Fifty shades of "no"

I've been sitting and stewing over the fact that one of my clients decided not to come to his session yesterday. Obviously, it's not the end of the world, and it's mostly likely he'll be back. But I know he's upset with me and he's struggling with a lot of feelings because of the difficult work we're doing right now.

Occasionally, clients with whom I've developed a fairly stable relationship (and I can tell you, that has usually come after quite a long time of working together- usually years), who I can almost always count on to be there for their sessions, refuse to come to music therapy. 

And  when I say "refuse to come to music therapy" I mean I've walked over to their building, signed them out, collected their outer gear, walked in to the group where they spend their days (along with the rest of the people who live with them and along with their staff people), and asked, "would you like to come to music therapy today?" 

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I'd like to pause here to say what a vulnerable moment this is- for me anyway- as a music therapist. I mean, I'm standing there, exposed, and, honestly, it's like inviting someone out on a date in front of their entire family. Only it's therapy (which is just as intimate as a date, if not more so at times) and the other people in their group may have feelings about this particular person being invited to go to music therapy (when they themselves are not being invited) and their support staff who usually have their own feelings about the person who's scheduled for music therapy as well as a series of opinions about me and what I represent (sometimes good and sometimes not so much). Additionally, support staff have a series of beliefs and understandings (usually passed down from their supervisors) about their role in clients heading out to programs (such as music therapy). Commonly, those beliefs and understandings involve making sure the person is clean and tidy and goes and does what s/he is supposed to be doing. 

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Now, most of the time, the folks I've worked with for a long time jump up and come over on their own and then pull me to the door. Others go and sit in their wheelchairs, waiting for me to take them out. Some people who have a harder time initiating actions or simply have a lot of physical involvement making it more difficult for them to stand and greet me, wait for me to approach them and let me know they want music therapy that day by making an effort to get up and go with me.

Over the years I've discovered a large (and important) part of my work is figuring out how my clients (most of whom don't use speech) communicate "no".  Some people (the ones who usually hop up to meet me) simply don't get up when I appear and remain seated. Some (who need more physical assistance) let me know by not allowing me- or just not helping me- to put on their coats. Others avoid going toward the door, and I've had a couple folks  pretend (vigorously) to be asleep. A few of my clients will come part of the way with me and then stop repeatedly or keep going in the "wrong" direction, and still others come to the session, wet themselves and have to return to their buildings to get their clothing changed. 

The gentleman I went to pick up yesterday is someone who usually gets up the minute he sees me and comes quickly over to take me by the wrist and pulls me toward the door. His "no" came after a particularly hard series of sessions in which I've been challenging his way of thinking about me and about the role of music therapy. 

His "no" started when he stayed seated, looking at me with a rather unhappy face, leaning his head on his hand. I wondered (out loud to him) if he had a headache (it was pretty loud) or if he was tired (sometimes he doesn't sleep too well). I waited a short time and then I told him I'd go out for a few minutes, come back and check again with him. "If you still don't want to come, that's fine, and I'll check in with you again next week."

So I went and stood in the hallway for three or four minutes and then tromped back in with my armload of sweatshirt, coat, gloves and a hat for him. He still didn't move. 

Mercifully, his support staff didn't tell him to "get up" (which is what usually happens, and, when they do that, he usually stands up and comes with me, but I'm well aware the entire time that he would not have been there had they not told him to be, which, I think we'd agree, is an awful feeling- for both of us). 

I offered to sit with him for a bit, because sometimes he actually needs some more transition time (or to just think about whether he really wants to skip music therapy that day- and it's very rare that he does), but he still didn't get up. 

Just as I was about to turn and leave, he got up and walked past me to the table (where there was more space for me to sit with him and also plastic blocks he likes to hold). He couldn't find any blocks (they were all zipped into a bag, and I guess he didn't want to mess with it just then), and he went to sit down in another chair. This time there was space next to him, so I sat down and pulled off my hat. 

I invited him to let me know if he wanted me to leave by looking toward me and if he wanted me to sit with him to indicate this by tapping my arm. He glanced my way, fleetingly, twice and made no move to grab my hand (which is what he generally does). 

"Okay then. I'll check in with you next week. I'm glad you let me know you didn't want to come today, and I'm glad you let me know you'd rather I don't sit with you right now."  

I wished the guys a decent weekend and headed out into the hall, kind of hoping he'd change his mind and come after me. He did not. 

