Reflected Sounds E-Book

• Herausgeber: Psychosozial-Verlag
• Kategorie: Geisteswissenschaft
• Serie: psychosozial
• Sprache: Englisch

Seitenzahl: 451

Veröffentlichungsjahr: 2013

Beschreibung

Music in therapy allows a sensual awareness of overlapping inner and outer spaces. This in turn allows thoughts to wander and linger over objects of interest that both contain the past and make possible the present, that are associated with amiable beginnings as well as leaving open what the future will bring. Due to these processes we do not only live once. Everything is reverberating, says Erich Fried, and continues: “and everything that I say about this echo, echoes and echoes“. This all happens within a further space, namely a social one that is able to maintain all social structures despite its fragility. The case studies presented by the different music therapists in this volume – previously in German and now in English translation – allow the reader to take a journey through very different spaces and to engage in a process in which their own presence develops through the resonance of events. Starting from common points of reference, that is, a psychoanalytic understanding of therapy and the use of music in individual therapy with patients suffering from severe and in some cases prolonged psychiatric disorders, the authors select that form of presentation which appears best suited for the respective case by alternating between descriptions, reflections, and explanatory or deeper theoretical considerations, by retrospectively organizing the material, by structuring, summarizing, or highlighting it, and – in specific cases – by including examples in the form of sheet music for the sake of illustration. With contributions by Jos de Backer, Maria Becker, Ingo Engelmann, Susanne Metzner, Inge Nygaard Pedersen, and Gitta Strehlow

Leseprobe

Susanne Metzner (Ed.)

Reflected Sounds

German original edition:

»Nachhall. Musiktherapeutische Fallstudien«

Copyright © Psychosozial-Verlag, 2007

The translation into English was kindly supported by Andreas-Tobias-Stiftung, Hamburg

Bibliographig information of Die Deutsche Bibliothek (The German Library)

Die Deutsche Bibliothek lists this publication in the Deutsche Nationalbibliografie (German National Bibliography). Detailed bibliographical data can be accessed via internet (http://dnb.ddb.de).

English EPUB edition of the German original edition

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Cover: Michael Dümpelmann: »Ohne Titel«, 2006

© Michael Dümpelmann

Cover layout: Hanspeter Ludwig, Giessen

ISBN German print edition 978-3-89806-740-9

ISBN EPUB edition 978-3-8379-6593-3

Contents

Preface (Susanne Metzner)

The Case of Adrian (Jos De Backer)

From cliff to cliff, year after year, down into the unknown. Music Therapy and Depression (Susanne Metzner)

Mine Alone Is the Land of my Soul. (Ingo Engelmann)

“I feel like my body is roped up – only in leaving the body is some freedom!” (Inge Nygaard Pedersen)

Music versus shards of glass (Gitta Strehlow)

Having to construct one’s own life instead of being supported (Maria Becker)

Preface

It is always in spaces where sound reflections arise: concrete spaces, where a clearly perceptible sound event is embedded in a flood of reflections coming from all directions and psychological spaces, where memories that are triggered by music lead to an intentional or involuntary awareness of past life experiences. When sound events connect with life events in such a way, spaces of concrete sound and imaginary psychological spaces overlap with each other, without losing the distinction between what is felt and what is real, between sensation and reflection, or between synthesis and analysis.

To leave behind the concrete presence of a sequence of sounds when listening to a piece of music and to not only hear individual sounds and their immediate relationship to one another as a justification for their coexistence, means to progress from the act of perception to the act of realization. This transition is apparently facilitated by the existence of sound reflection. Indeed, in the reverberation, memory is not the past of consciousness itself, but the past of music. However, because music has always existed in the imaginary, its reflection corresponds with our idea of the past.

Thus, we are dealing with a phenomenon, which can occur anywhere music is played and which can transfix anyone who is open to this experience. Music therapy avails itself of this in a special way. Music in therapy allows a sensual awareness of overlapping inner and outer spaces. This in turn allows thoughts to wander and linger over objects of interest that both contain the past and make possible the present, that are associated with amiable beginnings as well as leaving open what the future will bring. And this all happens within a further space, namely a social one that is able to maintain all social structures despite its fragility. And furthermore, we do not only live once. Everything is reverberating, says Erich Fried, and continues: “and everything that I say about this echo, echoes and echoes”.

The case studies presented by the different music therapists in this volume – previously in German1and now in English translation2 – allow the reader to take a journey through very different spaces and to engage in a process in which their own presence develops through the resonance of events. Starting from common points of reference, that is, a psychoanalytic understanding of therapy and the use of music in individual therapy with patients suffering from severe and in some cases prolonged psychiatric disorders, the authors select that form of presentation which appears best suited for the respective case by alternating between descriptions, reflections, and explanatory or deeper theoretical considerations, by retrospectively organizing the material, by structuring, summarizing, or highlighting it, and - in specific cases - by including examples in the form of sheet music for the sake of illustration. To maintain privacy, all names and other personal data have been made anonymous.

What makes each case unique is how the role of music is defined in it respectively always has to be redefined and the function of music as well as how music is handled in therapy, which is something that each patient and therapist always has to develop anew. Deviations from the standard setting of active music therapy with adult patients who are capable of verbalization, namely the alternation between talking and mutual improvisation, are more the rule than the exception here. So, for example, at one time there is almost no talking, at another time music is played only sporadically; in one case there is mutual playing without mutuality becoming a characteristic of the resulting music, another time a therapist plays for her patient; one time pieces are rehearsed, at another time compositions are played from a tape so that the distinction between so-called receptive music therapy or music lessons becomes blurred; at one time pieces of music that are the subject of conversation are not played; another time music serves to maintain discretion, to keep exactly that which has been experienced and that which was meant from coming up for discussion.

