Having an effect

I have been thinking about a session I had last week with one of the men I work with who is on the autism spectrum.  He and I have worked together, first in a small group and now individually, for the past ten years.  I have noted that I often feel quite lost in his sessions.   While it seems to be very important to him to have an opportunity to get out of his living area and walk to the Music Room (which is in another building), he generally just sits quietly when he gets there.  Occasionally, he’ll reach out and take one of the instruments I place near his chair (he is clear that he does not want to get up and come to the piano or explore any of the other instruments around the room), putting it back shortly thereafter.  He doesn’t use speech to communicate, although occasionally he may vocalize quietly.  So quietly, in fact, that I can barely hear him. 

I have been slowly making my way through Music Therapy with Adults with Learning Disabilities (Watson, ed., 2007), and I admit I felt relieved when I read the following: 

“The music made with adults with learning disabilities will be varied, as with other clients, but there may be particular characteristics.  The therapist may find that she is working with very little material (for example, when working with clients with profound and multiple learning disabilities).  This demands that the therapist is able to wait and listen, avoiding playing to fill the silence rather than in response to the client.  Other clients, whilst bringing music, may find it hard to initiate or lead music, leading to fragility in the contact between the therapist and client, where the therapist may feel as though they have complete responsibility for sustaining the music.”  (Watson,  p. 28)

I frequently feel as if I’m doing most of the musical work in my sessions at the institution.  Obviously there are a lot of reasons for this.  For one thing, the people I work with have movement challenges, making it very difficult (as Watson comments) to initiate and/or sustain interactions, musical and otherwise.  Another likelihood is that living in an institution for many years can bring about an intense case of learned helplessness.   I think, also, there tends to be an idea that I’m the one who knows how to make music, so it’s sort of left to me to do the main music-making.  Put another way, this is a setting that lends itself strongly to maintaining specific roles.

At any rate, during this particular session, I had a strong image of the notes from the music I was playing just bouncing off of my client and falling quietly to the floor.   I mentioned it to him, and then I let my mind wander around with that thought for a while.  If you read this blog regularly, you know that I am a firm believer that the feelings (and songs) that come up for me (and all therapists) while in the middle of a session are important pieces of information.  Naturally, it occurred to me to wonder (out loud) whether he too might be feeling a sense of ineffectiveness- in other words, of not having an effect on his life, on the people around him- a powerlessness in the face of the unfixability of...his life?  His surroundings?  His body (he has been going through some health issues lately and really has difficulty with medical type people)?

He didn’t make any clear overt response to my suggestions that day, but, as it happened, the following week, on our way to the Music Room, it was snowing out, and he was actually singing!  He had a quiet little melody which he was humming (with enough volume so I could hear that it was an improvised tune), and, while it was difficult to make out, it was clearly melodic.  Of course the minute we got to the Music Room he stopped singing, but he did add a few vocal sounds to the session.  Maybe it means something, and maybe it doesn’t...but it was nice to hear him sing.

References

Watson, T. (2007).  Music Therapy with Adults with Learning Disabilities:  Sharing Stories.  In T. Watson (Ed.), Music Therapy with Adults with Learning Disabilities (pp. 18-32).  Great Britain:  Routledge.

Mental Disability Rights International

I don’t even know where to begin.  I happened to find a video on the CNN siteabout the hideous conditions for children and adults with disabilities in institutions in Serbia .  I’m not sure how to link to it, but if you want to search for it the title is “Tied to cribs, left to die.”  A group called Mental Disability Rights International works to ensure that the rights of people with developmental and psychiatric disabilities are respected around the world, and they are the ones who created this video.  

I urge you to go to their website and read their reports and see the very painful videos they have made of the dreadful lives of the people left (apparently to die) in the various facilities in Paraguay, Romania, and Turkey (among others).  

