MUSIC AS THERAPY

by Selina I. Glater, M.A., RMT

I first heard about music therapy when I was twelve years old, and I was intrigued from the very beginning. Music for me was both a therapeutic and an aesthetic experience. It helped me through a myriad of childhood illnesses; it was there to soothe me, to enliven my spirits and to provide emotional outlet, through performance. In those formative years my self esteem grew by leaps and bounds from the accolades I received performing on the violin. I have always possessed qualities of warmth, sensitivity, and compassion for others who are physically and emotionally ill. Music made it possible for me to establish a relationship with the world outside of myself. Music is one of the most social art forms in that it creates communication between people in many different ways. It provides for non-threatening interaction. For some this may mean an escape (if even for a few short moments) from the closed world of illness. Severe and persistent illness may isolate a patient and threaten his or her identity. This can be especially true when the patient is hospitalized or depersonalized by the illness. A music therapy group activity may give such a patient an opportunity for self-assertion and a sense of belonging to a group where he or she is accepted. Music therapy group activities demand interpersonal cooperation and and interpersonal communication. As the therapist, I must be in rigorous control of my own emotions. The relationship between me, as music therapist, and the client is the basic catalyst for change. I must be able to resonate with the client's feelings and perceive an accurate view of the client's internal frame of reference. Above all it is imperative that I remain non-judgemental and accepting of the client, which is rarely a simple feat. My philosophy of music therapy is an eclectic one that encompasses concepts found in Rogerian psychotherapy (Humanistic), Cognitive Behaviorism, and Jungian psychotherapy (Analytical). It is the judicious use of these three approaches, depending on the client population, that remains crucial for my work as a music therapist. To see how this works I will introduce you to a composite person whom we shall call "Lee", and a set of circumstances and interventions that have shown promising results with very ill and difficult patients.

HISTORY:

This is Lee's first admission to a psychiatric health facility (a 24 bed acute in-patient unit). He was admitted as gravely disabled, is married, has five children and has shown increased paranoia and strange behavior, threatening his children, hitting his wife and defecating both in his clothes and at random elsewhere in the house. He has been off his anti-psychotic medication for one year prior to admission because of incidents of Tardive Dyskinesia. He was first seen at an Outpatient Clinic where he was diagnosed as having a delusional disorder, but his psychiatrist hadn't been able to delineate the delusions. During the early days of this hospital stay Lee wrote voluminous pages about a "Nation". It was unclear as to whether this nation was one that he was creating or whether it was a reference to his homeland. He had come to the United States in 1980 from circumstances of extreme poverty in China. His English is limited and gets worse as his psychotic condition intensifies. In an initial assessment during his mental status exam, the patient appeared thin, was preoccupied talking to himself and making noises, mumbling answers while laughing to himself. His thought content was difficult to assess due to his bizarre behavior and preoccupation with internal stimuli ("Voices"). Insight and judgment were poor. Intelligence appeared average. Admitting diagnosis: Chronic Paranoid Schizophrenia.

ASSESSMENT:

Lee's limited communication skills and general apathy along with thought disorganization prohibited a formal initial music therapy assessment. But, over a two week period observations revealed that he had the following range of musical skills:
Still, he actually participated very little in group activities and, in fact, frequently interrupted both individual and group sessions with continued talk of his "Nation".

TREATMENT AND METHOD:

The first priority in order to begin a successful music therapy intervention was the establishment of a trusting relationship. After an initial settling-in period, Lee made a commitment to see the music therapist on a daily basis. Throughout his involvement in individual music therapy sessions, he occasionally attended activity groups, and saw a psychiatrist regularly for consultation regarding his medication. Our one and a half month period working together was divided into three main phases. The first was approximately one week in length, the second approximately two weeks, and the third three weeks; simple as one two, three - but not quite.

PHASE-ONE: - SEPTEMBER 26-OCTOBER 8

We set up a schedule so that I could see Lee for ten to twenty minute sessions on Monday, Wednesday, Thursday and Friday. Almost immediately Lee and I began to discover his musical interests and abilities. He learned the pentatonic scale (on the raised black piano keys) very quickly, and then started a short, somewhat cautious exploration beyond them. At this stage of our work Lee did not speak to me but he continually communicated by playing on the piano in a pentatonic-improvisatory fashion, and there was some acknowledgment of my presence. He was attentive, quiet, and sometimes repeated one cluster of notes, displaying that he sensed good ending places. For this work, I matched his volume and timing by joining in, but adding no musical direction beyond whatever Lee initiated, and he tended to be moderate in both volume and speed. Next, I invited Lee to switch places with me and to play the bass, suggesting that he might like to play loudly. He spontaneously altered his hand position to play more strongly. During our first improvisation on the bass, Lee initiated an "accelerated" as well as a slow strong section. When asked if he liked to be loud, sometimes, he nodded affirmatively and made some strange noises. His second improvisation on the bass lasted for three minutes and had a gentle quality. He still did not speak to me except to say a polite, "Thank you", at the end of our sessions. It was during our fifth session that Lee initiated singing to the improvisation. He sang in his native language and still remained aloof and distant. The improvisation also had no constant tonality. His bass improvisation that followed was fast and loud, then slowed and stopped abruptly, concluding with a strong vocalization. When asked whether it felt good to sing in his native language, Lee shook his head, "Yes". I continued to complement him whenever he vocalized by singing following his lead with my own improvisations on pentatonic melodies. Lee agreed that the bass melodies seemed to move him.