Accordingly, it is not a specific predefined function of music nor a specific indication for a certain music therapy technique (listening to music or playing music, improvisations with or without references, etc.) which are characteristic for psychoanalytic music therapy, but how the musical material is handled and how the connected interpersonal and intrapsychic processes are dealt with, namely from a psychoanalytic perspective. To understand these processes, the psychology of self- and object relations, psychoanalysis and infant research, dream theory, the theory of transference as well as symbol theory appear to be of particular relevance, which the authors have made use of according to their respective backgrounds.

There was no specific motive for the sequence in which the case studies are presented in this book. Although the idea of concordance and contrast played a role, the order could have been different, because there are other criteria which could have been considered as well. Thus, the reader is encouraged to choose the order according to his or her own liking and to enter the different spaces – like visitors of an art exhibition – depending on his or her own motives.The following short commentaries about the individual contributions are provided to guide the interested reader in the selection of the material.

*

Under the simple title ‘Adrian – a case study’Jos de Backer describes eight therapy sessions with a young psychotic patient. With the help of detailed descriptions of the musical interactions, he shows how from an initially unrelated, for this clientele typical play - ‘sensorial play’ in de Backer’s terminology - so-called ‘moments of synchronicity’ develop and congeal into ‘musical forms’ as products of a process of understanding. The analytic expertise of his evaluation should not gloss over the fact that the therapy was quite strenuous for the therapist who was required to accept the sensorial play as the only possible kind of play and to internally retain the resonance of the non-resonance and to hold on to it musically.

The fact that a positive development in therapy was already evident within a short period of time puts into perspective the sometimes observed, general reluctance of professionals in the field of music therapy to use free improvisation in therapy with psychotic patients. What must be kept in mind, however, is that the therapist must be able to integrate the musical interactions in a musical-artistic and musicological context, meaning that ‘free’ is not synonymous with ‘disoriented’ or ‘floundering’ and that those characteristics of an improvisation, indeed would be stressful for the fragile ego structure of this client.

Similarly, the case study entitled ‘From cliff to cliff, year after year, down into the unknown’, a line taken from a motet by Johannes Brahms based on the song of destiny by Friedrich Hölderlin, is embedded in a clearly discernible musical-cultural context. The inpatient treatment of a suicidal 75-year-old patient suffering from depression consists of only eight sessions; thisrather short period of treatment resulting from cuts in public health expenditures as well as the general instability of psychiatric patients has become typical for music therapists’ daily work routine in inpatient treatment. Depression, the most frequent psychological disorder according to the World Health Organisation (WHO), is not so easy to treat with techniques of music therapy because the potential of the medium of music to move the patient physically and emotionally is often in a too sharp a contrast to the depressive immobilization of the patient.. Still, in music therapy there is the chance to generate associations,which stimulate the imagination of the patients on the one hand, while on the other it becomes possible to build on positive experiences with music, for example, as a medium for consolation or to promote feelings of togetherness. Following a creative impulse, the therapist developed an idea about how to work with the music, which the patient was ready to accept. Starting with her associations to fragments of the patient’s biography, the therapist improvised on the piano and began a peculiar dialogue that proceeded in a spiral-like fashion as a result of the interplay between resonance and divergence of the verbal and musical symbolization. The patient’s biography and both women’s experience with therapy started to become more and more interwoven, and a generational conflict typical for Germany began to unfold, which is a story that has not yet been told in publications concerning music therapy.

The roots of Ms. S. disorder, diagnosed as schizoaffective psychosis, the case described by Ingo Engelmann in his contribution ‘Mine alone is the land of my soul’, can be traced far back into her personal and socio-cultural past. The presented case study is a description of the longest ongoing therapy process in this entire volume, covering a period of 14 years, which has not yet ended as this publication goes to press. In view of this extended period of therapy, Ingo Engelmann must adopt a different perspective for his evaluation from other authors and naturally must structure and also condense his narration. However, through the numerous details he presents, he is able to show how the hue of the initially bleak and hopeless life and illness situation begins to brighten up, how the movements of searching at first only bring forth faint points of references but which finally lead to a therapeutic relationship that is differentiated even though it is characterized by a high degree of dependency on the long term. The fact that the author is able to see and value the failed attempts to end therapy as a part of the relationship and to keep the client from suffering from acute psychotic decompensation in an outpatient setting, testifies not only to the therapist’s wealth of experiences gathered over many years but also to his willingness to deliver himself to an unspeakable endlessness that is also threatening to the ego of the therapist. This, in turn would not have been possible without a stable institutional framework that unfortunately has become quite uncommon nowadays.

The therapy of a 46-year-old borderline patient with post-traumatic stress disorder reported by Gitta Strehlow under the title ‘Music versus shards of glass’ takes place in the same psychiatric institution. The capability of the patient to accept music as an element of the therapeutic relationship was so limited for long periods of time that talking made up the major part of therapy; thus, what was mainly required was the psychotherapeutic competence of the therapist. Still, even the rejection of music can be seen as a component of music therapy because in the end the patient was in the position to express her own distress by letting the therapist feel what it means to be robbed of a part of her (professional and musical) identity, to be forced to go without the satisfaction of vital needs, and - in addition to this - to be rejected, manipulated, or threatened with breaking off the relationship. The patient had no alternative to defend herself against this once real threat than to fall back on the mechanism of splitting or fragmentation.

