Working as a Music Therapist in Mexico

By Esther Murow

Introduction

In the following article I will try to make a short description of how my work as a music therapist has evolved as well as some of my clinical experience working in Mexico City.

Mexico is many countries, with a very rich musical and cultural tradition. Its sources stem from the mix of the pre-Hispanic cultures and the influence from the Spanish and other Western as well as African cultures. Mexico is also urban and rural, where the cities have become the concentration centers of migrating rural populations, looking for better life conditions and opportunities. As in many countries urban Mexico is very different from its rural counterpart. In the city there is more access to health and education services. In even larger cities there are many types of communities in a larger container, with very privileged areas and some very marginalized. Though Mexico has been known abroad for its cultural heritage and its economical crises, its development is immersed in the 21st century. Many people are surprised when they find out that there is access to the newest technological achievements.

Music therapy in Mexico is only beginning. Though there is a lot of interest in what it is and on its effect on health and personal growth, there are also a lot of misconceptions about what it really is. I have encountered that one of the obstacles for the growth of music therapy in Mexico is what I call "the myths" about what it is. I am sure some of them are well known to my colleagues around the world: "if you play a music tape the client gets well," or "just get some percussion instruments and have the children play and you are doing music therapy." I think one of the worst misconceptions here is that some people believe there is no need for professional training and education to practice music therapy. Being a music therapist has been a real struggle not to mention trying to educate health and education professionals about music therapy, and that it is a real profession in other Countries! On the other hand, there are many musicians and health professionals who are very interested in music therapy and its use.

A Vignette

But not everything is so grim. I have worked for many years as private consultant with children with developmental disorders. My work with one of these children stands out. He was a boy who had many characteristics of autism. Later he was diagnosed as with Asperger's syndrome. We started working together when he was five. He went to a regular school, where he was doing fine academically, though teachers had problems dealing with him in the behavioral/social aspects. He had just been through a traumatic experience at school, where nobody really understood what was happening to him. We worked together for about three years. He could communicate verbally, at the beginning he would talk about himself in third person, later he was able to speak in first person. He responded to verbal interactions, his attention span was very short, but increased over time. He could not describe his everyday experiences nor his feelings or inner experiences. He lived with both his parents, who were very caring and loving. He loved drawing the Little Mermaid and that is how we started interacting, drawing the Little Mermaid constantly.

When I showed him the instruments, at first he did not respond to small percussion instruments, sometimes he would sing incomplete songs. The breakthrough came when I brought in the guitar. Of course he wanted to play it so I let him strum it, then, I started singing, reflecting his actions and his feelings and the door opened! He was able to "sing" his feelings and his experiences, and how he felt unloved, and unhappy. He described how he felt his parents and school did not like him. (Mind you, that may not have been literal). That is how we worked for some time. Music gave him an outlet to express himself. Later in the treatment we worked with the autoharp. He would strum it endlessly, in a kind of perseverative behavior that served as a way to let out his anxiety. I tried to structure the experience so it had a goal, like "you can play as long as you sing at the same time" or "you can only play the chords twice and change what you are playing." As the work progressed I could see how he had learned to communicate and to express some affect, mostly physically, though his face remained quite unexpressive.

Working at the National Institute of Psychiatry

About eight years ago, I was invited to join a research group at the National Institute of Psychiatry "Ramon de la Fuente" in Mexico City. The project was to work and do research in a rehabilitation program for patients with chronic schizophrenia living at home. Music therapy was only one of the many (8 or 9) types of therapy the treatment group received: For a year the clients attended the program 3 afternoons a week. Though we could see that clients improved it was really hard to tell what part of their functioning had been affected by which kind of therapy. The question I was asked more often was, "what does music therapy do?" Over the years, we worked on three multi-therapy projects with the same design. With the first group I used an activities approach and I was not too pleased with it so when the second group started, I began using improvisational techniques. The goal was to develop communication skills and more importantly, affect and emotional expression.

