Sunday, November 30, 2008

Speaking of processing sessions...

I had an interesting session yesterday with B (I've talked about him before in terms of his uses of silence).  I figured, since I'm on this whole series of how to pay attention, I may as well use this as an example of how I think about sessions.

As a bit of background, I was on vacation this past Wednesday (when B and I normally have a session).  I had prepared him for this by letting him know when I saw him last week on Friday that I wouldn't see him until the Saturday after Thanksgiving.  

When I picked him up (part of my job is escorting my clients from their living areas to the Music Room), he was more than ready to leave.  His building was super-loud with the televisions all blaring and people loudly talking over them.  He's sensitive to sound to begin with, so I'm sure this was hellish for him (and don't ask me why I haven't asked people to turn the electronica down- I've asked, I've begged, I've discretely found the remote and turned the volume down- it's futile).  I took him to a quieter area (also one in which he wasn't getting kicked at by one of his housemates- who was clearly stressing him out) to help him with his coat and hat.  In the meantime, he pressed the back of his knuckles to the middle of his forehead.  

From here on, in list form, is an overview of what happened in the session and (in parentheses) my thoughts as to what may have been going on. In fact, through much of the session I felt uncertain (okay, through much of most sessions I'm not sure what's happening). My list is not exactly (not even close to) a real process paper, but the point of doing it is to help me think about B and what he might be experiencing. The hope is that, by trying to gain some understanding of his perspective, I can be of more use to him.  So here goes:

-After a while I noticed that he wasn't "allowing" me to play any music. He kept jumping up from the couch where he was sitting and pulling me to the door, engaging with me there. (Maybe he was avoiding the feelings that can come with playing music? When I've played particularly meaningful songs before he has had strong reactions.  Maybe he was feeling a need to connect with me literally rather than through the music?  Maybe he's feeling ambivalent- in terms of wanting to connect with me but not wanting to deal with the feelings associated with connecting with me- or with the music?)

-I tried empathy (I thought he may have been upset about missing his session on Wednesday, so I suggested that it may be hard to have people you like not be there for you.  I need to note here that his family has not paid him a visit in the entire 20 years I've worked there- maybe longer.)

-I acknowledged his possible ambivalence (love and hate you at the same time, Roia?  He did pause, but I still wasn't clear as to his reaction- as in whether I was on target or not.)

-I didn't apologize for not being there on Wednesday. (I included this, because I have had a tendency, in the past, to feel guilt-ridden for taking time off- heaven forbid- and I'm well aware that it is not helpful to my clients to spend a lot of time apologizing for not being the perfect music therapist- or the perfect maternal transference object.  Now, of course, having said that- don't think I didn't feel an awful lot guilty anyway, because he looked so darned upset.  Sigh.) 

-He kept "fighting with me" at the door. (It's hard to describe what I mean by this.  Mostly he just tries to open the door when he doesn't really seem to need to leave- i.e., to use the toilet- or want to end the session- because when I ask if he's finished with music therapy for the day he almost always goes and sits down.  So I wondered if this struggling with me at the door was an externalization of some internal struggle he was having?  Is it a way to connect with me physically?- which I wondered a few paragraphs ago- Or is it a way for him to say "I'm angry"? Or a way to say "you left me, and now I want to leave you" by trying to push my way out the door?)

-Was the fighting and struggling with me a way to cover up deep sadness?  I asked him "Is it okay to allow me to see your sadness?" (I think I was aware of a sudden sense of sadness, so that's why I asked.  He responded by sitting and making some pointed eye-contact.  Hm.)

-He also kept tossing instruments- even kicking them once or twice. (I use about four instruments to help him say some broad, general things- since he doesn't use speech to communicate.  The maraca is to say "I'm frustrated/angry", the tambourine "uncertainty/anxious", the cabasa "sad/disappointed", and the tube shaker "I'm okay today".  Interestingly, he hardly ever even touches the tube shaker.  Anyway, he had tossed the instruments- as usual- and on this particular day, while he was up and encountering them on the floor, he added a kick to them.  I'm guessing there was some anger, yes?)