In close contact with the team of the psychiatric ward, the therapist agreed to a risky game in therapy, which developed into an extremely uncommon suicidal symptom that thwarted all efforts of the therapist to provide empathy or identification. But is not an uncommon symptom fascinating in its own way? Despite frequent interruptions in therapy, a common theme started to emerge; lying exactly between refusal and fascination there was the bud, which would allow ambivalence to be accepted within a maturing relationship that in the end would make possible new creative uses of music.

‘I feel as if my body were in a corset – only if I leave my body can I feel some freedom’–is a title, which suggests some parallels to the psychopathology described in the previous case study. Inge Nygaard-Pedersen tells the treatment story of a 39-year-old patient suffering from multiple anxiety disorder. Here too, the goal was to help the patient accept her own existence and herunique selfand to recognize and learn to accept her own basic physical desires and emotional needs by means of a therapy approach that was initially more supportive, but later increasingly confronting in nature. As one well knows, the prerequisite for successful psychoanalytic therapy is the careful analysis of counter-transference, which in this case pushed the therapist to her mental as well as physical limits, leading to a state of disorganization and extreme strain. In order to make use of such counter-transferences and projective identifications for a deeper understanding of patients with ego disorders and in particular to avoid evoking the actualization of ‘bad’ object parts in a therapeutic relationship that is not yet sufficiently stable, the author connects different phenomena of counter-transference with the so-called ‘listening attitudes’, that is, specific attitudes of listening or, in other words, foci of attention that either concentrate on the behaviour and the expressions of the patient or on the perception of one’s own feelings in reference to the patient. It also appears logical to derive the concept of ‘listening attitudes’ from musical practice, because when playing music, musicians concentrate on both the other and on the self; however, Inge Nygaard-Pedersen is careful in this regard and does not make any premature generalizations.

What is especially interesting in this case study is that the significant turning point of therapy appears to have come about by spontaneous impulse, namely as the therapist beat on the drum. Incidentally, a similar situation occurs in the story of the treatment of the patient suffering from age-related depression. In both cases, there is a vital impulse that seems to contradict the dictum of abstinence, a breaking of therapeutic conventions, a renunciation of a forced and artificial reticence. Although such behaviour is conflict-laden for a conscientious therapist, if one considers this with the necessary detachment, it would be a mistake to respond to the extreme constriction (anxiety or depression) of the respective patient alone with an extremely narrow definition of the therapeutic role. Put to use constructively, in other words, accompanied by the willingness to accept responsibility for one’s own impulsive actions, the risky as well as uncompromising concentration on the moment is a special ‘moment of synchronicity’.

The only individual music therapy treatment in this volume that is conducted exclusively on an outpatient basis is described by Maria Becker’s ‘Having to build up one’s life instead of being borne’. It tells the story of a 29-year- old woman suffering from anxious depression, who was traumatized early in life and grew up in a difficult social and family situation. The central theme of therapy was working on her fear of dependency and on her aggression in coming to terms with a destructive introject. The patient’s attempts to cope had, for instance, taken the form of forcing herself into a self-imposed straitjacket of being a disabled person in spite of her cognitive abilities. At first she appeared to turn music therapy into a kind of music lesson, by which she initially thwarted her therapist’s attempts to become emotionally involved in what was unbearable for her. Or rather, was it that she protected her from this? Only gradually did the distress with the music become audible in the distress of the patient, in particular in her waveringbetween thetraumatic object and her idealized self-image. Feelings of unattainability, of having failed, of being overpowered, and of being harassed, which the therapist was confronted with in her relationship to this patient and which presented a major challenge in this outpatient setting, were the expression of a destructive dyadic relationship. The spaces in this therapeutic relationship that are boundlessly separated and superimposed are sometimes reflected so strongly in particular text passages that the reader would be attracted as well as repelled by them if Maria Becker had not provided a means for the reader to distance himself or herself from them and facilitated understanding through her detailed theoretical explanations. In this way, the concept of the representation of the alien (Erdheim) used by the author is once more realized on the level of the text. Only if disturbing and threatening experiences with the unfamiliar are buffered, can curiosity for and interest in the unfamiliar be stimulated and maintained.

*

The theory and practical application of music therapy are implicitly intertwined, and actions such as telling and reading case studies are closely related because they are based on the same aesthetic approach: groping forward little by little, thinking things over, testing, and (re)creating. In both cases, in writing and in reading, it is a matter of interpreting works and reorganizing experience and knowledge with the help of the works themselves and again reorganizing the works with the help of experience and knowledge. In this spiral-like process of gradual recognition, concepts such as conviction and truth that are connected to rationality play a role, however, it seems more appropriate to use the broader term ‘comprehension’, since this term also refers to the primary process and – in terms of Goodman (1997) – to the identification of nonverbal symbolism, which can be found in abundance in the presented texts as well as in the course of the therapies.