Horrified does not even begin to describe my reaction to the fact that in 2007 this level of inhumanity and injustice continues.    On the other hand, why should it shock me?  It is true that we have moved a long way in this country- a very long way from the deplorable situations you will see if you visit MDRI’s website and read their reports.  But the tremendous prejudice felt toward people with disabilities remains.  The abuse stays constant.  The inability to see beyond labels, the belief in lack, limitation, inability...it goes on and on.  

And again, I wonder, why would it shock me?  When our own country is apparently not concerned with the fact that torture is considered an acceptable form of treatment for prisoners of war.   Why should I be surprised at all?

Belonging

I was sitting with one of my clients yesterday afternoon, trying to remember what we had focused on the last time we saw each other.  He had refused to attend the previous session, and I had taken a few days off, so my brain was blanking a bit.  

I started to play the guitar (which, for some reason, always helps me think and hear more clearly and to remember what we’ve been doing), and I recalled that the song I had played recently was “Part of Your World” (yes, I know... it’s a Disney song from “The Little Mermaid”).  The focus was on what (I think) seems to be his longing to take part in what he perceives as the “world” outside of his cottage, his housemates, and his staff.  Only... yesterday, when I thought of the song, the word that came to my mind was “belonging”.

Belonging.  I was aware that that wasn’t the word we had used in his last session, but it seemed an interesting word to explore.  My mind immediately free-associated to the idea of belonging to someone, because that also seems to be an issue for him (okay, and maybe it’s an issue for me too).  

As my mind wandered I thought about the following:

*do we identify ourselves by the people and places we belong to? 

*And, when we don’t have any family (or don’t know whether our family remembers that we exist), do we lose a sense of belonging?  

*What does that do to our sense of identity?  

*If we have a severe disability, and we’ve listened to people’s opinions about who we are and what we are without being able to put in our own views, then what does that do to our sense of belonging (let along our sense of identity)?

*What does it mean to belong somewhere?  And, really, do we ever belong to anyone or anything? (I’m thinking here of our existential aloneness.) 

*When we feel as if we don’t fit in, and our way of being is so different that we never feel a sense of belonging, do we lose our sense of a “home base”?

*Does belonging to someone or to a place give us an experience of having a “home base”?

*From the other side of things, what does it mean to have someone “belong to” us?  Can someone actually belong to us?

I wondered yesterday whether it makes sense to say that, while we have music therapy together, we sort of belong to each other.  I couldn’t get my mind to move swiftly enough to clarify that thought, so I didn’t mention it in the session.  But I’m throwing it out here to look at it some more.  

It seems to me I’ve read about the idea of belonging a lot in the more recent person-centered literature concerned with expanding the social and emotional networks of people with developmental disabilities.  Heck, it’s enough of an issue for all of us, I imagine, but we may not necessarily be conscious of it all the time. 

I have to get along to work now, but I do want to revisit this idea of belonging to each other.  There seems to be a spiritual element to it that I like.  Yes.  I do believe that, one some level, we all belong to each other.  I suppose if we all thought about each other that way, we’d probably have a less frightening world. 

Paying attention

I’ve been thinking a lot about what it means to pay attention in music therapy.  I believe it started when I agreed to take practicum students from the music therapy program at Montclair State University.  I don’t, by the way, mean “paying attention” as a goal to be worked on with our clients.  I mean as a goal to be worked on for ourselves.  More specifically, I’m looking at what do we, as music therapists, pay attention to when we’re working?  How do we know which observations are relevant?  How does what we see/experience/notice/play musically or miss altogether fit into the context of therapy?  And, for crying out loud, what the heck does it all mean?  

Part of the training for music therapists (at both undergraduate and graduate levels) involves pairing a student (sometimes two students) with a professional in the field and having the student observe the professional as s/he conducts music therapy.   The student is simultaneously learning about therapy theories, the uses of music, and group dynamics and such in their classes at school.  Personally, I think this is an awfully nice way to learn, because you get to see and apply what you’re learning immediately, so it makes more sense.

