Tuesday, October 9, 2007

Sitting here in limbo

For some time now I’ve struggled during my sessions with a particular gentleman, trying to figure out whether he is ready to terminate or if he’s depressed and having a hard time doing anything or if he simply needs for me to fail him in some way.  

At some point last year he appeared to be bored in sessions- moving around the room in a somewhat listless manner, not seeming to be angry with me but also not particularly enthused about being in music therapy.  Please don’t misunderstand me- it’s not as if I think that people should come to music therapy and be all peppy and cheery and full of vim and vigor or anything.  It mostly seemed as if there was a gradual change in the relationship, but I couldn’t be more specific than that.  It was just that, for him, he seemed...well, it seemed to me that he may have been letting me know he’d gone about as far as he was meant to go with me.  My reasoning was that we’d been working together since 1995, and he had come quite a long way in that period of time, so I figured that was the logical conclusion.    

Now, termination of music therapy services is something that doesn’t happen all that often in an institution.  Well, okay, maybe it just doesn’t happen much in ourinstitution.  The feeling in our facility has generally been, “if the client is getting something out of being there, and there aren’t any problems, then carry on.”  I’m not necessarily against that way of doing things.  I think our clients need emotional support, and, since it takes quite a long time to develop a solid and consistent relationship, it seems sensible to continue indefinitely.  I suppose another way of saying it is that those of who work in developmental centers really become our clients’ support systems.  Taking that away when there isn’t necessarily an option to develop a non-paid support system doesn’t seem very fair or particularly therapeutically helpful.  

I’ve had to terminate with people when they moved out of the center to live in the community, and I’ve had clients who have chosen to simply stop participating in music therapy.  I also had to work towards closure with a large number of clients when I went to graduate school.  But I haven’t had a lot of experience with working toward termination with someone because they’ve achieved the goals and objectives that were set at the beginning of therapy.   

Well, I thought to myself, here’s an opportunity to have a complete therapy process.  We’ve gone from building a relationship to really using the music, to change (internally and externally), and now we can work toward closure.  So that was my big plan.  We could work toward closure.

I talked about endings with my client, and I started to prepare him, figuring we could start by decreasing our two sessions a week to once a week.  Since he doesn’t use speech to communicate, I had to rely on his actions, his reactions, and my own countertransference reactions to get a sense of how things were going.  For a long time, things just didn’t feel right.  I worried that part of the problem was me, because, if I were to be truthful, it was hard for me to think about terminating with this man.  He is someone I like a lot, and it has been so exciting to watch him grow as a person and in his relationships with the people in his life.  I fretted over the fact that he may have picked up on my reluctance to let him go, fearful that he was trying, in some way, to please me by not wanting to end.  

I suppose the best way to describe this period of time was to say it was one of ambivalence.  I got the impression he really didn’t want to end (and maybe he was afraid of ending), but I also felt as if he didn’t have much hope or commitment to music therapy as he used to have.  Much of the time I felt quite confused as to how to proceed.  

At some point I felt as if I’d made a terrible mistake and misunderstood his wish to end.  And, so, after a lot of conversation with my clinical supervisor and with my client (with, of course, the talking being on my end of it), I decided to go back to two days a week with him, feeling that he had actually needed more support from me when he appeared ambivalent and not less.

Now, after about six months of not working toward termination, I still don’t have a sense of what’s going on with him, and there continues to be a quality of “I’m not interested in this” happening at the same time as “this is important to me”.  While I haven’t mentioned it, it has certainly crossed my mind that endings of any sort are a major source of stress for him, and his ambivalence with regard to terminating may very well have been related to his distress around abandonment.  Session endings used to cause all sorts of angst for him (he used to fight me bitterly when it was time to say “goodbye”), but these days he seems rather listless, without a lot of fight left in him. 

I was thinking on Saturday about how I often feel as if I’m failing as his music therapist.  While I frequently realize I’m not quite on the right track with a lot of my clients, I don’t usually feel as if I’m messing up the relationship and really doing some terrible damage of some sort.  As such, I started to wonder whether I was picking up on some of his own feelings of failure, or, as I mentioned earlier, if he, on some unconscious level, needs for me to fail him (like in a reenactment of the many people who have failed him in his life).  

I shared some of these thoughts with him in our most recent session, and, while he was clearly listening (he was actually keeping a closer eye on me this past session than he has been doing of late) I didn’t get the impression that I’d quite gotten to the heart of the problem.  

As I played music with him, reflecting on the situation (because I really do find that I can think more clearly when I’m using the music), I suddenly found a question in my mind...”Is it possible that the real issue for him is his failing body?”  This particular man has always been an active and very independent person.  He propels himself in his wheelchair, he moves to what is of importance to him, and he is one hell of a determined guy.  In recent years though, he has struggled with a lot of health issues- sometimes serious enough to force him to be inactive for long periods of time.  His physical strength has decreased, and he’s not as agile as he used to be, and sometimes I wonder if he is experiencing pain.  Perhaps the real failure here has been his declining physical health?

So, I asked him if he was struggling with strong feelings about the state of his changed body and physical abilities.  He looked at me.  As we sat quietly together I felt a deep sadness descend over us.  It was the kind of sadness that always makes me want to do something, and fast.  I didn’t though.  I just sat with him, because it seemed to me that he needed some time (and maybe my quiet company) to experience his grief over this loss.    

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