change the client’s perception of him/herself (Stern, 2000, Trondalen & Skårderud, 2007). When lived experiences and the narrative based on real experiences are connected in real life, as in Simon’s case, a fusion of the two stories support meaning and symbolic emergence. This is particularly relevant in anorexia nervosa, where alexithymia, an inability to connect words and feelings, is often a central characteristic (Cochrane et al., 1993; Trondalen & Skårderud, 2007). Summary This chapter addresses expressive individual music therapy in an outpatient setting with a young man suffering from anorexia (AN/B). The theoretical framework is rooted in humanistic

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

CASE TWENTY-NINE Musical Improvisation in the Treatment of a Man with Obsessive Compulsive Personality Disorder José Van Den Hurk Henk Smeijsters Abstract A 31-year-old man who was undergoing psychotherapy for feelings of doubt, unrest and panic was referred to music therapy to work through his emotional and interpersonal blocks. Musical improvisation was used as the primary method over the one year of treatment. The authors worked as a team, combining perspectives of therapist and researcher in assessing the client, formulating aims, designing treatment, and evaluating progress. Background Information At the time of this study, John was a 31-year-old man who had been referred to a psychotherapist by a general practitioner because of intense feelings of doubt, unrest and panic when making decisions. His problems with decisions were pervasive, involving important life choices such as not being able to choose between his wife and his girlfriend, and everyday tasks as making an appointment to have his car serviced. John had been referred to a psychotherapist before, but he did not continue with treatment after the first session. This time, however, his panic attacks were increasing in intensity, and the need for psychotherapy was more obvious to him. John was living with his parents temporarily. He also worked with his father at the same company. John was very dependent on his father, and had, in fact, relied upon him for support while studying for his diploma. John looked to him as an authority figure, and the father, in turn, reacted strongly to his son, commenting regularly on his conduct and life. Being financially welloff was an important factor in John’s life. At work, John had occasional problems with his colleagues and supervisors; however he did function in a group of friends with whom he shared interests and hobbies. There were no indications that John was using alcohol, drugs or medication at the time of treatment, although in the past, his alcohol consumption had been higher. When therapy began, John was also under the treatment of a dietician for high cholesterol levels. John was referred to music therapy, because his current psychotherapist felt that music could help him to work through his rationalizations and emotional armors. Music Therapy Assessment

Because music therapy was being used in tandem with verbal psychotherapy, and because the authors worked together in combining treatment and research (Smeijsters, 1990), information on the client’s problem was gathered in several ways, including: (1) conversations with the psychotherapist previous to and during treatment; (2) a musical intake, consisting of 5 sessions in which both active and receptive forms of music therapy were used (e.g., improvisation, listening to music and looking at photographic materials, choosing preferred music, etc.); (3) short reports which the client wrote on request of the music therapist; and (4) continual communication between researcher and music therapist based on written clinical reports on each session. Data from the first three of these sources gave an impression of John as an obsessive neurotic character (Cullberg, 1988; Kuiper, 1989). John did not dare to make decisions, and he constantly wanted validation for any decisions that he did make. He had a strong need for order, and was unable to cope with any deviations from rules. He was afraid of being overwhelmed by irregularities, and he avoided experimentation at all costs. John generally took an intellectualizing or controlling attitude, repeatedly asking whether he should behave in one way or another and why. He rarely admitted having any emotions, although some did surface in the musical intake on a few occasions. He felt uncomfortable in the presence of the female music therapist, and was meek and passive when interacting with her. The music John produced during the intake was quite conventional, as if he were trying to adhere to musical norms or rules. It was characterised by fixed harmonies and diatonic melodies. He did not experiment. He chose large instruments, yet his playing was submissive. Motorically, his playing was restless, but the volume was rather flat. If rules were broken, he reacted strongly. On one occasion, he selected a piece of music that moved him to tears; on another, he selected a piece which was quite aggressive sounding. John’s intellectualizing attitude, his tendency to deal with problems and emotions in a rational, business-like fashion, his difficulties in accepting emotions, his rigid patterns of behavior, and his inability to be playful, all provided clear indications for music therapy (Schalkwijk & Luttikhuis, 1990) using an improvisational approach. By creating a safe atmosphere within the music therapy setting, and by using musical improvisation as a medium of self-expression, John would be able to learn how to make decisions, to be less concerned with rules and standards, to experiment with new behaviors, and to admit, express and vent his emotions. Method Music therapy sessions have been held once weekly over a one year period, and at the time of this writing, John is still enrolled in treatment. Sessions are one hour long, and are held in the rooms of the Music Therapy Laboratory in Nijmegen. Although both active and receptive techniques were used in the intake, active participation in improvisation has been emphasized since then. The improvisations are based either on a musical theme (rhythm, melody, etc.) or on a verbal theme (idea, emotion, event, etc.) related to the client’s life. The improvisations are aimed at engaging John in decisionmaking and experimentation, while also providing a screen for projecting his emotions (Priestley, 1975; Hegi, 1986).