Understandably, it’s not that easy to teach the skill of observation when you’re in a classroom and talking theoretically...or even when you’re having people role-play that they’re in a music therapy session and have whatever situation you’ve assigned to them (i.e., students might be asked to play the role of rowdy kids with ADHD or the role of an elderly woman with dementia, etc.) . 

Getting back to the practicum placement...gradually, the students begin their interactions with the clients by conducting part of the session (for example, they may start by preparing some form of a greeting song and then trying it out with clients).  By the second semester students are asked to conduct an entire session (while being closely supervised by the more experienced music therapist).    

As a part of the learning process, the students fill out various forms and come up with musical experiences based on the goals and objectives they choose. This is after observing the professional music therapist working with a particular person or group for a period of time.  Most students are also asked to complete logs- which, to the best of my recollection, are a way for them to look at some of the feelings and reactions they notice in themselves as they go through their practicum experiences. 

Because I don’t use an activities approach, I adapted a form for my students to fill out which reflects the relationally-based and process-oriented approach that I do use.  It asks a lot of them, particularly with regard to paying attention and learning how to be in a state of perpetual observation.  

One of my favorite authors is Patrick Casement, who I discovered by accident one day while I was rummaging through books in the Hahnemann University (now Drexel University) library.  His book “Learning From the Patient” is an excellent resource (even though he’s not a music therapist) for learning how to...well, learn from our clients as well as learning from our own reactions to our clients.

There is a lot to pay attention to in music therapy.  There’s the client to notice (and all of the stuff that goes along with being that particular human being);  there’s the music (which, of course, has all sorts of elements), and then there’s ourselves (and the feelings that we notice floating by as we are engaged in the process of doing music therapy).

Clearly there’s more to think about on this subject, and, since I’m working on putting together a presentation and an article about paying attention, you’ll probably be hearing more about it in the next few months.

Notes on power and control

The following is a handout from a presentation I did at Kardon Institute for the Arts in October of 2003.

Examining Power and Control in Music Therapy with

People who have Developmental Disabilities

In order to become more aware of the beliefs which you bring to your work, consider the following questions:

What are my beliefs about music therapy?

•What does my idea of the "perfect" music therapy session look/feel like?

•What is my expectation about what occurs in a music therapy session?

•How do I respond/react when reality doesn’t meet my expectations?  

•Do I choose to receive supervision?  When issues come up for me, do I address them in my own therapy?   

•What sort of theoretical approach do I use?  Do I use activities?  Do I use a behavioral approach?  A psychodynamic approach?  Am I product or process-oriented?

•Does music therapy “fix” people?

•What aspects of music therapy are healing?

What is my belief about the role of my clients?

•Should my clients always "listen" to me?  What if they don't?  What if they choose to not attend sessions?  How do I respond?

•What happens if my client is "acting out"?  How do I perceive it?  As manipulation?  As a way to gain control?  As a way to communicate?  Do I need to see it as being "good" or "bad"?

•What kind of language do I use to describe my clients- especially those who have severe disabilities (i.e., “I work with MR/DD’s” versus “I work with people who have developmental disabilities”)?  

•Do I talk about my clients in terms of their diagnoses and symptoms?  Or do I see my client as a person first?

•What if what my clients want for their lives is different from what I or their service team wants for them?

•How do I respond when a client has a “crush” on me?  Or wants to give me a hug?

•How do I feel about working with clients who are “clingy”?  How about those who are “hard to reach”?

•Do I arrive on time to sessions?  

•Do I start to speak in a higher-pitched “tone” (as if to a child) when I am addressing someone with a developmental disability?

•What are my “triggers” (i.e., the things to which I tend to react strongly)?

What are my beliefs about myself as a music therapist?

•What do I believe my role as a music therapist is?

•What does it mean about me if my session doesn't go as I planned?

•How do I deal with my agency's expectations and ideas about what my role should be?

•What time of day do I function most effectively?  What time of day do each of my clients function most effectively?

•How do I feel about having power?  Do I like to be in charge?  Do I avoid being in charge?  

