Saturday, February 18, 2012

Online Conference for Music Therapy 2012 Resources- Part 3

Recognizing and Responding to the Emotional Pain of People Who Don't Use Speech

This is the third installment of the handouts for the 2012 Online Conference for Music Therapy. This is a selection of quotes I have found useful to my thinking as a music therapist. The references for the quotes are also included. 

Roia Rafieyan, MA, MT-BC

Quotes I Have Known and Loved

“...the way others make us feel is the best clue as to the way they themselves are feeling.”  (Lovett, 1985;  p. 80)

“Real behavior change comes from a relationship;  the more serious the need for change, the more serious this relationship needs to be.  This need leads us from the realm of technology with its powers of predictability and orderliness into the uncertain and shifting territory of philosophers and poets.  What does it mean to be honest?  What does it mean to be present for another person and for ourselves?  What are the balances, at any moment in a relationship, between acceptance and challenge, between listening and being heard?  How do we invite others to accept our caring and concern and how do we all grow to feel we are part of one another in this world?  These uncertainties and failures have often led to difficult behavior in the first place.  How do we grow beyond it?”  (Lovett, 1996;  p. 224)

“Countertransference is part of every therapeutic relationship (regardless of the therapist’s theoretical orientation).  By definition, unrecognized and unanalyzed countertransference impedes our ability to be fully and actively present in the room with the client.” (Pearlman and Saakvitne, 1995;  p. 23)

“...empathy allows the therapist to gather information about the world the patient lives in and to use the information to build connectedness with the patient.”  (Cohen and Sherwood, 1991;  p. 220)

“We sometimes forget that our work often involves significant personal change and, equally dangerous, we forget how such change happens in our own lives.  Many of us have changed because ‘life happened’- events and the people in our lives significantly altered the way we saw the world.  Sometimes this is an abrupt turning point, sometimes a process occurring over years.  Sometimes- but this is only a small part of how most people actually change their behavior- we elect a formal relationship with a therapist to help us change, but no therapist (I hope) would presume to launch a program for change without taking time to get to know the person’s background and personal style.  This kind of groundwork is essential in forming a therapeutic alliance.”  (Lovett, 1996;  pp. 85-86)

 “Music psychotherapy involves three dynamic elements:  the client, the therapist, and the music.  Within this triad, the therapist and the music work together to help the client, serving similar or complementary role functions, very much like two parents working together to help their child and with the same possibilities for alliances, rivalries, conflicts, and valences.  Thus, both therapist and music can serve as a source, activator, and object for transference and countertransference, and both can provide the transitional space needed to work out the various role relationships being reenacted within the triad.”  (Bruscia, 1998;  p. 76)

“...systematic self-analysis must be a part of an effective containment effort.  Specifically, therapists must examine their own contributions to the intense feelings generated in the dyad.” (Gabbard and Wilkinson, 1994;  p. 82)

“Our attunement to our countertransference requires the same evenly hovering attention with which we listen to our client’s material.”  (Pearlman and Saakvitne,  1995;  p. 23)

“The important thing is not our flowery language, but rather that we are fully present and attentive to our companion.”  (Muller, 1996;  p. 117)

 “Many therapists are much more willing to assume the mantle of the good object than the cloak of the bad or threatening object.  Perhaps this is why so many of us are shocked when we realize the degree of anger and abuse we have to absorb from patients in the course of a career.”  (Lewin and Schulz, 1992;  pp. 228-229)

“...psychotherapy does not promise perfect attunement or mirroring, but entails repeated cycles of connections and disconnections and then repair and reconnection.”  (Pearlman and Saakvitne, 1995;  p. 17)

“...there is a common myth that the experienced analyst or therapist understands the patient swiftly and unerringly.  Although some patients try to oppose this, risking the retort that they are ‘resisting,’ other patients do expect it.  Perhaps it satisfies a wish to find certainty.  Some therapists also appear to expect it of themselves;  perhaps to gratify an unacknowledged wish to be knowledgeable and powerful.  It is not surprising, therefore, how often student therapists imagine that immediate understanding is required of them by patients and supervisors.  This creates a pressure to know in order to appear competent.”  (Casement, 1991;  p. 3)eve of “not 

 “Fresh insight emerges more convincingly when a therapist is prepared to struggle to express himself within a patient’s language, rather than falling back upon old thinking.”  (Casement, 1991;  pp. 27-28)