I headed back to the Music Room, pondering the whole thing, reminding myself that he was likely wanting me to feel as rejected as he'd probably felt in our session. 

But then the inevitable worry began: Did I say something in the wrong way in his last session? Did I accidentally offend him? Did I hurt him by saying something he wasn't ready to hear yet? Is it irreparable? Will he give up and stop coming to music therapy? 

As I was pondering these questions, yet again, this morning, I realized, not only is this the usual litany I go through when a client chooses to not come to music therapy on a given day, but my confusion- my wondering what happened, did I do something wrong, will this person leave- probably very much mirrors the feelings my clients have had with regard to their families placing them in an institution.

Perhaps (along with "no") I was "hearing" his (and many of my clients') experience of ambiguous loss,  which is a loss that doesn't have clear closure and around which there are questions and a great deal of uncertainty. It's often thought of in terms of families' feelings regarding a child who is disabled or mentally ill or a parent or spouse who has Alzheimer's (for example), but there is little, if anything, written about the experience of the person whose family sees them as "gone" or "lost" to them because of their disability. 

When I arrived back in the Music Room, I found myself singing the following song, and once again, I felt amazed at the way our minds speak to each other through music.

Reflecting on feelings of powerlessness (a video blog)

I didn't say it specifically in the video, but I think my whole countertransference reaction was very much about feeling a sense of powerlessness - my own ("I can't fix it for you, and I hate that.") as well as what I believe was my client's experience ("I feel abandoned and forgotten and unable to change my life."). 

The state of "I don't know"

There are a few recurring themes (if I may go all musical on you) which I've noticed in my work with Bc.  One is that sometimes he shows up, and sometimes he doesn't.  Another is that sometimes he seems very interested in what we're doing- all involved, playing music, engaged, and sometimes he doesn't. Yet another is sometimes he's very groggy in his sessions (and sometimes so am I), and sometimes he's not.  

Okay, so maybe there's actually only one theme here:  sometimes yes, and sometimes not so much.  

I haven't worked with Bc all that long (comparatively speaking).  I'd say it's only been, maybe, three or four years. I've often found, having worked in an institution for almost (gasp!) twenty-one years, that it takes more like six to eight years to start to get a sense that maybe we have a relationship happening here.

On two separate occasions, in the past month or so of working with Bc, I've had this very strong sense of feeling bothered.  Not exactly bothered, really- it was more a wondering, "Does this man really want music therapy? Am I just getting on his nerves?  I have to work so hard to get his attention, and even when I may actually have his attention, I'm not sure that he's interested in this.  Do I even exist as something or someone who matters to him?  I just feel like he's avoiding dealing with me, and I'm constantly trying to get a sense of 'does this matter?  Do I matter?'"

So there I was, pondering these things, and it suddenly hit me. "Is this how Bc feels in his life? Like he has to work so hard to get people's attention, and then maybe they'll be interested in paying attention to him, and maybe they won't. Maybe Roia will stick around, maybe she won't. Is it worth the effort to trust someone who's probably going to disappear anyway?"  

It has occurred to me that it's possible that my clients spend a large amount of time experiencing uncertainty. And I, by extension, as their music therapist, spend an equally large amount of time feeling uncertain. I've written (well, I've made mention of) ambiguous loss in two previous posts (here and here). Families disappear.  Staff comes. Staff goes.  The thing is, I think it's connected to this constant state of "I don't know" that my clients and I seem to co-experience in our sessions.

If you've ever been in an institution (for whatever reason), then you start to notice that, in spite of all the schedules and the "you're supposed to be here at this appointed time" and the regimented this, that, and the other thing, the menus, the activity schedules and so on...there is still a strong sense of uncertainty in the experience of being there.  

By uncertainty, in this instance, what I mean is, "Which staff is on today/tonight? What kind of mood is s/he in? What is that going to mean for the kind of night I'm going to have or not have? Is this person still my staff, or has s/he moved on to work in another building? When will my family be visiting me? Do they know I'm here?  Do they care?" You get the idea. 

As a music therapist, I'm called on to hear this somehow and translate it to music.  To give it a voice.  To acknowledge it. This constant state of "I don't know."

Thoughts while on vacation

Last week most of my sessions went to hell.  Now...I try to be a responsible music therapist, and I let everyone know that I’ll be on vacation, being specific as to when I’ll be away and when I’m planning to return.  

I realize that some of the folks I work with may not care that I’ll be away, some won’t remember that I told them I’d be away, some will remember and will hold it against me for a long time, some will think I’m abandoning them, and some will be jealous or angry that I get to go on vacation and they don’t.