•How do I feel about compliance and non-compliance?

•Where do I stand/sit in relation to my client(s) during the session?

•How much (physical) assistance do I offer (i.e. to clients who are unsteady?  to hang up coats?  In toileting?, etcetera)?  

•How frequently do I intervene (i.e. When someone is struggling with feelings?  When clients are aggressive toward themselves?  Toward other group members?)?  Do I have a need to “make it better”?  

•Do I feel pressure from my clients to “make it better”?

•How do I handle days when everything seems to be going wrong? (In my sessions?  In my life?)

What is my belief about the role of the music in the therapy session?

•Do I see music as the therapy?  Or do I see music as a way to develop and express the therapy relationship?  Or do I see music as a separate entity to be projected upon?

•Do I recognize that a relationship exists between the client and the music, as well as between myself and the music, both of which are crucial relationships to address, acknowledge and analyze?

•Is it important to me to plan out the entire session?  Or do I have a general idea of where I want to go within the session (i.e. based on goals for my client and how the particular person uses music)?  Or do I follow my client's lead most of the time?

•How do I feel about silence?  Can I tolerate my client's need to not make music?

What is my belief about the experience of making music during the session?

•Do I play the whole time?  Or do I leave musical space for my client?  Who is doing most of the playing?  What if my client wants to play the whole time?  Without me?

•How does it feel for me when my client expresses very strong feelings in the music (or in words)?  And if the strong feelings are directed toward me?

•Are my own musical needs being met outside of the therapy session?  Or am I inadvertently getting my musical needs met within the session(s)?  Do I know what my musical needs are?

•Are there certain types of sound/music I avoid?  Are there certain sounds I gravitate toward?  

•Do I have a need for the music to sound a certain way?  

•How comfortable am I in my own music making? Do I always use the same instrument?  How do I feel when I use an instrument to which I am less accustomed?

•How do I feel about improvising?  How do I feel about my voice?  

Interesting things to read:

The Dynamics of Music Psychotherapy Edited by Kenneth Bruscia;  1998;  Barcelona Publishers;  Gilsum, NH;  ISBN#:  1-891278-05-3

Cognitive Counseling and Persons with Special Needs:  Adapting Behavioral Approaches to the Social Context by Herbert Lovett ;  1985;  Praeger Publishers;  Westport, CT;  ISBN#:  0-275-91651-0

Violence and Abuse in the Lives of People with Disabilities:  The End of Silent Acceptance?  by Dick Sobsey;  1994;  Paul H. Brookes Publishing Co.;  Baltimore, MD;  ISBN#:  1-55766-148-0

Power Tools:  Thoughts about power and control in service to people with developmental disabilities by Dave Hingsburger;  2000; Diverse City Press Inc.;  Eastman, Quebec, Canada;  ISBN#:  1-896230-18-0

The Ethics of Touch:  Establishing and Maintaining Appropriate Boundaries in Service to People with Developmental Disabilities by David Hingsburger and Mary Harber;  1998;  Diverse City Press, Inc.;  Eastman, Quebec, Canada;  ISBN#:  1-896230-12-1

  

Handbook of Mental Health Care for Persons with Developmental Disabilities-  1999 Revision by Ruth Ryan, MD;  1996;  The Community Circle Publications,  1556 Williams Street,  Denver, CO  80218;  (303)316-8794

Thinking About Institutions:  Milieux and Madness by R.D. Hinshelwood;  2001;  Jessica Kingsley Publishers;  London;  ISBN#:  1-85302-954-8

Interesting Internet Resources

http://disability-abuse.com/cando/

http://www.normemma.com/arhellbe.htm (Where you can find the article “Hell-bent on Helping:  Benevolence, Friendship, and the Politics of Help” by Emma Van der Klift and Norman Kunc)

http://thechp.syr.edu/ (The Center for Human Policy has interesting articles.)

http://www.quuxuum.org/~greg/journal/contents1.html (Where you can find the Pennsylvania Journal on Positive Approaches)