In addressing this subject, the philosopher Martin Seel (2004) says that understanding is something very ordinary: “It is not only required in communication but wherever anybody is active in a specific way. This is so because actors are understanding persons. They understand themselves and their situation in one way or another. They are guided by their insights that give them orientation. They do not solely have intentions, they know that they have intentions (and, sometimes, even which ones). They do not solely have opinions, they know that they have (sometimes correct) opinions. For whoever understands, understands that he (or she) understands. He (or she) knows that what he (or she) does or does not do is open to subjective and intersubjective judgment. Whoever understands at all also understands that not all understanding is understood on its own. He can ask himself how a thing, a situation, a story, a fate should be understood – and how he should understand himself” (l.c.). (translation by E. Hertweck)

In this volume, six music therapists - each with his or her own individual psychoanalytic approach that varies somewhat from the others - tell their stories of treatment that document the processes of mutual searching by therapist and patient, the aim of which is to find moments of understanding. These are special rather than ordinary moments of understanding which are desperately awaited in therapy, with a clientele who suffer from serious psychiatric disorders, in view of the lack of understanding, missing resonances, lack of emotional commitment, doubting, and aimless wandering that have lasted for long periods of time.

As authors, the therapists pick up the thread of self-questioning that has been woven into each music therapy case right from the start. It is this perspective of becoming involved in order to understand that is adopted by psychoanalytic music therapy. The goal is to understand the comprehension that guides this kind of practice. Although the stories deal with how practitioners have understood their actions or how they understand their actions in retrospect, the process of comprehension cannot be considered finished as this book goes into print. This is so because not everything that is presented is included in the process of retrospective comprehension. There is still enough raw material, which one could understand or interpretations, which could be somewhat different if the perspective is changed. The authors are fully aware of this; hence these missing pieces should be seen neither as omissions nor as an intentional symbolic clinging to non-understanding. Rather, their acting, feeling, experiencing, and contemplating are all connected with a conception of the self and of the world that always makes them reexamine the question how something can be understood.

All the same, they are surrounded by comprehensions that arise from the experiences and convictions of others or that have become consolidated in the form of theories and concepts, the institutionalized professional profile, and the conventions of music therapy; these are forms of an objectivity that, however, can be challenged in reference to its comprehensibility and rationality. Thus, the text is written for an implicit readership that is allowed to formulate hypotheses and expectations concerning the development of the therapeutic process at any point in reading. As they read, the readers bring into play their prior comprehension of music therapy, their knowledge of the psychiatric clientele, and/or psychoanalysis in order to make concrete or fill in the gaps that have been left in the text. Their preconceptions are either confirmed, modified, or rejected in further reading; they are shattered and broadened by the ‘resistance’ of the text. Thus, from this perspective, it is by all means possible to consider this collection of texts as a kind of course book on psychoanalytic music therapy because the writings are the crystallization of an ongoing learning process. They address the question of what it means to be a participant (therapist, patient, reader) in a world that is founded on human understanding, and they deal with the world as it is experienced and understood.

Magdeburg, April 2013

Susanne Metzner

Literature:

Fried, Erich (1979): Nachhall. In: Liebesgedichte. Berlin (Verlag Klaus Wagenbach).

Goodman, Nelson (1997): Sprachen der Kunst. Entwurf einer Symboltheorie. Frankfurt am Main (Suhrkamp Taschenbuch Verlag).

Seel, Martin (2004): Weltverstrickt. Das Verstehen verstehen. Über den Sinn der Geisteswissenschaften. In:  DIE ZEIT 22.04.2004 Nr.18

1 Metzner, Susanne (Ed.)(2005): Nachhall. Musiktherapeutische Fallstudien. Giessen (Psychosozial Verlag).

2 generously supported by the Andreas-Tobias-Kindstiftung, Hamburg

The Case of Adrian

Jos De Backer

Introduction

A psychotic patient lives in a world of presence. He is the defenceless 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 fulfil their representative activity, even words are treated as meaningless things, as pure sound objects.

Working in music therapy with psychotic patients, one sometimes encounters characteristic, repetitive and consistently similar musical patterns. Psychotic patients tend to express their experiences and conflicts in musical improvisations, by ‘fragmented’ play, or constantly repeating rhythms or small melodic sequences. From clinical supervision and a general overview of relevant psychoanalytic and psychotherapeutic literature, looking specifically at Bion (1967), Dührsen (1999), Fonagy, P. and Target, M. (1996, 2000), Freud (1925), Lacan (1955, 1981), Ogden (1997), Tustin (1990), Van Bouwel (2003) Van Camp (2003) it became clear to me that this style of playing (with repetitive rhythms and melodic fragments) could be understood as an expression of a psychotic’s ‘sensorial play’. They cannot experience this music as something from themselves; there are only sounding sounds in which they are not implicated. They are not ‘in-spired’ 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. Thereby, 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

The University Centre Sint-Jozef is primarily a psychiatric hospital, connected to the ‘Katholieke Universiteit of Leuven’. The specific task of the Sint-Jozef hospital is described as the provider of specialised psychiatric care defined within a scientific basis and delivered by a multi-disciplinary team. The hospital has 17 different wards and comprises 355 beds for full hospitalisation, 65 beds for partial hospitalisation at night and 35 places for day-care. The hospital also functions as a development centre and highly values scientific research. In the centre there is a scientific ethical commission that monitors all research, with the possibility of redirecting projects where necessary    As a music therapist I am part of a department with a structured psychotherapeutic setting. Here, young psychotic patients and/or youngsters with a previous episodic psychotic history are treated in a residential setting. The setting caters for people with the diagnostic criteria for schizophrenia and the paranoid, as well as the autistic type. There are also youngsters with a schizoaffective disturbance, or a severe personality disturbance such as borderline personality disorder and schizotypal personality disorder described in DSM-IV. Symptoms such as delusions, hallucinations, thought and perception disturbances, hypochondria, grotesque interpretations, disturbances in body functions, autistic-like extreme regressive behaviour and serious contact disturbances are those most commonly found. With hardly any exception, this concerns patients with a weak 'ego strength' (for instance deficient reality testing, deficient logical thinking, deficient boundaries, limitation possibilities).