-A couple of times, since he was really pushing at me to get out the door, and I didn't want him to have a toileting accident in case he actually needed to go, we went and walked down the hall.  He didn't need the bathroom, but he didn't want to leave either, so we ended up walking back to the Music Room. (I asked if he wanted to go for a walk to get some air/exercise- didn't seem to want to go- that, of course, was when he went and sat down.)

-When it actually was time to leave he didn't seem to be too happy about it. (I had taken him- yet again- down the hall and this time he did use the bathroom, and when we got back he didn't want to go in the room. I think it was because it was time to go, and he didn't really want to go back to his building. I had to go in the Music Room and get our coats.)

-When we got to his building, he paused on the way back in, and he let me open the doors this time. Usually he dashes in ahead of me and gets all the doors himself. (I got the sense that it was simply hard to let go at the end of the session. I realized how heavy my heart had gotten during the course of the session, so I also felt the sorrow of having to end for the day.)

So that's how I process a session.  Most of my thoughts happened during the session, and I wondered some of them out loud and some of them I couldn't quite fully form.  I still couldn't tell you for sure whether he was upset about our missing a session due to my vacation, upset because it was Thanksgiving and the holidays bring him sadness, or he was simply overloaded from day after day of noise and needed to vent to me in the quiet of the Music Room.  Or something else entirely that I would never occur to me to think.

The whole point of calling it a process is that we look at what happens over a long period of many sessions, not just one single day.  But this is what happened on a particular day, and I put it into the context of our entire period of work together (it's been eleven years of work, as it happens).

Wednesday, November 26, 2008

Paying Attention in Music Therapy Series- Part 1: How to Process a Music Therapy Session

I've written before about paying attention in music therapy. It's such an important aspect of our work (made even more so by the fact that many of us work with people who don't use speech), I decided to do a series on the subject.

The first thing I learned in clinical supervision was how to write a process paper. Appropriately enough, it helps you process (in other words, think about and examine) the session by looking at what you were hoping to do, what actually happened, and how your client(s) reacted and how you reacted. It's an intensive exercise, but it's worth it, because many music therapists are used to doing activities and focusing on the product of therapy (the goals and getting to the goals by using specific activities). As such, it's a very new experience to pay attention to the process (looking at relationship and the development of the relationship and how it's manifested in the music). Furthermore, when you aren't sure what's going on- maybe therapy isn't progressing, or maybe you feel uncertain as to how to proceed, or you find yourself having strong reactions to a particular client- it's a way to dissect the session into its smallest parts, thus (hopefully) slowing the whole experience down enough to be able to see where, why, and how the therapy is getting stuck.

Create two columns next to each other on a piece of paper. Listen to and/or watch an audio or videotape of a session (if you have neither audio nor video, you'll have to do this from memory). In the first column right down exactly, in the order that it happened, what you did and what happened (what music you played, what you said, how your client(s) responded, etcetera). In the second column write down (opposite of what you did or what your client did) what you were hoping to do, why you chose to make a particular intervention, and how you felt about your client’s response(s). For example:  

(Column 1) I went in to the building to pick up my client, Joan, for music therapy. She was waiting for me at the door, because she can see through the door when I come in. We walked to the Music Room. She waited for me to help take of her coat. I sat at the piano, and I invited her to join me in the chair I had set up next to me. She walked around the room, touching different instruments. I sang the greeting song I usually sing to her (and so on). (This is your objective experience. Just the facts)  

(Column 2) I was excited about going to get Joan. I really like her, and I was looking forward to doing our session. I was surprised but pleased that she seemed so eager to come with me today. When I helped her take off her coat, I wondered whether she really needed my help, or if she's just used to other people helping her with it. I found myself feeling somewhat frustrated that she continues to walk around the room and ignore me when I sing a greeting to her. I wondered if other people feel frustrated with her as well (and so on). (This is your subjective experience.)

Tuesday, November 18, 2008

"On the right track" versus "trying again"

I was just reading an interesting post by Dinah in the Shrink Rap blog about "What People Talk About in Therapy".  I had to click on it, because, as you know (if you regularly read my blog), I do music psychotherapy with people who don't use speech as their primary means of communication.  As you would imagine, I'm always wondering what my clients (many of whom are on the more involved end of the autism spectrum and all of whom live in an institution) would talk about if they could.  Of course, I also try to read what autistic people have to say (knowing full well that what one person has to say isn't what every person has to say) as well, since the internet has become a rather handy resource in that respect.  