The approach to psychotherapy is based on several constructs, including: • • • • • • •

The aesthetic illusion (Kris, 1952) which by its protective function makes acting and feeling less threatening The creative performance that brings healing (Klein, 1955; Winnicott, 1971) The unblocking of emotions by evoking, reliving and physically discharging them (Lowen, 1969) Gestalt concepts like awareness, response-ability and experiment (Perls, 1969; Hegi, 1986; Frohne, 1990) Client-centered, humanistic ideas on self-concept (Rogers, 1961) The role of mourning in working with the past (Kuiper, 1989) Improvisational techniques used by the music therapist are derived from Bruscia (1987) (See Glossary). Treatment Process

Based on the assessment findings, the music therapist and researcher identified “focus points” for the treatment process. Focus points are problem areas of the client which have been identified as priorities for intervention. As such, they are goals that the therapist keeps in mind throughout each session. Focus points are established through a spiralling process. Based on assessment, the most important areas of concern are identified for different stages of treatment. General aims and specific objectives are then formulated along with strategies for intervention. Then, based on what results are achieved with the client, these areas of concern, goals, objectives, and treatment strategies are constantly adjusted. In the present case, this process was carried out jointly by the therapist and researcher. Subsequently, the role of the therapist is to implement the actual work with the client, and the role of the researcher is to observe the reactions of the client to various therapeutic strategies, and to evaluate the client’s progress in meeting the objectives. This cooperative approach helps to give the therapeutic work more accountability. John’s music therapy can be divided into three stages so far, each with its own set of focus points. First Stage After the musical intake of five sessions, the first stage of treatment lasted 10 sessions. This stage was defined by its own focus points, aims, treatment strategies, and expectations of progress. Focus Points. Five focus points were established for the beginning stage of treatment. They were: (1) John had an intense need for security, predictability and set rules. From the very first contact, it was obvious that John did not want to take any risks. He was afraid of the unknown. In musical improvisation, he demonstrated these fears by being passive,

submissive, uncreative, and lacking in spontaneity. He selected instruments with which he was more or less familiar, and he did not experiment with them. Whenever the music therapist did not conform to his rules or expectations with regard to music-making, John would become tense and irritated, demonstrating his inability to deal with unpredictable behavior in a flexible, creative way. (2) John had feelings of inferiority which resulted from his inability to meet his own unrealistic aspirations and standards. He behaved very conservatively, and sometimes thought that he was useless. In music therapy, these characteristics were evident in John’s self-criticism when attempting to play an existing piece perfectly, and in his comparisons of his improvisations with music of mentally deranged persons. In his personal life, his high aspirations were evident in the area of finance. Possessions, like a big car, served as compensation for feelings of inferiority. A vicious circle had come into being, in which standards and aspirations led to feelings of inferiority which had to be overcome by even higher standards and aspirations. (3) John often doubted himself and needed validation, approval and reassurance. These could be regarded as symptoms of his inferiority feelings, and were particularly evident when making decisions. For John, making a decision was taking the risk that his choice would not meet with the approval of others. He therefore continually questioned others before deciding anything in order to insure their approval. This occurred when choosing musical instruments and in the comments he made about his own improvisations. (4) John had an intellectual, non-emotional attitude. He talked a lot, but in a businesslike fashion, constantly seeking rational explanations and suppressing any emotions. He played music mechanically, and reported experiencing no feelings or tensions. He would never expose or express his feelings in the sessions, and talked about feeling ashamed to do so. On those occasions when he could express his feelings, he admitted to being very sensitive. At the end of sessions, he always asked for explanations or interpretations of what he did. These attempts to rationalize and intellectualize his emotions can be taken as methods of defending and protecting himself against being hurt. (5) John feared intimacy, and often behaved in a self-centered manner. This was clearly shown in his music-making. He would play without paying any attention to the therapist, and would not dare to make musical contact or have the experience of playing together. He would not try to match what the music therapist did, and he would quickly change his music if the therapist matched him. Musical contact was established only when the music therapist specifically asked for it. These ways of avoiding intimacy were particularly evident when the situation called for equality, and when there was no clear delineation of who was leader and follower. Aims. Given these focus points, the aims established for therapy were to help John: to abandon rigid patterns, to accept and react to unpredictable situations, to experiment and take risks, to take more initiative and responsibility, to make choices more freely, to enjoy his own