The length of treatment generally is three to six months. Certain patients chose to stay longer and can remain for up to one year. The ward can offer treatment to 40 patients at any one time.

Case Adrian

Anamnesis

Adrian is a seventeen year old adolescent. There were clear arguments for child psychosis at the time of admission, with fantasies, psychotic tantrums, blending together with the mother figure, and the inability to make adequate social contacts. As Soenens (2002) emphasizes the psychotic syndrome with young people is not unequivocal. Besides this, there were clear autistic-like features, such as going into a trance through auto stimulation, and also becoming relaxed when hearing the voice of his father (which, in a rather autistic way, gave him something onto which he could cling).

The parents of Adrian had been divorced for five years, but were reported to have separated eight years previously. The patient lived with his father or with his mother, according to what he wants at any one time, and also according to his mood. Although Adrian could have been able to have a good relationship with his parents, stepfather and brother, this was not possible because he had the conviction that he was not able to give love to them. On a social level Adrian had become completely lonely. School was also a very emotionally charged topic. He was, at the time of admission in his third year of high school, but would have to repeat that year again. At the point of the admission he had only been to school for four weeks, even though the school year had started six months previously.

The patient described auditory hallucinations, which were mainly voices that said incomprehensible things to him, as well as visual hallucinations (in particular, colours in the sky and a spaceship that came to him), without experiencing these phenomena as anything threatening. The patient also verbalised paranoid thoughts towards others, in the sense that he thought that people did not want the best for him. These ideas, however, did not apply towards his parents. The patient was reported to have a vitalised depressive presentation with confirmed anhedony, anergy, apathy, loss of initiative and insomnia.

Adrian also told how, since the age of six, he broke off branches of trees and waved them in front of his face in order to come into a kind of disassociate trance. He called this ‘zwadderen’ (neologism), a word that he developed for this ritual. When he went into this form of autohypnosis, he started to live very quickly in his aggressive ‘thought-world’, from which he said he had a lot of pleasure. The patient had several aggressive explosions at home, at school and at the youth psychiatry ward, where he had been initially sent. He repeatedly damaged the ward furniture and his own belongings such as a television and a stereo cassette recorder and he said that he tried to control his aggression by damaging things.

He felt better in the psychiatric clinic than at home, partly because of the presence of peers, and partly because of the security it offered him. Adrian had a few megalomaniac fantasies, through which felt he held the power over life and death, suffering and pleasure, illness and recovery. Adrian had an enormous, intense fascination with the idea of torturing people and then killing them afterwards by cutting their throats. More recently, he also seemed to have developed rape fantasies. Adrian reported how he wanted to torture his own girlfriend, which would give him a greater sexual pleasure than to make love in a normal way. Adrian told of how these thoughts sexually aroused him. However, in spite of this, he sometimes experienced a great agony when he realised that these penetrating thoughts were not normal. It was already the case that these very aggressive, uncontrolled thoughts had been ruling his functioning for a long time. Adrian was ambivalent: on one hand, he reported that he treasured his perverse and destructive fantasies in his trance-like states moments and how they sexually arouse him, while on the other hand, he reported that he experienced a great sense of personal agony from these fantasies, and had himself suggested he should be monitored in a youth psychiatric ward. This was how he arrived at the youth ward of the psychiatric hospital. A few months later, he was sent to the open therapeutic, structured ward for young psychotics.

Adrian sang in a school choir during his elementary school period. This singing activity ended abruptly because of an admission to the children’s psychiatric department. After that, he did not learn to play any musical instrument.

During the treatment, medication was prescribed for Adrian, but he refused to take it. He was prescribed Pipamperon (Dipiperon) a classic neuroleptic for behaviour disturbance, aggressively, hostility and impulse-regulation. The possible side effect of this medication is hypotension. The refusal of prescribed medication, such as seen with Adrian, might have some connection with what taking the medicine stands for, such as injury or the self-image of the patient, (Peuskens et al. 1988). The use of medication reminds the patient constantly of his illness and his weakness: “I have to be sick, because I have to take medication.” The prescription of medication or an increase of medication can mean an attack on the omnipotent fantasies of the patient because it is a sign of the loss of his control over the relationship with the therapist.

Presentation on admission

Adrian had difficulty integrating into the structured, multi-disciplinary approach of the ward. He did not take part in either the verbal group psychotherapy sessions or in the ‘theme’- meetings, occupational therapy, group music therapy or leisure activities. Only the sporting activities organised within the department were important to him. Words and relationships with the different therapists were too frightening and threatening for him, and the nurses reported feeling unsafe, with a sense of being under threat during interactions with Adrian.

Adrian’s facial expressions and attitude demonstrated a certain tension and the nurses had the feeling that he could become unpredictably aggressive.

During the weekly team-meetings, team-members expressed their powerlessness about providing Adrian with a reliable treatment and they came to the conclusion that he would be better off with individual music therapy.

Individual music therapy

Session 1: ‘Getting acquainted’

Adrian was punctual for his first appointment and he greeted the therapist with an insecure handshake. He appeared unsure and tense, avoiding eye contact and looking shyly about him. Adrian immediately sat at the piano and played the introductory melody of ‘Für Elise’1 and then asked the therapist if he could teach him the piece. This was piano music that he had known from his school days and which he had rediscovered on the ‘Napster’website. Unable to play the piano, he was unaware why this piece was so important to him or why he wanted so much to be able to play it. The therapist did not respond to his request and instead explained that music teaching was not part of a music therapy treatment. The therapist explained the framework for individual music therapy and that the sessions would take place every Monday afternoon. Adrian was invited to agree with the framework of the music therapy treatment.