I am, however, always curious to know what it's like to do psychotherapy with people who talk out loud.   

Here's a particular part of Dinah's post that I wanted to ponder:
Psychotherapy is often about finding and elucidating patterns for people. Have you noticed you always feel badly at this time of year? That you've been feeling worse since we stopped the medicine? How you talk about your boss the same way you talk about your mom? How you make assumptions about the reactions of strangers that keep you from even trying to get what you want? Maybe it resonates, maybe it doesn't, I can always try again.
Even though the folks I work with don't use speech, they certainly have very clear behavioral patterns and styles of interacting.  And I find I do the exact same thing (noticing and pointing out patterns) in my sessions. Of course, because it's music therapy we also have the added opportunity to notice patterns in music-making (or music-avoiding, or instrument-throwing, or dead silence, etc.). I also tend to pay attention to my own typical patterns of reactions to specific clients. Between the process of taking note of my issues and the "miracle" of projective identification, there is usually some illuminating moment somewhere (even if I'm not always sure which way to go in my work with a particular person).

The challenge, as always, is that my clients' behavioral patterns can just as often be related to motor planning difficulties, and they may not reflect what is actually going on in that person's mind. And, yes, just because someone is able to tell you what's going on for them, it doesn't mean that s/he is going to be accurate, talk about the "real issue", or be aware of what's going on internally, and so on. 

What I specifically appreciated about the above quote, however, was that she notes (with regard to her interpretations and observations):   
Maybe it resonates, maybe it doesn't, I can always try again.
Many people who come to watch me work (most of them are music therapy students sent to do observations or doing their practicum with me), or those I to whom I describe how I work, ask me "if your clients can't talk to you, how do you know you're on the right track?"

Well, the most obvious answer is that I don't always know whether I'm on the right track. I may be on the absolutely wrong track. And, as Dinah kindly points out above, "I can always try again." As I've continued to do this work I've discovered over and over again that therapy isn't usually about being "on the right track" as much as it is about "trying again."  Going back to Dinah's blog: 
In my past ramblings on psychotherapy, I made the comment that sometimes people seem to talk about trivial things that happen in their lives --I think I used the comparative price of beef as my confabulated example for my confabulated patient-- and they still find therapy helpful. I noted that therapy can work even if the patient doesn't come every week: help is where you find it and people have different needs and extract comfort & cure in different ways.
I may, at the end of a session, think, "wow, that was a whole lot of not much happening," and yet it's not unusual to have the following happen: I prepare to leave the client's cottage where I just dropped him off, and he suddenly comes running back over to me and wants to leave with me. Obviously, something in that session touched him, and he found some meaning in being there with me. Maybe it's because I generally do "try again" when I get it wrong.  Maybe it helps my clients know that they can try again too. 

Tuesday, November 4, 2008

"That was so much fun!"

"That was so much fun!"  Well!  I don't usually hear that from the direct support staff who take part in music therapy groups with me.  Actually I don't usually have any staff with me when I'm doing music therapy.  Long ago I decided to work alone when I do sessions, because the direct support staff and I tend in very different ways.  Ahem.  

As such, you may be wondering why I actually decided to include the staff when I started a new music therapy group with the women in Group 2.  Well, for one thing, this can be a pretty rough crowd- I've seen one of these women tear apart an entire bathroom, ripping down shower curtains, tossing clothing and bathing items asunder, and then shred her clothing in a matter of seconds (let me tell you- that's a talent).  Another woman tends to yank hair, scratch, and bang her head on the floor.  As you might imagine, having their support staff around could be a very good thing.  

Another reason I wanted the staff in this group to come with me is that they are consistently with that specific group on Monday evenings.  Most importantly (to me anyway), these three group leaders (as they are referred to in our facility) really seem to like the ladies they support (I'm not being nasty here- sadly, I don't always see this attitude in this line of work).  They were very enthusiastic when I asked them if they were interested in our doing a music therapy group.  