“I am suggesting that countertransference - as an aspect of projective identification - is not only the basis for analytic work but central to the basic process in all human communication and knowing.  We only know what is happening because we are moved from within by what we have taken in and responded to from our own deep feelings.  The space between people is filled - when it is and to the extent it is - by what we evoke in one another.”  (Young, 2005, March 27)

“Exploring one’s countertransference involves asking oneself whether this response feels unfamiliar, significant, unusual.  What does the response tell you about feelings that may be out of your awareness?  Does a particular dream stay with you?  Are you behaving differently with this client than previously?  Than with other clients?  Are the feelings more familiar to you in a different (e.g.. non-clinical or historical) context?  Do they seem alien or distressing or syntonic and comfortable?  These questions invite the therapist’s awareness and self-exploration which both deepen and expand her use of countertransference.”  (Pearlman and Saakvitne, 1995;  p. 27)

“My ego ideal, as regards my functioning as therapist, required that I endeavor always to be helpful to the patient, that I be unflaggingly interested in him, and that I experience no negative emotions whatsoever toward him- let alone express such feelings to him openly.  I regarded my personal identity as changeless, and my therapist-role as similarly fixed and absolute. 
I have described elsewhere that, in the course of subsequent years of personal analysis and clinical experience sense of identity has most reliable source of data as to what is transpiring between the patient and myself, and within the patient.  I have described...the ‘use’ of such fluctuations, in one’s sense of identity as being a prime source of discovering, in work with a patient, not only countertransference processes but also transference processes...[Searles, 1966-1967].
The main point of the present remarks is analogous to the one just quoted:  as with the analyst’s overall sense of personal identity, so the customary style of participant observation which he has developed over the years, his observation of the ways wherein he finds himself departing from this normative style, in his work with any one patient, provides him with particularly valuable clues to the nature and intensity of this patient’s transference responses and attitudes toward him.  Beyond the analyst’s privately observing such variations in his customary mode of participant observation, he can find it constructive, with increasing frequency as the analysis progresses, to share these data with the patient.”  (Searles, 1979;  pp. 577-578)

“When we discard technological responses to personal problems, we leave a world of some predictability (the primary reassurance that technologies provide) for a world of uncertainty...”  (Lovett, 1996;  p. 96)

“Therapists sometimes have to tolerate extended periods during which they may feel ignorant and helpless.”  (Casement, 1991;  p. 8)

“It is all too easy to equate not-knowing with ignorance.  This can lead therapists to seek refuge in an illusion that they understand.  But if they can bear the strain of not-knowing, they can learn that their competence as therapists includes a capacity to tolerate feeling ignorant or incompetent, and a willingness to wait (and to carry on waiting) until something genuinely relevant and meaningful begins to emerge.  Only in this way is it possible to avoid the risk of imposing upon the patient the self-deception of premature understanding, which achieves nothing except to defend the therapist from the discomfort of knowing that he does not know.”  (Casement, 1991;  p. 9)

“My best experiences in supervision have resulted from the supervisor asking me what I was feeling at a particular moment - usually a moment when I felt I did not understand the material.  I would go so far as to say that this has never failed to provide at least some enlightenment.  Interrogating the countertransference must not be seen as seeking a fact which is available on the surface of the mind.  Countertransference is as unconscious as transference is.  Understanding it is an interpretive task.”  (Young, 2005, March 27)

References for Quotes
Bruscia, K. E. (1998).  “The Signs of Countertransference” (pp. 71-91) in The Dynamics of Music Psychotherapy (Bruscia, K. E., Ed.).  Gilsum, NH:  Barcelona Publishers.

Casement, P. (1991).  Learning from the Patient.  New York:  Guilford Press.

Cohen, C. P. and Sherwood, V. R. (1991).  Becoming a Constant Object in Psychotherapy with the Borderline Patient.  New Jersey:  Jason Aranson Inc.

Gabbard, G. O. and Wilkinson, S. M. (1994).  Management of Countertransference with Borderline Patients.  Washington, D.C.:  American Psychiatric Press.

Lewin, R. A. and Schulz, C. (1992).  Losing and Fusing:  Borderline Transitional Object and Self Relations.  Northvale, NJ:  Jason Aranson.