After this verbal introduction Adrian asked whether he was allowed to improvise at the piano on his own. After this question, the session continued.

Sensorial play

Without any apparent mental preparation or any sense of anticipating inner silence, Adrian began to play.

Theoretical definition of Anticipating Inner Sound (AIS) (silence): One can describe the anticipating inner sound as the musical presence of an inaudible sound, in the silence that the music therapist experiences and listens within at the moment that he is going to play music with his patient. In the silence before the improvisation the player anticipates the unknown that will come. This ‘preparationsilence’ allows one to come into resonance with oneself and, in a music therapeutic context, with the other, where it is necessary to create an inner space. Each authentic musical play derives from this.

He played fragmented melodies, which sounded like broken (arpeggio) chords. Looking at the way he played (leaning back on his chair, with his hands dangling), it seemed as if he wanted to withdraw from the playing or perhaps even to remove himself from the whole situation.

[Excerpt 1: score of a sensorial play]

Theoretical definition of sensorial play: Sensorial play is a term describing the characteristic playing of a patient where, while producing sounds, the patient is not able to connect with or experience these sounds as coming from himself. The patient’s music is characterised by repetitiveness and/or fragmentation. The improvisation cannot really be begun nor ended, and there is no clear melodic, rhythmic or harmonic development, no variation and no recapitulation. The patient is perceptually and emotionally detached from his own musical production.

Therefore, improvising is not a real ‘experience’ for the patient.He is not inspired or affected by the music and he remains disconnected from the sounds and the playing. There is an absence of shared playing and inter-subjectivity with the therapist in the sense that the patient does not engage in the joint music. The sounds remain outside the patient and do nothave any connection tohim. In terms ofthepsychopathology of psychotic patients, one can say they cannot create a psychic space that allows symbolisation, thus making it impossiblefor them to appropriatemusical material. The music therapist experiences the patient as isolated, and becomes completely caught up in the patient’s music (i.e. the musical behaviour) and is not free to introduce hisown musical images and because of this, no interaction is possible, and it is impossible to engage in a shared timbre in the ‘co-play’. (De Backer J. 2005, pp. 268 -269)

Adrian immediately played in a way that is commonly found in some psychotic patients. He seemed to be lost in an endless process of creating sounds that had no apparent meaning. In this short improvisation (and also in subsequent fragmented improvisations from this first session), there was no clear beginning, and no intended end, giving an impression of ‘no past and no future’. It was an endless repetition of successive, short and fragmented sounds, where nothing appeared to, or could develop. Adrian’s playing was pure sensoriality, existing entirely within itself, where nothing further could happen. There was no sign of dynamics or musical development.

Within this music, some fragmented pieces of sound could be heard, rather like isolated events, disintegrating within an empty sound-space. There was no sense that his playing was connected with his internal emotional state - everything happened externally to Adrian, nothing could be integrated and the therapist experienced an intense emptiness in Adrian’s musical improvisation. The therapist found it impossible to reach any point where he felt any emotional experience or reaction. The therapist did not experience any contact with Adrian, either in his attitude or speech, or in his musical playing. Everything the therapist offered was ‘spat out’ at him immediately. All contact was avoided and the therapist had a sense that what lay behind Adrian’s behaviour was a delicate and brittle fear. The therapist was therefore very careful not to overwhelm Adrian, aware that he could retreat and that he might then stop the treatment immediately.

It was the experience and interpretation of the therapist that Adrian forced him to believe that only he (Adrian) had control over the situation, the musical playing and the session as a whole. In the transference, the therapist experienced tension and a desire or need to express aggression. At the same time, the therapist felt that Adrian considered this aggression to be too threatening, because he could not control it. He was anxious that he might lose all contact with himself once he had released this aggression.

Whilst listening to the improvisation, the therapist had the impression that Adrian was losing himself in a meaningless experience. Adrian’s improvisation was not grounded in the way that it had no support or space within it. The therapist longed to offer Adrian some structure by giving him the opportunity to improvise together and as soon as this was suggested, Adrian agreed at once.

Holding on

Adrian and therapist were seated next to each other at the piano, with Adrian on the right hand side. Without preparing himself mentally or entering into resonance with himself, Adrian immediately started to play. The therapist however did take time to enter into resonance with himself, Adrian and the therapeutic situation. He briefly looked at Adrian and slowly rested his right hand on the piano keys and played an open neutral octave (g’ – g). Not only did the opening musical sentence of the therapist offer a calm foundation, but it also sounded expectant or anticipatory. In this way the shallow mood created by Adrian was transformed into a deeper therapeutic atmosphere.

Comparing the tempo held by Adrian in the previous improvisation, this pace was now much lower. During the first improvisation, Adrian’ playing was very busy and nothing could develop from it. Now the therapist offered a more sustained, sober style of playing, providing a musical underpinning that was unambiguous and clear. This was serious music, but not without engagement from Adrian.