music, to let go of his unrealistic expectations, to be less isolated and to allow greater intimacy in his music-making. It was decided that, only after a safe atmosphere could be established in music therapy, would aims related to his emotions be pursued. Action Plan. It was decided that the best way to accomplish these aims was to engage John in improvisatory situations that systematically varied the amount of risk and intimacy involved. The main variables were: whether John had to choose the instruments, whether the instruments were familiar to John, and how much distance the instrument created between John and the therapist. Several levels of risk and intimacy were identified for organizing each session: (1) The music therapist selected two different but familiar instruments (e.g., guitar and percussion), one for John and one for herself. In this way, John did not have to make any decisions, and was permitted to play a familiar instrument that was distant from the therapist’s in terms of timbre. (2) The music therapist selected two identical, familiar instruments (e.g., two drums). Here John did not have to make choices or deal with anything familiar, but had to tolerate the closeness in sound of his instrument and the therapist’s. (3) The music therapist picked two unfamiliar instruments (different then identical). This allowed John to experiment with something new, first at a safe distance from the therapist, and then with increased closeness. (4) The music therapist picked one instrument for both John and her to play, first a familiar one and then an unfamiliar one. Here John did not have to make a choice, but had to tolerate the intimacy of playing on the same instrument. (5) John picked the instruments in the same order as described in 1-4 above. This added the challenge of decision-making, while allowing him to control familiarity and intimacy. The improvisations were sequenced during the sessions according to the above levels. The musical improvisations following the combinations of freedom of choice, familiarity and intimacy formed the most important element of the plan of action. Daring to experiment, taking initiatives, making contacts and learning how to enjoy one’s own spontaneous performance were worked on through the improvisations. When improvising with John, the music therapist initially used techniques of “empathy” (e.g., imitating, synchronizing, pacing and reflecting), as defined by Bruscia (1987). Care was taken to offer enough distance, while also creating a safe place for John to begin taking the necessary risks. After a safe atmosphere had been established, the music therapist began to use techniques of “elicitation” and “redirection,” such as repeating, making spaces, interjecting, introducing change (Bruscia, 1987), all aimed at encouraging John to experiment, take initiatives, and react spontaneously. To strengthen intimacy, she used techniques of “intimacy” (e.g., sharing instruments and sharing intensity of playing). See Glossary for definitions.