Lovett, H. (1985).  Cognitive Counseling and Persons with Special Needs:  Adapting Behavioral Approaches to the Social Context.  Westport, CT:  Praeger.

Lovett, Herb (1996).  Learning to Listen:  Positive Approaches and People with Difficult Behaviour.  London:  Jessica Kinsley.

Muller, W. (1996).  How Then, Shall We Live?  Four Simple Questions That Reveal the Beauty and Meaning of Our Lives.  New York:  Bantam Books.

Pearlman, L. A. and Saakvitne, K. W. (1995).  Trauma and the Therapist:  Countertransference and Vicarious Traumatization in Psychotherapy with Incest Survivors.  New York:  W. W. Norton.

Searles, H. F. (1979).  Countertransference and Related Subjects:  Selected Papers.  Madison, CT:  International Universities Press.

Young, R.M. (2005, March 27).  Analytic Space:  Countertransference in Mental Space (Chap. 4).  Retrieved from

Online Conference for Music Therapy 2012 Resources- Part 2

Recognizing and Responding Musically to the Emotional Pain of 
People Who Don't Use Speech

As many of you already know, working at becoming a better listener, a more mindful clinician, and a curious practitioner is one of my passions. And this struggle to make sense of my experiences as a music therapist is something I try to share in my writing. 

To that end, I offer you links to a number of blog posts I've written over the past five years that are (mostly) directly related to the ideas I shared in my presentation for the 2012 Online Conference for Music Therapy. 

Some folks asked about working with groups, and I made note of posts addressing that subject. I also included a post about writing a process paper, which I still think is one of the best ways to start thinking about your sessions ( or should I say re-thinking your sessions?). 

I hope you find them to be useful.

Roia Rafieyan, MA, MT-BC

9/9/09 blog post

11/26/08 blog post (Writing a process paper)

5/1/09 blog post (Group music therapy countertransference example)

4/7/09 blog post

2/6/10 blog post (on not being understood)

1/26/10 blog post (quote from Mercedes Pavlicevic’s book “Music Therapy: Intimate Notes”)

10/25/09 blog post

9/29/07 blog post (addresses respecting “no")

2/10/10 blog post

6/7/11 blog post (countertransference songs)

12/27/10 blog post (working with groups)

11/21/10 blog post (countertransference songs)

12/6/11 blog post (using music to process countertransference)

11/29/11 blog post (using music to try and understand clients who don’t use speech)

6/24/11 blog post (communication)

7/14/11 blog post (countertransference and communication)

Online Conference for Music Therapy 2012 Resources- Part 1

Recognizing and Responding to the Emotional Pain of People Who Don't Use Speech

Thanks so much to those of you who were able to join me at the 2012 Online Music Therapy Conference! And to those of you watching the recordings, a hearty welcome as well. For anyone else who may find this to be of use, feel free to make use of the information but please give me credit for having made the effort to put this together. Thanks! 

Roia Rafieyan, MA-MT-BC

Elements to Pay Attention to as You Work to Listen to People Who Don't Use Speech

Pay attention to what’s going on for your clients
The physical
·       Sensory/movement issues?
·       Medical issues?
·       Environmental issues?

The historical
·       What has gone on in this person’s life- including trauma history (biography)?
·       Patterns of behavior and contexts within which they occur?
·       Relationships with family, peers, staff (and any changes in these)?

The musical
·       How does the person use music?
·       Which instruments/sounds does s/he gravitate toward (vocal or instrumental)?
·       Meaningful music?

The right now experience
·       What’s going on in the relationship and how is my client responding to the experience?
·       How is the person using music/sound/behavior to connect/disconnect?
·       What questions are coming up for you as therapist?

Pay attention to what’s going on for you
The physical
·       What are my somatic reactions during the session?
·       Do I have a pattern of responding in a particular way?
·       How am I feeling physically on a given day?

The historical
·       Have I done my own therapy work (aware of my own issues)?
·       How much support do I need to do this work?
·       What beliefs and ideas do I carry with me?

The musical
·       Have I taken care of myself musically?
·       What are my musical blocks (fears) and needs?
·       What role does music play in my life?

The right now experience
·       What’s going on in the relationship and how am I responding to the experience?
·       What patterns are emerging (for my client and for me)?
·       What thoughts, fantasies, songs etcetera, are running through my head while we’re working together?