I get this.  I’ve been going on vacations for a long time, and my clients have been dealing with it for a long time.  But every time I start the process of letting my clients know “we’ll be missing music therapy next week” and they start the International Grump at Your Music Therapist Day proceedings, I start to wonder (okay, okay, I start to worry), “do they even care?  Is it really me (and my guilt) making a bigger deal out of this than is really necessary?  Am I really helping by letting my clients know that I will temporarily be gone?  Is it actually me who is going to have such a hard time letting them go while I’m away?”

Yes, I suppose they’re all good questions, and to be an effective music therapist I will probably need to be aware of these concerns on some level.  On the other hand, in spite of the implied “No, Roia, I don’t care that you’ll be away on vacation!  You just leave!  I’m tired of music therapy with you anyway!  Hmph!”  attitudes that I get on my way out, there’s usually an awful lot of “I want to hold your hand” when I return.

So, um, maybe the real point for me is to have something to worry about.  Sigh.

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.    

And now...playing the role of "The Bitch"

We music therapists have this investment in being “nice”.  You know?  We’re the ones who are “nice” to our clients, we treat them differently from the staff who does their direct support (of course, it’s because we don’t have to make people brush their teeth and take rectal temps and stuff like that).  Dare I say?  We need to be seen as “special” by our clients as much as they want to be “special” to us (see yesterday’s post).  Oh yeah.

Anyway, when my clients respond in a positive way to my treating them respectfully and caring about them (and generally being “nice”), it’s a good feeling...for all of us...UNTIL it becomes clear that we’ve got a crush going on.  Then I have to start the old “we don’t have that kind of relationship” speech.   I say “old” because I have given this speech so many times over the last fifteen years it’s ridiculous.  

Now, it’s not as if my clients believe me or take me seriously when I say this to them, so I have to remind them over and over and over.  I have to keep saying repeatedly, “I will not act on your feelings, but you are welcome to explore your feelings in the music, and we can talk about them” (well, okay, “I can talk about what I think you might be feeling, and I’ll feel embarrassed and worry a lot that I’m just putting ideas into your head that really aren’t yours...”). 

It’s not enough for me (because this is all for me, isn’t it?) that I have to worry that I’m misinterpreting some innocent affection from my clients as a huge crush.  I also have to feel guilt (are we noticing a theme here with the guilt?), because I have to consistently and in as caring a manner as possible keep rejecting my clients’ (possibly, or more likely probably) skewed perception of me. 

I’m not insane (well...).  I mean, I realize that this is a necessary part of the therapy process, and it’s helping my clients, and consistency is next to Godliness, and appropriate therapeutic boundaries are new and unusual to people whose space and person-hood have been regularly and incessantly violated, and crucial to their feeling safe (eventually).  I also realize that it’s because I keep maintaining those boundaries that my clients are able to trust me enough to somehow attempt to communicate that they have very strong feelings for me.   Okay.  I get all that. 

It’s still hard not to feel like I’m being cast into the role of “The (rejecting) Bitch”.  A-ha!  Guess who’s involved in a traumatic reenactment now!  

See, now this is why I like to journal and write about my work experiences.  In the process of blah-blah-blah I sometimes recognize something I neglected to recognize, or forgot that I knew on some level or at least at some point in the therapy process. 

Yup.  I can see how this can definitely be a reenactment.  “Fine!  You, Roia, can reject me...just like my family.”  It’s a hell of a lot easier to be angry with me for being “The (rejecting) Bitch” than it is to be angry with Mom (“I mean, maybe there’s hope that she’ll return and see the error of her ways, so it wouldn’t be wise to be angry with her- especially if anger was why I was rejected in the first place!”).  Someday I’ll have to write about ambiguous loss.  (Pauline Boss has an excellent book about this subject called- conveniently enough- Ambiguous Loss:  Learning to Live With Unresolved Grief.)

At any rate, it takes a long (long) time, but eventually my clients get it.  We’re not going to have a big triumphant rescue from the institution.  I’m just going to continue to be your boring old music therapist who will invite you to look at your darn feelings and figure out how they connect with the rest of your life.  Great.   And when that happens I hear a guy in my head on an echoing loudspeaker saying, “And now (now, now, now) playing the role (role, role, role) of ‘The Bitch’ (bitch, bitch, bitch)...Roia (roia, roia, roia)!”  And, of course, the crowd goes wild.