Verbal instructions were also helpful. For instance, the music therapist would say: “Let’s try to make contact by reacting to one another’s music,” or “There is no need for you to prove yourself.” Progress. During the first stage of music therapy, changes were observed in John’s musical and verbal behaviour over a number of consecutive sessions. Changes could also be observed outside of the therapy situation, although it cannot be claimed with any certainty that these changes were caused by the music therapy, because John was also receiving psychotherapy concurrently. There was, however, a logical connection between focus points, therapy techniques and behaviour in and outside of music therapy. During the first few sessions, there were only brief spells of playing together, at which time John would quickly change over to a different rhythm or musical instrument. When he took up the music therapist’s rhythm he did not really make contact, but rather went his own way. John reacted to the music therapist’s playing only when she demanded him to do so. He hardly paid attention to what she was doing, and was centered primarily on his own regulated, mechanical, technical and not very spontaneous ways of making music. The music therapist tried to get into feelings underlying the music, but found she could not. John’s verbal comments and written notes further underlined his musical behaviour: “I keep a distance, it seems like I am not there;” “I feel like I have to achieve something;” “I am afraid of exposing myself;” “I am insecure and I feel ashamed.” In later sessions of the first stage, these tendencies gradually changed. Playing the piano enabled him to pay more attention to the music therapist, because he could let go of his ambitions. This did not happen with the electrical guitar, which brought out his feelings of having to prove himself because he had studied the guitar. On the piano, this competitive spirit disappeared, and he was able to come out of his egocentric isolation and react to the music therapist. His music became more vital and dynamic, and it expressed more feeling, however spontaneity was still lacking. In subsequent sessions, John spontaneously picked the piano for his instrument. He increasingly dared to put more of himself into it, to respond to the therapist’s music, and to experiment without fear. Playing the piano, close to one another, was initially experienced as threatening. The fact that John abandoned his rigid, rule-oriented attitude was evident in statements like: “I increasingly experience the therapy situation as relaxed;” “I feel less like having to achieve something;” “The ensemble was more imaginative, less beautiful, but more enjoyable though;” “The performance is more intensive.” These reactions showed that he still had a normative frame of reference (“less beautiful”), but that he was also learning to see the possibilities of non-normative, free self-expression. He felt more relaxed and liberated, and he discovered that through music, imagination and emotional intensity were possible. John showed considerable insight into his own musical behavior. He wrote down, for example: “I find it difficult to take the lead when I am on unknown ground;” “I am afraid of setbacks;” “I only take the initiative when I feel quite sure about something;” and “When I am on unknown ground I wait and see what happens.” As for events outside of therapy, John indicated that he went for trips in his car without having to meticulously arrange and discuss everything in advance. Although he still had some difficulties with insecurity during these excursions, he had never dared taking such an uncertain

step before. John was developing a new attitude, one which was generally less rational and controlling, yet more self-assured. He said that now he knew what he wanted, what he was capable of doing, and what he felt. This was further evidenced by his intention to return to his wife, and the fact that he felt stronger with respect to his girlfriend. Second Stage As therapy continued, and John made more progress, the original focus points needed less and less emphasis, except for one. Up to this point, the acceptance of and dealing with emotions had only been touched upon indirectly. John had greater insight into his own behaviour, and had made changes in his behaviour both in and outside of music therapy, but he had not overcome his emotional blocks. Given his progress in the other areas, and his decision to end the relationship with his girlfriend, it seemed the appropriate time for him to pay more specific attention to working at the emotional side of things. Focus Points. At the beginning of the second stage, which lasted for 8 sessions, the focus points were readjusted as follows in consultations with the client: 1) John had an indistinct personal identity. His concern for rules and norms, and his constant efforts to conform to other people’s standards, had led to a self-concept in which there was no room for certain needs and feelings of his own. Because of this, John had lost touch with parts of himself, and had a weak identity, one that allowed for inaccurate self-evaluations, insecurity, indecisiveness and dependence. 2) John’s emotions were repressed. Underlying his conforming, technical and rational attitudes were many emotions that had not been adequately acknowledged or expressed. In addition, after he split with his girlfriend, he had to adequately deal with his feelings of loss, and the natural mourning process that ensues from ending such a relationship. Following the first step of making a decision comes a second one—living through the emotional consequences of the decision. John expressed a willingness to work on his feelings of grief. Aims. These focus points were shaped into two aims: to help John discover his own identity, independent of confirmation and approval; and to enable him to relive repressed experiences and go on living emotionally. Action Plan. In the routines used to strengthen John’s identity, all instruments in the room were used, so as to enhance the experimental character of the activities. Initially, the music therapist and John together selected: what instruments would be used, how long they were to be used, when to switch to another instrument and in what way the music should be played. Making decisions together still retained an element of confirmation by the therapist. Later, John would take on these responsibilities by himself. This would help him to focus more on his own desires, needs, and wishes, and thereby express his own identity. Improvisational techniques employed by the music therapist during this stage were primarily in the “redirection” category (e.g., differentiating, intensifying, and intervening).

