"You are showing them that they exist"

Excerpt From the transcript of the On Being show in which Krista Tippett interviewed Michel Martin:

MS. MARTIN: What we are simply saying is, I see you. I mean, I know for example when — you know, when I was working for “Nightline,” and I went to Turkey after there was a terrible earthquake there, and like, you know, thousands of people were killed. And I was feeling really useless. Um, thinking, boy I wish I were a doctor. I wish I were a structural engineer. I wish I could do something more useful. But then people would come up to me and say, thank you for being here. And I would feel, like, wow, why are thanking me? And then I thought — and I called my — you know what we do at a time like this. You know, I called my husband, because [laughs] I really feel like so useless. What am I doing here? And he said, you are showing them that they exist. And I appreciated that, because I’ve held onto that. It’s like sometimes the best thing we can do for people is let them know that we see them.

MS. TIPPETT: Mm-hmm.

MS. MARTIN: And so sometimes, you know, other people’s bad news is, you know, their lifeline, and letting them be understood. In fact, this was the very first story I did when I was at The Post as a little baby reporter at The Washington Post, and I was sent out on the summer — it was one of those terrible stories that you hate to do because some little boy had fallen out the window of the projects.

MS. TIPPETT: Yeah.

MS. MARTIN: And I had to knock on the woman’s door to get a comment from her. And I kid you not, I walked around the block three times before I mustered the courage to knock on her door, because I knew I had to. And I felt like, you know, and I knocked on the door. And she — and I said, I’m so sorry, I heard about your son, I came to see if there was any — a comment that you had. And she said, where have you been? Because she felt that if someone from the media didn’t come, then this was invisible and it had no meaning. And she had things she wanted to say, like why weren’t there any safety screens on the windows, which there were supposed to be. So, I bring that up to say a lot of times, what sometimes what middle class people see as intrusion, other people with no power see as validating their existence.

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This part of the conversation was so meaningful to me, particularly a day after sitting with my clients in their "I hate this place!" rage, fear, anxiety, uncertainty. Literally, from the first session to the last, I heard some variation on this experience of powerlessness. In the first cottage, one of the women was screaming about how much she "hates this place!" The person I actually went to pick up for her session was having a rough time of things, and I found myself feeling quite lost and powerless to be of much help to her. The person I worked with in the afternoon was clear in his wish that I would take him away, because he indicated a wish to leave the session space for a while and he directed me straight to one of the vans sitting in the parking lot. 

My last session was with a challenging group of men who live in an untenable situation- stuck in a room, all day long, dependent on whoever was coming in to support them, and angry, frustrated, powerless. One of the men, the youngest in the group at only 31, yelled and yelled and yelled, as he often does, but this time, even though he doesn't use words to speak, I distinctly heard, through his yelling, the words "I HATE THIS PLACE!! I HATE THIS PLACE!!" 

Our session had begun with one of the guys being pushed back into the room by his annoyed staff person. I knew he preferred not to be with us, and I had encouraged him to go and be in the other area, so instead of taking off his shoes, his shirt, his pants and grabbing at me, he kindly got up and walked toward the door. His staff person pushed him back in, because, she said, "he keeps going and leaving the day area and eloping, and we are so short-staffed, I can't watch him and all these other guys as well, so he's going to have to stay in here! Everyone gets frustrated that there aren't any staff, and then they call off!" She, too, was in an awful situation.

It was hard to know what to offer the men, musically, that could even come close to supporting them. All I could do was acknowledge it and let them know, "I hear you, and, yes, it is very hard to live here, and right now it's also very hard to work here. And I hear you saying you hate this place, and I'm sorry you're feeling so disrespected." 

And so, as I felt as if absolutely nothing I could do would be of any help to the guys, one of the most poignant moments was when the young man who was screaming came over to me, after four times, handing me my guitar case and seemingly letting me know he wanted me to leave, picked up a brush that was sitting on the table, and he handed it to me. I was holding my guitar, and I thought, "Whaaaa?" Until he pulled my hand to his head, and he kept a hold on me as he slowly had me brush his hair. 

So, Michel Martin, thank you for reminding me that what I do have to offer my clients is "show them that they exist."