Pay attention to what’s going on in the music
The physical
·       What instruments are we using (vocal/instrumental? quality of sounds produced?)?
·       Are you/your client mainly using your voice or playing instruments?
·       Use of silence?

The historical
·       Which music has been important to this person and to you as therapist as you’ve worked together?
·       Do any particular songs trigger any particular reactions for your clients?
·       Musical themes which you/your client keep coming back to?

The musical
·       How musical are we being (aesthetics)?
·       Is the music being neglected entirely?
·       What role is the music taking on within the context of psychodynamics?

The right now experience
·       Why am I playing right now (what am I hoping to find out?  What am I looking for?)
·       What is going on in the music right now?
·       Who is playing/singing what right now?

Pay attention by:
  • Reflecting and interpreting
  • Learning more from reading, asking a lot of questions, taking classes, other disciplines
  • Listening more (especially to people who have autism)
  • Do your own work (get therapy, get supervision, join a peer supervision group)
  • Be aware/mindful
  • Ask yourself questions and be willing to find out the answers
  • Consider “whose need am I meeting here?”
  • Learn to tolerate ambivalence, ambiguity, not knowing, uncertainty

Sunday, February 5, 2012

Music therapy at the boundaries

It happens I'm a part of a group on LinkdIn for psychologists, counselors and coaches. Not that I'm a psychologist, counselor or a coach, mind you... 

But anyway.

We've been enjoying (okay, I've certainly been enjoying) a robust discussion with regard to the question of "how much of our personal selves do we share with our clients?"

To the best of my recollection (which is a bit, er, well, let's just say it's not what it used to be), Rachelle Norman has tackled this question (a couple of times, actually) in her blog, Soundscape Music TherapyA while ago she wondered how much should she share regarding the birth of her baby (who is awfully darned cute, if you must know), and, in a more recent post, she talked about The Top 10 Rules to Break. A big hooray to you, Rachelle, for addressing this complex and apparently rather heated issue!

So, back to the conversation going on at LinkdIn...

I've been sort of surprised at how many counselors and therapists seem to believe, rather ardently, that the "rule" regarding the "therapist as blank slate" is too stringent. A large majority advocate sharing more of themselves as a way of "being authentic" with their patients. If I'm understanding them correctly, they seem to feel, "that's what our clients are really looking for- for someone to be authentic with them."


Among the questions that came up for me in reading comments along these lines was: are we really being inauthentic with our clients if we don't share on a personal level with them? And does being authentic with someone always mean being transparent? 

When I looked up the word, I learned that being "authentic" is associated with being genuine, or being truthful. Which is not the same as being self-revealing. Hm.

For me, I think the question of what and how much to share of ourselves boils down (as most things in the therapy situation seem to do) to another central question: whose need am I meeting in this situation?

As many music therapists are aware, simply because of the nature of our profession, we actually share quite a bit of ourselves through the music-making we do with our clients during sessions. Just as we learn about our clients through their musical expression, they learn an awful lot about us when we interact with each other musically.

Obviously, we do our best to keep to professional boundaries- for many legitimate reasons. One very large reason is the power inequity. It is (usually) a paid relationship. Therapy isn't meant to be a friendship, and, whether or not we choose a fairly egalitarian approach to our work as music therapists, we can't control (or ignore) our clients' perceptions that we have a certain amount of power, authority and influence in their lives. 

As an example, in my particular line of work (with people who have intellectual and developmental disabilities), I often remind myself of the fact that I have keys to my clients' homes, and they don't.

I wonder if, in the end, it's about coming to terms with the duality (maybe it's a plurality?) we are asked to hold as music therapists (or any kind of psychotherapist, I imagine). Yes, our clients often do come to us in pain and in a tremendous state of need- for, among other things,  friendship and for people to be 'real' with them. Simultaneous to that, we are bound to uphold our code of ethics, to maintain an awareness of our own unmet needs (and our rather human tendency to want to take care of those needs in all of our relationships- including those with our clients), and an awareness of the power dynamic that exists in the therapy space.

It certainly isn't easy to keep track of these various elements. Of course, as my supervisor often reminds me, "that's why they call it work."

What are your thoughts on boundaries and being authentic with clients? Does it depend on the situation? Or on the particular group of people receiving services? Are you likely to have more "flexible" boundaries with certain groups of clients and not as much with others? And what does that fact say in terms of the ideas and beliefs we hold about the particular groups of people we serve?