The strategy for helping John to express emotions involved having him musically represent or depict a feeling. For instance: “Recall the atmosphere, the feeling of the past week;” “Play the times in which you feel good and the times in which you feel bad.” While John played these titled improvisations, the music therapist supported him with techniques of “empathy” (pacing, reflecting), “referential” techniques (projecting) and techniques of “emotional exploration” (holding). Progress. The effects of these two strategies could be seen in changes in John’s musical and verbal behaviours. As a consequence of the first stage, John’s fear of the unknown had been lessened. He was able to choose unfamiliar instruments more readily, as illustrated by statements like: “I felt less restrained in changing instruments; I changed instruments out of curiosity, with the objective of improving the ensemble, and as a reaction to what the music therapist was doing.” Still the fear had not entirely disappeared, for John would still not dare, for example, to look into the covers of the recorders. In the beginning, the client hardly offered any resistance to the music therapist; his musical identity was weak and he mostly let himself be guided by her. After he had come out of his egocentric isolation and had made creative contact in the first stage, he still could not offer any resistance. When the music therapist cut straight through his performance, he avoided the confrontation and either let the music therapist have her way or switched to another instrument. This way he could escape any “problems.” He did not yet have behavioural alternatives at his disposal with which he could display his own distinctive features. Some irritation arose when the music therapist played the recorder, but John did not protest, but rather let it happen. This passivity gradually diminished. In contrast to the superficiality of earlier sessions, John showed more and more concentration and force in his playing, focusing attentively on his improvising for long periods (at times as much as 45 minutes). He showed great self-assurance when using the kettledrum, to him a symbol of strength and self-confidence, and on the vibraphone, he started to allow the notes to reverberate. At this time, the music therapist changed roles, and gave him the lead and herself took the supporting part. By doing this she achieved that his individuality was more stressed. A statement like “I liked having to take the initiative each time and being supported by the music therapist” indicated a reinforcement of the identity. While doing the representational or referential improvisations, John was able to begin reliving past moments of grief. In selecting and playing the various instruments, he projected several emotions. He used the zither as an instrument of sadness, and played it in a grating way, sustained the notes. He expressed his hesitations and obstacles on the temple-blocks and other small percussion instruments. On the split drums he got into a trance, which provided him a moment of regression and flight from the present, but he used powerful strokes on the kettledrum to bring himself out of the trance and back to reality. Feelings of sadness were sometimes accompanied by violent emotional release, as shown in the following example. John was depicting his sadness on the zither while the therapist supported him on the orchestra bells. His sadness was expressed mostly in low, soft and whining sounds which he transferred from the zither to the vibraphone. As the improvisation continued, he started playing louder and louder, with two sticks at a time. Then

he switched to the kettledrums, and his movements and the sounds got fiercer and louder. Finally a sturdy, cheerful and powerful sound arose from the drums. Through this musical process, John went through the stages of a mourning process, characterised by grief, anger and illumination. His verbal comments afterwards verified this: “By playing the vibraphone, the kettledrum and the drums I finally achieved complete relaxation,” “I got out of it and I feel indestructible,” “I impressed upon myself that I was doing what was best for me.” He said he wanted to hang the zither on the wall, as a symbol of grief overcome, but in reality, it took considerably more time to adequately deal with his grief. Undoubtedly, the most important event outside of music therapy was John’s acting out his decision to return to his wife and end the relationship with his girlfriend. John knew what he wanted now, and he openly admitted it. In his work situation, he acted more self-assured and he was capable of doing things without the confirmation of others. What he did made him feel “good.” He said he generally felt well, and that he was no longer unhappy. Another event illustrated John’s new way of coping with difficult situations. He reported an incident in which he was trapped in an elevator for five hours. Throughout the entire time, he did not panic, but instead remained calm and self-assured. Third Stage The third stage began after John had adequately dealt with and expressed the various emotions involved in splitting with his girlfriend. Lasting only two sessions, this stage can be regarded as a consolidation of previous accomplishments in therapy. Its main focus was trying to find a balance between distance and proximity, which involved the integration of several of the old focus points (taking decisions, making choices, intimacy, emotional response, identity). During the improvisations, John could lead the ensemble into a certain direction by means of rhythm and dynamics, without needing confirmation for this kind of behaviour any longer. The music therapist supported him. Where previously she had always had to take the initiative; the client’s resolute manner now made it difficult for her to do so. The client’s relation with his wife was still strenuous, though, especially where sex was concerned. This problem was closely related to the focus point on intimacy. It was decided that the individual therapy is to be followed by relation therapy. The relation therapy will not be taken into consideration here. Discussion and Conclusions It is striking to see that, consistent with the anticipated indications of music therapy, this approach to treatment was extremely well-suited to John. Problems in his daily life found a direct translation into the music therapy setting. Furthermore, John himself was fully capable of making links between his behaviour in and outside of music therapy. For example, John did not dare to take responsibility in his normal life, and he did not do so in his musical improvisations either. In his relationships with others, he hardly offered any resistance, and in musical improvisation he could not confront the music therapist’s challenges. On the whole, John underwent a sequence of changes which can be directly related to stages of treatment. John strengthened his identity through a number of steps. During the first