The tempo of this music was less forceful, but there was also the potential for confrontation as well as compliance. The therapist left space for something new to happen. A tension full of expectation emanated from this playing, where the therapist waited to see what would happen, also noting that this tension and expectation was not present in Adrian’s playing. The therapist slowed down his own playing in order to create a therapeutic space and mood. Adrian was completely dependent on the therapist’s playing and was not actively involved in the improvisation, during which neither musical voice could find each other. This was a musical interplay on two levels, without contact between either (i.e. between Adrian and the therapist). The therapist quietly continued with his melody whilst Adrian tried to impose his own disjointed contribution; however, nothing came of this. When the therapist introduced a musical ending Adrian did not collaborate with this, abruptly breaking off the improvisation. Whilst the therapist felt that he could not hold Adrian’s sensorial playing, he also knew that his music at this stage seemed to have no effect on or meaning for Adrian

In this session, playing and talking mingled together. The unboundaried nature of the transition from playing to talking and vice versa was unique to Adrian’s therapy and it characterised the sessions up to and including the seventh session. Throughout this period of therapy it was impossible to distinguish between playing and talking; this phenomenon could be described as a kind of ‘mud’.

Adrian gave short answers to the therapist’s questions and looked straight ahead, at the keys of the piano and then towards the therapist. Finally, he took the cymbal that was beside the piano, struck it a few times and played a hasty tune on the piano – indicating perhaps that he was rather lost in this situation. The therapist experienced the disjointed playing of the cymbal and the piano as an escape from any conversation. On the one hand Adrian signalled that empathically the therapist came too close, and on the other he nullified any hint of a connection between himself and the therapist, stating “it means nothing, I feel nothing”. For this reason the therapist kept his distance and only partially acknowledged the resistance shown by Adrian. He did not make eye contact with Adrian and the ‘game’ between them remained in the musical play, rather than in any non-verbal exchange. Then, hesitantly, Adrian put his hands on the keys and played a few notes. He stared ahead as if he did not know which way to look and very briefly played the same motif as during the first improvisation (in three-four time). As the therapist intuitively repositioned himself slightly backwards, more space appeared between him and Adrian. Adrian now spoke directly to the therapist, who listened attentively. While listening, the therapist tried to hold Adrian mentally. He felt that because Adrian was continually switching between playing and talking, this inherent tension indicated that something was the matter, or that something unexpected might happen. The playing and talking that followed were fragmented. The therapist then positioned his chair closer to the piano and therefore closer to Adrian. Free improvisation followed and showed some release in the tension.

The impossible play

There followed four fragmented improvisations that were distinguishable by Adrian’s inability to begin or end the music. The inability to ‘anticipate an inner sound’ was present during all the improvisations and throughout the entire music therapy session. There was no structure, rhythm or phrasing noticeable during and between the playing and talking. The interaction seemed to be a kind of singular ‘mud’, where nothing could be grasped or held onto and nothing was allowed to develop musically.

[Excerpt 2: score of a sensorial play]

Appropriating the musical material in this way was therefore impossible for Adrian. The music remained totally external, strange and aimless. The therapist was thrown into a turmoil within which it was impossible to develop any structure in his music making. Adrian was immediately tempted to fill up every silence, perhaps also experiencing this as an emptiness that needed to be filled. By doing so, he made it impossible to create a psychic space where ideas could develop and where there could be fantasies or thoughts. It was also impossible to reflect verbally, because everything remained external to him. He frequently broke off a sentence and started to play repetitively or in fragments for a while, only to stop suddenly.

Adrian agreed another appointment with the therapist and the session was concluded. Directly following this first session, the nursing staff reported that they found Adrian very aggressive, tense and restless. In his living space on the residential unit Adrian reacted - he kicked chairs and tables, but significantly did not cause any damage and after an hour, he calmed down.

Session 2: ‘Managing boundaries’

During his next appointment Adrian announced to the therapist that he wanted to stop the individual music therapy treatment immediately. His tone of voice was fearful and aggressive. The therapist observed that Adrian had found the music therapy too intense to continue.

Adrian said: “I felt very upset after the first music therapy session. It stayed with me for three to four days… In any case, I want to stop. The music therapy only made me feel worse.”

Therapist: “At times I feel that music does something for you. At this moment you see this in a negative light… You indicate that music is threatening and it is possible that the session is not sufficiently structured, making it difficult for you to bear or hold onto any of the experiences you might have, and that upsets you.”

Adrian: “I just want to stop. So, see you Jos.”

Therapist: “You say yourself that something happens, which is not the case with the other therapies, and that music appeals to you. Maybe as a therapist, I went too fast…You indicated that you wanted to play ‘Für Elise’ piece, and maybe I can help you with that.”

Adrian: “I don’t want any more to do with this.”

Adrian stood at the open door looking in the direction of the therapist. It was a tense moment and Adrian’s mood and posture showed fear and uncertainty.

The therapist then offered a further appointment.

Therapist: “Adrian, you show me that something is happening and you can use this in a therapeutic way. If you want to engage with this, I will be there with you”.

Without closing the door Adrian returned to his department. The therapist wondered if this was an indication that the door had not been closed for good. The therapist had noticed that there was a paradox in what Adrian had said. On the one hand Adrian reported that in the first session he no longer felt anything, while on the other hand, he now said that it was too much for him. It was interesting to note that Adrian always expressed the fact that the therapy didn’t interest him or that he couldn’t care less – for instance he said, “I can’t take any more, the music is too much for me, it makes me worse, I have to go”. Equally, he was very much aware that the session had an effect on him for the following three to four days. This was remarkable, because normally he would take off in an easily way from this kind of experience and would not allow anything new to happen.