We agreed to move the ladies from their usual living area (a room with no outside windows, in the middle of the cottage, surrounded by a lot of noise from neighboring day areas) to a room across the hall where the recreation staff works.  It's generally a quiet room, it's contained, it has chairs (even though various members of this group like to be mobile or recline on beanbags), and we can use fewer lights (the fluorescent lights are quite horrible) because it has windows.  

I also wanted the staff to understand the point of music therapy- give them a context within which to interpret what they might experience in the sessions.  I wanted to give them an idea of what I'm doing, why I'm doing it, what I'm watching and listening for, and how I'm going to do what I do. So I gave each of them a copy of a detailed memo I wrote a long time ago for supervisors who periodically come to observe sessions.  

I also gave them the Music Therapy Observation Form I've been working on for quite a while.  It's a complex form which I usually have my practicum students fill out  on a weekly basis.  It asks a lot of questions meant to provoke thought with regard to what the music therapist is seeing, sensing, hearing, and musing about during the group.  It also encourages attention to the relational qualities and dynamics within the group and how these might be expressed (or avoided) in the music.  It also notes some of the elements which might be going on (or ongoing) for clients in addition to the experience of being in the music therapy group (illness, sensory issues, motor planning problems, traumas, family stuff, etc.).  

We've had three sessions so far.  If all of the group members (minus their staff) show up we have seven women- which may end up being a lot, but we'll see how it goes.  The best we've managed so far is to have six women and two staff people. Sometimes the ladies decide to go to bed early, sometimes they head out with the teachers, and sometimes they need a break from the group and want to do their own thing.  

All but one of the women in the group are somewhere along the autism spectrum.  And, again with the exception of the one woman (who is dealing with mental illness along with her developmental disability), none of the ladies use speech to communicate.  They are, however, women with voices.  Quite a range of voices, I might add.  From low and gruff to high and sweet.

One of the things I noticed with regard to the group leaders is that they tend to chatter almost constantly with the women in their group.  This is actually, in many ways, a very good thing.  So I didn't want to discourage their natural tendency to want to interact, but their conversation, while animated and pleasant for the most part, was making it awfully hard to actually hear the group members.

Last night three of the women were present in the group.  I gently invited their support staff to listen- reminding them, "this is your opportunity to hear the ladies you work for in a completely different way."   They were quiet, and they listened. And it was great!  

I offered V a maraca.  She had come in to the room using her wheelchair, because her staff, M, was concerned she'd grab at and scratch everyone (and, indeed, she did seem headed in that direction as she began to pull roughly at M's shirt).  V held the maraca, evidently curious enough that she was able to settle herself down. In fact, she didn't grab anyone else for the rest of the session.

K was awake (last week she slept on a cushion we had brought for her- this time she had a big long beanbag and a blanket).  K is often asleep during the day, because, from what I can gather, she doesn't sleep well at night. I sang a greeting to her (and to her housemates). I invited her to turn toward each woman in the group (she is also visually impaired), asking them to alert her as to where they were located in the room by making some form of sound (her staff included).  She listened quietly as each of us made a sound or greeted her with a "hi, K" and turned her head to acknowledge that she had heard us.  

M switched chairs a number of times, making sure to stay near me, even maintaining visual contact.  She sang through much of the 30-minute session, quietly, a high-pitched and delicate collection of short little four and five note melodies and bursts (for lack of a better word).  

At one point, L agreed to come in to join us.  She still had a cold, but she accepted the tube shaker from T (her staff), and she shook it vigorously for about 30 seconds, set it down, picked it up to give it one more good shake, and handed it back to T and left.  

V eventually decided she wanted to get out of her wheelchair and sit on the beanbag with K (apparently they like each other well enough and are used to sharing this space).  There was no scratching or grabbing.  K decided to stand and move to the music (I too got up to sing and rock across from her while I followed her rocking on the guitar).

It was hard to have to sing "goodbye" to them all, because it truly was enchanting to watch the group transform into this lovely music-making collective.  T was astonished and excited (having assured me when we began that she had read all the papers I'd handed her the previous week and found them fascinating).

As we sang "goodbye" V, who had been holding the maraca so quietly, decided to join in with her voice.  Indeed, "that was so much fun."