sessions of the first stage, he was completely self-centered. As a result, there was hardly any contact with others initially, and there was little possibility for experimentation and reactions within the improvisations. By creating a safe environment, and offering new possibilities within it, the music therapist helped John to let go of unrealistic expectations and standards, and to achieve a freer and more sharing kind of music-making. Out of his normative egocentrism, John came to discover new possibilities in himself: the ability to perceive and react to others. As he discovered himself, he was able to discover the other, and vice versa. In the beginning of the second stage this led to a more flexible but nevertheless submissive musical stance. John did not offer any resistance, and had no clear musical identity as compared to the music therapist. He only found his identity after the music therapist gave him the leading role in the improvisations. In the third stage, John was so strong that he wanted to keep the leadership role. In summary, John went from having no contact to having experimental but subordinate contact, to having a contact in which he developed his own identity. In the end, John was able to communicate and interact with another person without losing himself in the process. Acknowledging and dealing with emotions also took John through several steps. Initially emotions arose, incidentally or accidentally. Experimenting with different behaviours and learning to enjoy this new way of playing, both of which occurred during the first stage, developed a further dimension in the second stage when he learned to accept emotions. That the two coincided showed in John’s verbal reactions. He once commented that being less open to pleasure took away from some of the pleasure to be sure, but it also lessened the sensitivity to pain. John had the idea that not being able to enjoy things is the price one must pay to rid oneself of pain. With the increase of pleasure during the first stage, feelings of grief were allowed to enter during the second stage. Acknowledging the importance of emotions was preceded by greater freedom and pleasure in social interactions. Thus, the second stage can be regarded as a “deepening” of the first stage. There, John actively sought for a musical equivalent of his emotions and he found a suitable musical vent for his feelings of anger. Where the first and third stage focused on musical interaction, the second stage focused on the symbolic meanings of the musical instruments and on the musical utterances which made reliving emotions possible. What happened in music therapy was a close analogy of what happened in reality, outside of the therapy situation. However, there was one large difference: musical improvisation was no more than playing, without any actual, negative consequences. This shielded situation helped John to cross a threshold. The non-verbal and non-rational nature of music therapy was responsible for getting him away from old patterns of behaviour. The music provided him with a situation that was unfamiliar to him, with unregimented and limitless possibilities for playing, all with physical and emotional appeal. It was also important that John did not have to prove himself, and that in the therapy situation, the process of making contact through music was given more importance than the artistic quality of the musical product itself. Upon reflection of how the focus points shifted, one finds that music therapy proceeded in a spiral pattern. Primary problems and the therapeutic objectives derived from them were exchanged for others; realizing certain aims followed only upon accomplishment of others. This