The therapist agreed to teach Adrian ‘Für Elise’ and indicated that he could learn the piece as part of a process that moved towards free improvisation, while remembering that any of this kind of ‘teaching’ took place within the music therapy situation. Being aware of the transference, the therapist could sense an intense fear and an uncertainty which Adrian himself could not bear. In situations like this it is the role of the therapist to carry what cannot be held by the patient. For this reason, the therapist was clear and unambiguous about the usefulness of the therapy, and adhered strongly to the arrangement for the next appointment. However, a sense of failure remained with the therapist, even it was clear to me that Adrian’s disclosure of limitations should not be seen as finality but rather as an essential feature of the therapy.

Session 3: ‘Für Elise’ returns’

Adrian arrived at his next session, albeit 15 minutes too late. It was as if in some way he allowed the therapist to feel insecure about whether he would arrive or not, giving him the feeling that it was Adrian who controlled the therapeutic framework. It was Adrian who was in charge and control and it was he who decided whether or not he should attend.

The therapist was able to give form to this uncertainty about the absence of Adrian by improvising on the piano before he arrived. Improvisation before or after a session is a part of this music therapist’s method of work. After a confusing or chaotic session - or in this case, in search of an audible silence - he uses a free or ‘reverie’ improvisation, to reflect and to enter into resonance with the image of the missing patient. Adrian is the kind of patient who wanted to quit the therapy and who now left the therapist in doubt as to whether or not the treatment would be continued. The therapist wondered how this could develop further. Improvisation in cases like this allows the therapist to mentalize what it is that, for Adrian, cannot be digestible at this time.

The first tones resounded in the empty music therapy room for a long time. A melody developed, and by using the piano’s sustaining pedal the therapist managed to link the sounds so that there was a sense of flow. With the therapist’s addition of the left hand, the melody became more harmonically embedded. The bass sounded strong and full and the music created an atmosphere that was cradling, comforting and consoling. The therapist let the last sound float away, as if his ear was ‘glued’ to it; the resonating silence created calm, filling the emptiness. Whilst improvising, the therapist had the image that he needed to give Adrian more space and to accept and respect his fears and limitations. He had an insight that Adrian saw the learning of ‘Für Elise’ as the essence of music therapy and that Adrian could grasp this as an opportunity to control the therapeutic framework. Within this, he could manage Adrian’s resistance. Teaching him ‘Für Elise’ meant knowing where both of them were going and it was in some way comforting to have this certainty. Music therapy was still too much of an unknown territory for Adrian. ‘Für Elise’ could throw him a life line, with some sort of implicit guideline relating to what could be allowed to happen within music therapy. With ‘Für Elise’ he could control in the same way as he maintained control over the session by turning up or not. (A certain parallel can be drawn to the case of a young psychotic patient described by Metzner 2001.)

Initially the therapist did not accept Adrian’s ‘Für Elise’ proposition, realising the real issue was that the therapeutic space itself was too threatening. When the therapist ignored the suggestion, Adrian distanced himself totally from the treatment, saying: “I won’t be coming any more…when I’m in this strange and scary environment, I’m afraid of losing control and striking out. It’s far too dangerous for me, I don’t need this.” While the therapist was thinking in a reverie-like way about this, Adrian came in to the room. The therapist approached him and greeted him with a cautious hand shake. Adrian’s hand shake felt frail and scared (therapist projection). Adrian showed a nervous and timid attitude, looking briefly at the therapist. Adrian apologized for being 20 minutes late; he had forgotten about the session. The tension this caused in the therapist is a communication of an affective projective identification (Rosenfeld 1971).

Adrian immediately asked to start with ‘Für Elise’.

‘Für Elise’

This was not a piano lesson in the traditional sense. The therapist played a few notes of the piece which Adrian then imitated. This was based on visual and audible copying - a type of rote learning. It was learning through imitation; the therapist goes first, Adrian repeats. Small steps were taken, each beginning with the familiar start of ‘Für Elise’. In a sense it was a repetitive pedagogical learning experience.

Adrian stressed again that for him the learning of ‘Für Elise’ was about achieving a certain goal within the music therapy treatment. He made it known that this ‘learning’ was symbolic for the usefulness of his time spent in psychiatry. In this way, he could symbolise or encapsulate something about his psychiatric stay, what it meant to him, and what he could take with him when he left the psychiatric institution. ‘Für Elise’ has been attributed with various functions during the therapeutic process with Adrian.

Adrian’s boundlessness

The boundlessness in Adrian’s play comes clearly to the fore at the start of the next improvisation. Adrian had already sat down at the alto-metallophone and, assigning the therapist an alto-xylophone, he started to play. The therapist then set down his assigned instrument in front of Adrian, who was already playing, and continued to play without even looking up or taking the therapist into account. In this way therapist and patient could not start the improvisation together.

[Excerpt 3: score of a sensorial play]

There was no contact at all between them. The therapist could only try to join the almost repetitive play of Adrian, a feat, which was almost impossible. The therapist felt like an object that was not allowed to or could not take part in the musical play. Adrian was also not able to conclude the same improvisation. He played glissandi, which erased the play metaphorically. As a consequence there was no clear boundary between making music and not making music.

[Excerpt 4: score of a sensorial play]

The inability to round off the interpretations

Adrian continued to bring the verbal interpretations to an abrupt end. He was unable to leave anything to resonate. The playing could not be made into something substantial and was prematurely concluded, resulting in the fact that Adrian could not appropriate it. The playing disappeared into nothingness.

The way in which the therapist ended the improvisation allowed Adrian to hear and experience how an improvisation could reach a conclusion. Reacting intuitively, the therapist let the last tone or chord post-resonate (this was also a feature in the later improvisations).