How to be together

We sat together yesterday, our group of seven, on a Monday afternoon. And the curtains in the room were open to the afternoon sun, closed as the sun blinded us, and then open again to watch the beautiful dark frames of leafless trees against the pink and yellow and blue sky as the sun began to set. And, with the early evening news as a background, we noticed, for ourselves and with each other, our music was made of...

...sound and silence,

terror and safety,

change and consistency,

feeling frozen and being in motion,

comfort and discomfort,

certainty and uncertainty,

sleeping and awake,

light and dark,

presence and absence,

judgment and acceptance,

loud and quiet,

intensity and gentleness,

curiosity and detachment,

containment and freedom...

And then, this morning, I read and listened to this gorgeous conversation between Krista Tippett and Ann Hamilton. When Krista asked her what questions we should be asking, without hesitation, Ann responded:

"...how to be together. I mean, isn’t that — that seems like the biggest question. How to be together." (Ann Hamilton) 

Yes! And yes again!

There are so many who believe music therapy sessions with people who don't use speech as their first language are about "playing for your clients." In fact, it is about

listening, 

noticing, 

playing,

 experiencing,

 being

 and wondering 

together.

"...when you’re making something, you don’t know what it is for a really long time. So, you have to kind of cultivate the space around you, where you can trust the thing that you can’t name. And if you feel a little bit insecure, or somebody questions you, or you need to know what it is, then what happens is you give that thing that you’re trying to listen to away. And so, how do you kind of cultivate a space that allows you to dwell in that not knowing, really? That is actually really smart, and can become really articulate? But, you know, like the thread has to come out, and it comes out at its own pace." (Ann Hamilton)

"I Wish I Knew How It Would Feel To Be Free"

It started some months ago when I, quite by accident, discovered that one of the men I work with (he's autistic, he doesn't use speech to communicate) can indicate "yes" or "no" by pointing to (well, usually by grasping and releasing) one of two index cards. He doesn't need my help (other than to hold the cards in front of him). 

He doesn't always do it. In fact, sometimes he very pointedly chooses not to do it. Sometimes he crumples up the cards and tosses them aside. Which is why they're laminated.

I think, understandably, his feelings about communicating and being heard are deeply conflicted. Even if he were to begin pointing at more words and letters to communicate, the likelihood he'd be listened to is...well...slim. The people in his life are largely committed to seeing him as severely disabled. Period.  

We've been sitting in that unsettled, anxious, frustrated, what-the-hell-do-we-do-now state for a while. I can see he wants to say more. He picks up the letter boards I keep nearby, but he gets upset and then tosses them on the ground.

Aside from trying to come to terms with the whole idea of actually communicating with me and having me understand him- overwhelming in and of itself for him, I think- there's the fact that it probably won't change his life in any appreciable way. 

When it was time to stop we walked back to the unit and I dropped him off in his group (letting him know when I planned to return for his next session). I went into the office and signed him back in, and then I walked around so I wouldn't upset him by walking back through his group. He doesn't tend to like when we have to end.

But he knew I was there. So he left his group (much to the dismay of his staff) and wanted to follow me. He doesn't usually do this, so I sat with him for a little while in the back hallway. 

I wasn't sure what to say, but the words that ran through my mind were the title of a Billy Taylor song, I Wish I Knew How It Would Feel To Be Free. 

I didn't remember much of the song, and I wasn't sure it was something I could conjure up sitting there in the hallway. All I could think to offer him was the reminder that "nobody can take away who we are inside." 

We sat quietly as the shift changed and after a few minutes he got up and headed back in to his day area. 

Sometimes this work is really hard. Really, really hard. 

Well, what do you know?

I was minding my own business, journaling away last Sunday morning, listening to (yet another excellent episode of) On Being, where Krista Tippett was interviewing Lawrence Krauss, a theoretical physicist. The aspect of their conversation that caught my attention was this comment: 

Mysteries are what it's all about. In fact, not knowing is much more exciting than knowing, right? Because it means there's much more to learn. The search is often much more exciting than the finding. Mysteries are what drive us as human beings. 