made the music therapist continually aware of the possible effects of her actions. If music therapy is effective and leads to changes in behaviour, these changes in consequence influence the further course of the treatment. Thus, therapy is a continual and spiralling process of readjusting the focus points, aims, and plans of actions. Thus, treatment methods are not established a priori. During this case study, the music therapist and researcher worked in close cooperation. The researcher took the part of the critical partner in this, the one who was constantly asking questions like “What is the problem?”, “Is the problem still the same?”, “Why are certain objectives selected?”, “Why is an objective being changed?”, “Why do you take this plan of action, this method?”, “What do we do if actual events cross the treatment?”. He also organized the rough data and fed it back to the music therapist. The music therapist’s part constantly changed along the continuum of leading versus following. Sometimes she followed the client, in those cases where creating a safe atmosphere or the supporting of expressions of emotions were concerned. At other times she took the active, leading part, because the client needed structure, or because the client needed a certain challenge, or because the client needed someone in opposition. Thus the participating role of the music therapist, one of the features of music therapy, can be described in terms of several gradations of activity. Glossary Aesthetic illusion: a situation of play and fantasy in art that is not dangerous or forbidden because it is not real. Differentiating - simultaneously improvising music that is separate, distinct, and independent of, yet compatible with, the client’s music. Holding - as the client improvises, the therapist provides a musical background that resonates the client’s feelings while containing them. Imitating - echoing or reproducing a client’s response, after the response has been completed. Intensifying - increasing dynamics, tempo, and rhythmic and/or melodic tensions. Interjecting - filling in spaces in the client’s music. Intervening - interrupting, de-stabilizing, or redirecting fixations, perseverations, or stereotypes of the client. Introducing change - initiating new thematic material and taking the improvisation into a different direction. Making spaces - leaving spaces in one’s music for the client to fill. Obsessive Neurotic Character: individuals who regard thoughts as more important than feelings, and who have a strong need for orderliness and an incapability of making decisions. Pacing - matching the client’s energy level. Projecting - having the client improvise music that depicts a real situation, feeling, event, relationship, etc. Reflecting - matching the client’s moods, attitudes, and feelings. Repeating - reiterating the same rhythms, melodies, lyrics, movement patterns, etc. either continuously or intermittently. Synchronizing - doing the same thing as the client at the same time.

Techniques of Elicitation: (Bruscia, 1987) Techniques of Emotional Exploration: (Bruscia, 1987) Techniques of Empathy: (Bruscia, 1987) Techniques of Redirection: (Bruscia, 1987) Techniques - Referential: (Bruscia, 1987) References Bruscia, K. E. (1987). Improvisational Models of Music Therapy. Springfield, IL: Charles C Thomas Publisher. Cullberg, J. (1988). Moderne Psychiatrie Baarn: Ambo. Frohne-Hagemann, I. (Ed.). (1990). Musik und Gestalt. Paderborn: Junfermann-Verlag. Hegi, F. (1986). Improvisation und Musiktherapie. Paderborn: Junfermann-Verlag. Klein, M. (1955). The Psychoanalytic Play Technique: Its History and Significance. In P. Heimann (Ed), New Directions in Psychoanalysis. London: Tavistock. Kris, E. (1952). Psychoanalytic Explorations in Art. New York: International Universities Press. Kuiper, P. C. (1989). NieuweNeurosenleer. Deventer: Van Loghum Slaterus. Lowen, A. (1969). The Betrayal of the Body. New York: Collier Books. Orlinsky, D. E., Howard, K. I. (1986). Process and outcome in psychotherapy. In S. L. Garfield and A. E. Bergin (Ed.), Handbook of Psychotherapy and Behavior Change. New York: John Wiley & Sons. Perls, F. S. (1969). Gestalt Therapy Verbatim. Lafayette: Real People Press. Priestley, M. (1975). Music Therapy in Action. London: Constable. Rogers, C. (1961). On Becoming a Person. Boston: Houghton Miflin. Schalkwijk, F., Luttikhuis, C. (1990). Opstellen over Kreatieve Therapieén. Nijmegen: Hogeschool Nijmegen. Smeijsters, H. (1990). Methoden van Onderzoek in Muziektherapie en Andere Kreatieve Therapieen. Nijmegen: Hogeschool Nijmegen. Smeijsters, H. (1991). Muziektherapie als Psychotherapie. Assen/Maastricht: Van Gorcum. Winnicott, D. (1971). Playing and Reality. London: Tavistock.

Other E-books in this Series Available from: www.barcelonapublishers.com Case Examples of the Use of Songs in Psychotherapy Case Examples of Improvisational Music Therapy Case Examples of Guided Imagery and Music 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)

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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)

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