PHASE TWO: - OCTOBER 9-OCTOBER 21

Fifteen minute sessions became inadequate, and we started to go on for twenty to thirty minutes. Lee's improvisations were becoming increasingly pentatonic, and more deliberately shaped. I was watching the pitches he played and choosing notes which would create chords, whenever I could. This resulted in a constantly changing tonality, and both Lee and I were always adjusting to try to fit together tonally. There was a rapport, and he was focused and productive, often singing spontaneously as we improvised. One session that is particularly memorable occurred just before Halloween. Once again Lee began to sing spontaneously with my improvisations this time it was in English! He seemed proud and delighted as he sang "Happy, happy Halloween, my heart is happy". It was a breakthrough for him, and we both knew it. From that time on he would sing in English as often as in his native tongue. While this work marked a significant development in Lee's concentration and level of trust, it must be noted that his ability to relate to the therapist (and hence, to others on the unit) was greatly increased.

PHASE THREE: - OCTOBER 22-NOVEMBER 12

Lee's improvisations in this phase tended to be much more extensive, and flowing than previously, often lasting for 5 minutes. They included a lot of simple scales, repeating each note in the scale using various rhythmic patterns. This phase was also marked by his speaking to me in English. Our musical communication grew as did our therapeutic relationship. He was now singing and speaking to me in English. During one session he called me a "desert flower" and he sang to me about the beauty of flowers. Then, to my surprise, he got up and gingerly did a little dance, very stylized, I assumed in form normal to his culture.... coming back to the piano, very pleased with himself, to continue with our keyboard improvisation. This little dance seemed to open the door to more and more direct contact, and confiding contact with me. I was "safe", and he could speak freely about his distrust of his psychiatrist, about his "Nation", his grief over losing his parents, his impoverished life, and a host of other topics of concern to him. It was at this time also that, with his permission, I began to audio and video tape our sessions, carefully following all of the protective rules of our mental health department. The following are a few notations that show his progress: 10-22-91: Patient initiated contact today. He came to music therapy at 3:00PM. We finished the session at 3:30. Patient began to play piano on the black keys only. He stated "I hate the lie-man". When questioned about the "lie-man" he said that "the doctor lies to me". Patient was very verbal and participated actively in today's session. 10-25-91: Patient was verbal today and participated actively in music therapy session. He still has unusual mouth movements with less grinding of the teeth. As per Dr. Brown's request I asked patient about his mouth movements and he responded that he was making movements like a monkey and that he cannot control these movements. Patient spoke about his writings and said that they were about "war with another nation". He is revealing more delusional content during this session. 11-6-91: Patient seemed happy today. He expressed a desire to go home and sang a short improvised song about going home. His communication skills are improving as is his ability to concentrate on questions asked of him. Some delusional material is present although he did not speak about "Nation" today. Some involuntary mouth movements still noted. He closed the session by telling me "You are my Mother".

EVALUATION AND CONCLUSION:

Lee responded strongly to music therapy interventions in the areas of emotional expression, self-image, a and his ability to form a trusting therapeutic relationship with the therapist. His verbalization increased and his psychotic delusions, while still present, were beginning to be replaced by more acceptable and appropriate interactions at the end of music therapy. The music therapist continually acknowledged the importance of the "imaginal" and deeply understood that his delusional system was a coping mechanism for him - a way of being "safe". Through intensive music therapy work, Lee was able to integrate his three worlds: America - his "Nation" ("imaginary") - and China (his native land). His concerns found expression in free improvisation. He showed considerable progress in releasing his feelings through this medium, taking full advantage of my open invitations to play however he felt. He moved from the closed, dark, psychotic world of limited verbalization to an open and trusting world filled with verbalizations in both English and his native language. There was also a non-musical benefit within the music therapy relationship. The fact that I was not identified by either Lee or by myself as "....having responsibility for altering the structure of his everyday life..." freed his emotional expression of any agenda other than to experience and deal with his feeling. Lee's sense of a positive identity gradually blossomed over the course of these sessions. He invested an increasing alertness and care in his creative improvisational work. Much of this gave rise, within him, to a sense of ability and pride. I believe that Lee's increased absorption in and appreciation of his world grew organically out of the validation that he received in these sessions: validation of his emotional responses to his situation, validation of his perseverance and ableness, and validation of his ability to be heard and enjoyed in a deep exchange with another human being. The music interventions contributed a natural meeting ground, a flexibility of structure, and absorbing focus and challenge, and most importantly, the richness of its own beauty.
SELINA I. GLATER is a CAMI JOURNAL Advisory Board Member who works in Santa Barbara as a registered music therapist and as the Director of Consumer Advocacy and Outreach for Sanctuary Psychiatric Centers.. She previously authored an article in The JOURNAL's "Client" issue, and is a governor's appointee to the California Mental Health Planning Council.
This copyrighted article appears by permission of The JOURNAL, a quarterly publication of the California AMI. The JOURNAL provides insightful and provocative articles on a variety of topics concerning the neurobiological disorders (Schizophrenia, Depression, Bipolar, OCD, Borderline Personality Disorder, etc.) and is a valuable resource for consumers, families, and therapists. To order a $25 annual subscription or back issues, please contact:
The JOURNAL
California AMI
1111 Howe Ave., Suite 475
Sacramento, CA 98525
(916) 567-0163