He extended the idea by noting:

One of the values of science is to make us uncomfortable. Somehow that's supposed to be a bad thing for many people, being uncomfortable. Being uncomfortable is a good thing because it forces you to reassess your place in the cosmos. And being too comfortable means you've become complacent and you stop thinking. 

As I listened to him I realized something kind of interesting: I think not knowing is what has kept me passionately in this field for so long. 

Think about it a second. 

When we think we know (the answer, what's going on, what someone's problem is, how things should look, who someone should be, and so on and so forth) we are no longer learning, no longer curious. We stop at the surface, and, because we know then we presume there's nothing else to think about or to find out.

When we're new professionals we either think we know or we think we're expected to know most of what there is to know about music therapy. What we often don't realize is that all we know are the very basics- that there's a whole world of knowing we haven't even begun to come in contact with yet!

It took me a lot of years (and a lot of clinical supervision) to finally understand that my real job as a music therapist is to go out there and ask my clients what they need me to know and learn in order to better support them. 

So many times in my younger (pre-clinical supervision) music therapy days I went into sessions knowing what needed to be done to "help" my clients. I didn't ask, I wasn't curious about what was going on or why my clients might need to be or do things the way they were being or doing things. They were disabled. There was a list of things I knew about disabled people. There was a list of ways music was supposed to "help" disabled people. 

So I went in with my music therapy interventions, applied them, and waited for the activities to work. This is what I was taught (or at least this is what I understood of what I was taught). And when my interventions didn't work I was frustrated with my clients and wondered, "what the hell? Why isn't this working? This is what I was told to do!"

Somehow I had inadvertently stepped into the medical model of music therapy: "Here are the symptoms associated with a particular population of people. Liberally apply music therapy activities to alleviate said symptoms and to increase skills. Music is, after all, intrinsically reinforcing. Success." 

In other words, I'd go into sessions with the attitude of "I know what the problem is, and I know the solution." Except that I wasn't having a lot of success.

Finally I got myself some clinical supervision, and I learned about process-oriented, relationally-based music therapy. But when I stopped doing activities and began to use an improvisational approach, I was terrified! I had no idea what to do- ever. I was convinced I'd failed as a music therapist, because I didn't know anything any more! 

Add to that fact that I work in an institution, and institutions are notoriously entrenched in the all-knowing medical and behavioral model of understanding people. Sitting there quietly with someone (because I didn't always know what to do) and singing about what that person was doing or what I thought it might be about (as opposed to gathering everyone in a circle- or trying to- and forcing them to play instruments with hand-over-hand assistance) was an open invitation to criticism and "why are you just sitting there doing nothing, Roia?" 

But I trusted my clinical supervisor who told me "trust the process". 

As time went on, I discovered the joy in finding out who my clients actually were and began to appreciate the opportunity to get to know them in a more authentic and human way. I got more comfortable with the idea of going into a session and not knowing - not knowing what was going to happen, not knowing (yet) the person in front of me, not knowing exactly what music would be needed that day, not knowing if I was hearing my client properly, not knowing if what I offered was going to be accepted or even make sense. 

And that engaged me in the work of becoming and being a music therapist like nothing ever had! I began to understand music therapy from a whole new perspective: 

We are artists, and we are scientists, and art and science are not about knowing. They're about trying something out (an idea, a hypothesis, some direction) and discovering, or messing up, making mistakes, and figuring out better questions to ask. They're about not knowing, about wondering and curiosity, and finding out what we don't realize we don't know. 

That's amazing to me! And waking up every morning with the thought, "I wonder what will happen today with my clients," and being completely curious excited about that, is what drives my passion for music therapy. Even after doing this for 26 years!

To borrow from Lawrence Krauss again:

In fact, what's really beautiful is every time we make a discovery in science, we end up having more questions than answers.

Yes! 

