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).

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.)

"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.