It is well known that schizophrenic clients have a difficulty in experiencing and expressing their feelings. At one point it was thought that schizophrenics were not able to feel emotions and that that their experience of positive feelings was even more blunted than the experience of negative ones. Now it is known that expressing and experiencing emotions and feelings are two different parts of the "emotional experience" construct (Limpert & Amador, 2001).

In my work in music therapy I emphasized the possibility of expressing feelings though the music, and the possibility of re-learning how to feel these feelings through some music listening techniques. We worked with each group for a year, and even though I could see a real improvement the assessment instruments did not show it. So I went into a new dimension of the work and have been researching and working on how to measure therapeutic change when we are dealing with such dimensions as inner experience and emotional expression and musical behavior.

I remember a group experience with a small group of clients. All of them had at least another sibling who also had severe mental illness. I proposed we improvise around the theme of what was it like and how did it feel to have another sibling who was ill and on top being responsible for him. When we talked about it they said it was OK, they didn't mind. When we started playing, the feelings came out and it was obvious to them how painful the situation was and what a burden it was on them when they were sick too. We went on to work on how they could deal with all the emotions that had come out, like guilt and impotence and how they could deal with the problem in real life.

Another very moving and interesting experience with this group was that music therapy gave them a space for positive experiences. We did some directive imagery experiences, where I would guide them through structured images. I chose some supportive music (I usually work with classical music). The patients were not only able to create a positive experience in their imagination, but they could also see themselves the way they were before they got sick. They could also recognize their resources they used to have and those they could try using in their present everyday life. That gave them a sense of what it was like to be healthy and of the resources they used in every day life. I could not say how that changed the overall results of the treatment but I can say that the music gave them an experience that enriched their inner life and allowed them to see themselves differently.

The Music Therapy Unit at the Institute

About a year and a half ago I joined the Institute as a full time music therapist, and created a Music Therapy unit, both were the first in Mexico! It was both recognition and a challenge. The largest part of the work was and is still to come.

The next step at the Institute was to describe what music therapy did for patients with schizophrenia, specifically if it can be used as the main therapy and how it could be useful in the treatment and rehabilitation of chronic schizophrenic clients. The Research Committee at the Institute finally approved a project where the research group would be divided into three different groups, each receiving a different kind of therapy. One was a multi-therapy group, (with no music therapy), one was a social skills training group and one was a music therapy group. The clients were assigned randomly to each of the therapy groups. I finally got to work with a group whose only therapy (besides medication and psychiatric care) was music therapy. This was a very different experience too, because as the main therapist I had to deal with many other aspects of their functioning that I didn't have to when the groups received many other therapies. I worked with improvisational techniques, and focused once again on communication, social skills, and affect expression. I also worked on the behavioral concomitants of emotional expression, like facial expression and body posture, as well as verbal (voice) inflection and expression, all this in order to give the clients the tools to function in their community whether it be home or work. The program lasted six months and the clients attended two sessions a week. I used improvisation as the main therapeutic method.

Working with this kind of population is always a challenge. Most clients I work with are all medicated and pretty stable with only a few positive symptoms and mostly negative ones. Though they have the same diagnosis they are all very different and it is always necessary to find equilibrium between the individual and group needs. For the clients the first contact with music therapy is to discover the instruments (mainly percussion instruments), the way they sound, and the different ways they can be played. For most of them that is the first time they had been in contact with this kind of musical instruments. At the beginning, some clients have a hard time understanding what music therapy is; some think they are going to get music lessons and get frustrated when they realize they are not going to get lessons and they ask "how they are going to get better playing and singing?" As in any therapeutic process clients have to learn how to use the medium, and when they learn about all the possibilities the music experience offers they become involved in the process!

We begin working on emotional expression and social interaction. We improvise to the feelings, try to "feel the feelings," and explore new ones. We listen to what other people play, and play with them. Then we talk about what the group feels the others are playing. We improvise in dyads and in small groups, where the group members have to listen and respond accordingly. We work on personal qualities as well as on problems, and we explore the music and the practice in real life to find connections. In almost every session we do group improvisations as this gives the clients a sense of sharing and belonging.