More on "not knowing"

I have been slowly making my way through Mindful Therapy: A Guide for Therapists and Helping Professionals by Thomas Bien. I have mixed feelings about the book, but every so often I come upon some passages that seem quite relevant to me. This is one of them:

An attitude of not knowing is, I believe, extremely valuable for the mindful therapist, as it is in Buddhist practice. When you think you know, you stop being open. Not knowing helps us remain open to the patient before us, seeing this person as a unique individual in a unique situation rather than another 'case' of depression, or anxiety, or marital difficulties. Not knowing, while the opposite attitude from what we learned in our education, is our best friend in the therapy room. The wise therapist respects not knowing, is comfortable with it, and even cultivates it. We cannot understand if we think we already know. And to know you don't know, taught Confucius, is the beginning of knowing. (p. 138)

I write a lot about uncertainty. It seems an integral part of my work. I've also written about the state of "I don't know" and about getting lost. 

I suppose it all boils down to different ways of acknowledging, with some humility, that we music therapists often don't know, in a session, what's best, what's going on, and how to proceed. But we are present, and we trust the process and the music.

Trusting the process

I have been thinking about my practicum student this evening.  I think she’s trying to let me know that she’s nervous about the fact that during this semester she’ll be leading the music therapy group she’s been observing for the past four months.  Part of the reason for her concern is that I don’t do activities, and my sessions are largely improvised.  As such, there’s no script, no specific tasks I expect people to complete, and there’s the not knowing what’s going on- particularly since my clients can’t say it with words (or even with music a lot of the time).

It’s scary, especially when you’re new to music therapy, to tolerate not knowing the answer.  Sometimes I think that the only thing I have that a student doesn’t have is just enough trust in the process to be able to stand it when I have no idea what’s going on in a session.  After thirteen years of being reminded by my own clinical supervisor that everything that happens in the session is “grist for the mill” I finally believe her.  I’ve made tons of mistakes, I’m sure.  For the most part, my clients are still there.  We’ve looked at my mistakes, and we’ve looked at theirs, and we all lived, and we still do music therapy together.  

I happened to be looking through one of my many notebooks full of notes, and I came across a few wonderful quotes from Wayne Muller (it’s from the beautiful book How Then Shall We Live?  Four Simple Questions That Reveal the Beauty and Meaning of Our Lives).  I will have to share these with my student:  

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

“...it is not the act but the awareness, the vitality, and the kindness we bring to our work that allows it to become sacred.” (p. 194)

“But what if ‘don’t know’ is not a signal to push and work and struggle, but rather an indication that it is time to be quiet, listen, and wait?” (p. 180)

“I learned to trust the truth that music can tell about things.”  (p. 113)

I have every confidence that my student will grow into an excellent music therapist.  She is caring, patient, aware of her own internal struggles, and she pays close attention to people.  She’s also not afraid to make music.  Once she realizes that she has all she needs to do the work of music therapy, I’m sure she’ll feel better.

Getting lost

Last weekend I had to drive home in the middle of a sleet/rain/snow “event” at 11:30 at night.  So there I was traveling slowly homeward (or so I hoped) when I realized that I had made a wrong turn, and I was now driving along some very curvy roads I’d never been on before- even in the light of day.  I wasn’t particularly panicked, because I had a general idea as to which way I had to go in order to eventually get to where I needed to be (so I could, theoretically, get home at some point).  It did, however, take a lot more time than I expected to finally get to a road I recognized.  Mercifully, I didn’t do any sliding around and ending up in a ditch, and I did finally get home some time after midnight.  

Now, the reason I didn’t freak out when this happened is that I regularly go out driving with my friend, Darrin, and I make a point of getting lost and driving in unfamiliar places so I’m forced to find my way back.  My reasoning is that this way I won’t get so scared when I get lost.  I don’t tend to like having unexpected things occur, so I figure that practicing helps me get used to the experience.  

I started to think about this theory of mine, and I realized it applies just as much to being a music therapist.  I use a process-oriented approach.  That means that I don’t have a specific plan in mind when I do sessions.  We’re not doing Activity A then Activity B followed by Activity C.  Moreover, I work with people who don’t use speech to communicate.  This means I’m lost a lot of the time when I’m doing therapy.  I have an idea of where we want to go (increased communication, greater ability to cope with strong feelings, using the music to express anger rather than using actions, etc.), but I don’t always know how we’re going to get there.  And that can be scary.  

Lucky for me I practice getting lost a lot so I don’t have to worry as much when it happens.

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.

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.