Borrowing Ryan Howes' Seven Questions

In response to my last post Adam suggested I answer the seven questions Ryan Howes posed to well-known psychotherapists.  That seemed like an awfully nifty idea to me, so I'm going for it.

1.  How would you respond to a new client who asks: "What should I talk about?"

Hmm, this is an interesting question for me, because the vast majority of the folks I work with don't use speech, and they all have some form of developmental/intellectual disability.  Also, since I'm a music therapist, I think the larger fear tends to be, "oh, my God, she expects me to know how to play music!"  Given that fact, I do spend some time talking about what music therapy is, some of the ways we'll be using music, and making sure to explain that music therapy is not meant to be for professional musicians (although there are music therapists who do work with people who fall into that category).  Then I do a lot of modeling and invite people to begin to play with sounds in a new way. 

It actually takes quite a while before my clients are able to grasp the concept of psychotherapy. In spite of their having experienced years of skill development activities and behavioral interventions, most of the people I work with have rarely had the experience of someone doing psychotherapy with them- let alone music psychotherapy.

2.  What do clients find most difficult about the therapeutic process?

I work with folks who live in an institution and who have major abandonment issues (often complicated by trauma and ambiguous loss), and I think the hardest things for a lot of my clients is saying goodbye at the end of each session.  I use a relationally-based approach, and it sometimes takes many years (I'm not kidding when I say "many"- it has sometimes taken up to 5 or 6 years) to develop a working relationship with my clients. Once that relationship is established, all of those painful, unexplored, unacknowledged feelings of being left surface with a vengeance. Termination isn't a lot of fun either, but that happens a lot less often than ending weekly sessions.  

3.  What mistakes do therapists make that hinder the therapeutic process?

I can speak to mistakes I made as a beginning therapist.  One major one (in the beginning) was making assumptions about what my clients knew/understood and what they didn't.  I always treated my clients (labels and all) respectfully, but it was a surface respect.  As I truly got to know them (and received good clinical supervision and learned how to really engage in the process of music psychotherapy) that turned into a deep respect for the wholeness and intelligence within each person.

Another mistake I made initially was not focusing on the relationship.  I spent a lot of time trying to get my clients to do musical things, so I ended up focusing on what they were doing/not doing and on the things that I wanted them to do instead of focusing on the process and the building of the therapy relationship.

Something that has challenged me (and students I've supervised) over the years is thinking I needed to know the answers, always know what to do in a session, and be the "perfect" music therapist.  I guess that's probably a familiar stumbling block for a lot of therapists. An extension of that is not taking vacations when I've needed them. 

An issue specific to music therapists is the need to know when we are avoiding using the music in the process and when we are using the music to avoid the process.  Something my clinical supervisor pointed out to me many years ago is that playing music through the whole session is like having a verbal psychotherapist talking the entire time and not letting the client say a word!

4.  In your opinion, what is the ultimate goal of therapy?

I would say that coming to terms with and accepting ourselves as we are in this lifetime and maybe not taking ourselves so seriously would be an ultimate therapy goal.  But I'd probably be projecting.  :-)  

5. What is the toughest part of being a therapist?

Institutions can be a hard place to live.  Knowing that many of my clients missed out on opportunities to grow up with their families because of now outdated beliefs about disabilities, knowing the continued overt prejudice and disrespect they continue to experience because people can't or choose not to be bothered to look beyond the outside appearances or question beliefs about developmental and intellectual disabilities, knowing how much abuse goes on, and, worse, knowing that, were my clients to move into a group home, their risk of abuse goes even higher, because there's even less oversight...these things truly hurt my heart in ways I can't even describe.

6.  What is the most enjoyable or rewarding part of being a therapist? 

There's a very specific moment I most love in my work.  If you read my blog, you know that I have to go pick up my clients from their buildings and walk them over to mine.  As I said, above, it can take a long time to establish any kind of rapport. The first time my client jumps up to meet me for his/her session is a special moment indeed, because it means that I've become a specific person to him/her, and it indicates to me that s/he is now invested in the work we're doing together.

7.  What is one pearl of wisdom you would offer clients about therapy?

I must admit this question has me a bit stumped.  I'd probably encourage my clients to not give up hope.  Also a lot of my clients don't quite get the "as if" part of therapy, and they seem to feel very frustrated with me for not being able to "fix" their lives by taking them away from their particular challenging life situation.  I remind my clients that their goodness, their happiness, and their worth doesn't come from being in therapy or from me (the therapist).  It's an inherent part of their being human.  They might discover those things about themselves in the context of music therapy, but they were already a part of them.  The challenge is to recognize those things in ourselves (because it's not only our clients who struggle with this) outside of the therapy space and to live from that truth.

The Holiday Tour de Blogs

Since it's "The Holidays" and all, I figured I'd take a break from actual thinking and reflection about work to read about some other people's ideas and thoughts.  

Here are two I particularly liked:

1)  I was over reading Zen Habits, Leo Babauta's blog, and I thought this particular entry about "The Six Greatest Gifts You Can Give Your Loved Ones" had some very useful advice for music therapists as well.  I particularly liked #4, which was about giving your loved ones "a voice". He notes:

Too often our children or spouse might talk to us but are only met with a disinterested nod or other small acknowledgment, or we’ll make light or fun of what they say, as if it’s not important. But giving a person a voice, and showing that their words matter, will have a long-lasting different in their lives.

If we substitute "our clients" for "our children or spouse," and we acknowledge that people who don't use speech still have things to say and are making an effort to be heard, then I think this could just as easily be directed to those of us who work in institutions.

2)  Here's another interesting blog I happened upon today.  Ryan Howes has been interviewing well-known psychotherapists, using the same seven questions for each, and today he interviewed Glen O. Gabbard (someone whose work I have read and appreciated a great deal).  

Here's a particularly nice thing he said about what he likes about doing this work:

Therapists are paid to talk to interesting people all day. In this regard, we are in a privileged profession. The pleasures are many: connecting with someone at a profound level of intimacy that is rare in other situations, learning about other cultural and psychological perspectives on matters of great importance to the human condition, and helping others enrich their lives and make changes for the better.

Nice stuff out there to read while you're taking a break from celebratory adventures.  

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).