In the last group I worked with, at the beginning the clients were not able to listen to each other. As time went by, they could hear the group playing together, listening to changes in the music and changing accordingly the way they played. They showed some changes both in the music and in the interactions: they played shorter phrases instead of going on and on forever, they also talked with shorter sentences and were more aware of the response of the listener. They were able to change the rhythmic pattern - in a very simple way - instead of playing the same pattern forever, since they were not aware of what they were playing. They were also able to respond to dynamic nuances and changed the way they played according to what the other persons in the group were playing. This translated in a longer attention span and more empathy to the other members of the group. They were able to pick the instruments they wanted to play depending on what they needed to express. They became more expressive and more aware of the others and their feelings and needs. We did some improvisation experiences so they could practice some planning skills.

Of course all the group members were different, so some changed in certain areas, and others showed different changes. One of group members had a really hard time talking, though his language skills are intact, and it was a lot easier for him to play. He could interact through the instruments and the music, but he could hardly do it with words. At the end he could respond saying short phrases, and smile to the rest of the group!

In Closing

At the end of the program, some people still had a hard time expressing themselves through the music, though some improved their communication and social skills, enough as to be able to go out and try to find a job or to be emotionally closer and more expressive with their family. I still have a lot of unanswered questions about my work with schizophrenic clients: as a clinician I see how they improve though the treatment period. I still wonder about the power of music, I can tell when we had a good session, because the music - though very simple - holds everything together. That doesn't happen every time, but it happens often enough to make me think that given a choice I wouldn't work with these patients without the music. As a researcher I still have to "prove" - especially for the Institution I work at - the therapeutic effects of music. The challenge is to find the way to do it, what assessment instruments work for this type of population and where do changes happen more specifically when we use music therapy.

Last week we finished the treatment phase of the research project. Results will be out in a couple of months. Hopefully I will be able to publish some of them in a music therapy journal. Other results from former groups are in Spanish (Murow & Unikel, 1997; Murow, 1998).

At the Music Therapy Unit at The National Institute of Psychiatry in Mexico City we also work with clients with dementia in early and middle stages, women with eating disorders, and clients with anxiety disorders. We are planning to expand our work and range of interventions. With the eating disorders women again I work mostly on feeling recognition and on how to deal with those feelings, since one of the biggest problems is that they have managed to "turn off" their emotional life. I work mostly with music listening techniques for stress and anxiety management, and some music imagery and mandalas (some of the abilities I acquired during my GIM training with Dr. Bruscia).

Most of the work is still to be done: we have to educate health and education professionals and consumers on the uses and power of music therapy. It is urgent to establish an educational program at the University level for people who are interested in becoming music therapists. We have to establish links with our colleagues abroad who can and want to share their experience with us.

That is where I practice Music Therapy, in Mexico City, the largest city in the world. As I said it has been a struggle in many ways, the same struggle many of us have faced when decided to devote our professional lives to working with the music and with our clients. But with the struggle, come the rewards. Having been able to establish a Music Therapy program in Mexico City is only the beginning of Music Therapy in Mexico.

References

Limpert, C. & Amador, X.F. (2001). Negative Symptoms and the Experience of Emotion. In Keefe, R. S. E & McEvoy, J. P. (Eds.): Negative Symptom and Cognitive Deficit Treatment Response in Schizophrenia. Washington, D.C.: American Psychiatric Press.

Murow, T.E. & Unikel, S.C. (1997). La musicoterapia y la terapia de expresión corporal en la rehabilitación del paciente con esquizofrenia crónica. Salud Mental, Vol. 20-3: 35-40.

Murow, T.E. (1998). El uso de la musicoterapia para mejorar las relaciones interpersonales de los pacientes con esquizofrenia. Revista de Psicología Iberoamericana, Vol.6, No. 4.