Music, Metaphor and "Being with the Other"

Music Therapy with Psychiatric Patients

By Teresa Leite

Introduction

This paper is about metaphors, symbols and music. This paper is also about playing, creating and "being with the other". I believe that music is made of symbols. As we play with music symbols, they become metaphors, i.e., meaningful creative "pictures" of the way we experience ourselves and the others in the context of a relationship.

Much has been written in the literature about the difficulties of the psychiatric patient articulating metaphoric and concrete meaning (Libbey, 1983). Much has also been said about how music improvisation can improve the patient's relatedness (Stephens, 1983). In this paper, I will propose to the reader some considerations about the ways in which music can provide us with an alternative realm of relational experience. In the context of the musical interaction between therapist and patient, metaphors can be created which allow both participants in the process to create and play together while being free of the constraints and conventions of verbal meaning.

I think of music psychotherapy as a blossoming experience, as well as an experience of togetherness that goes beyond the realm of verbal understanding. The main idea for this paper is that music can be, at the same time, a factual and a symbolic experience involving creativity, self-expression and interaction.

The process of creating music as a shared experience helps us to integrate its meaning into the concept of who we are and how we relate to others. It also helps us find a way of relating that satisfies our own personal needs and yet adjusts to the objective circumstances of the world around us. This can be done in the music as we combine spontaneous musical expression with aesthetic considerations and concrete sound-production issues such as the choice of instruments, recording, etc.

In this paper, I will be reflecting upon some theoretical principles, which can be applied to the music-making experience, why it can be described through metaphors and how it can be used in a therapeutic context to improve the psychiatric patient's satisfaction in the area of interpersonal relationships.

The concepts presented in this paper are based on my experience doing long-term individual music therapy with adults carrying a psychiatric diagnosis and receiving services on an outpatient basis. The main techniques used in session were music re-creation (mostly songs), music improvisation and verbal discussion.

In the work with psychiatric patients, psychotherapy is usually a life-long process, an ongoing work of support where we accompany the patient's journey throughout life. Once a patient-therapist relationship is established and the work starts developing, the music therapy session becomes an interactive play situation in which the client exercises his most intact, healthy abilities and continuously improves his relating skills.

It is the therapist's goal to help the client develop an awareness of him/herself and accompany him/her in the process of coping with life's stressful situations, especially the ones involving interaction with other people. This clinical approach is based on the belief that music is an integrated part of the Self. To approach the person's music making process is one way of approaching the whole person and his/her global functioning patterns. Therefore, the music-making experience becomes an active metaphor for the way in which the client does or will come to experience interpersonal situations in his daily life.

Music, Metaphor and the Therapeutic Process

The issue of verbally translating music phenomena has always generated a lot of debate in the music therapy literature (Kenny, 1989; Amir, 1999), with common agreement on how limited verbal language becomes in the explanation of the non-verbal processes that take place in a music therapy session. One possible way to bring these two levels of experience closer is the use of music-related metaphors to describe the psychological processes and interpersonal dynamics that may occur in therapeutic music making.

In order to make such descriptions useful, we need to define a theoretical frame from which to understand both Music and Therapy, before we attempt to describe the music therapy process through the use of music-related metaphors.

Symbols and Music

Symbols are very interesting entities. I am always amazed to notice how a musical piece, a painting or a choreography can accurately represent a specific idea, a feeling or even a full experience. In my work as a music therapist, I've always been fascinated by the fact that in a particularly meaningful session, musical events have an impact on the client through the symbolic experiencing of what it represented to him, more so than our verbal discussion or interpretation of them. It is my belief as a music therapist that symbol and experience are crucial elements of any psychotherapy process. But what is Symbol?

The Encyclopedia Americana (1984) defines it as an expression that "combines a literal and sensuous quality with an abstract or suggestive aspect. It has a concrete referent in the objective world but it also makes this referent suggest to the observer a meaning beyond itself" (vol. 11, p.196).

The use of the words Symbol and Symbolism extends to other disciplines such as Philosophy, Psychology and Aesthetics. An important aspect that is emphasized in this definition is the double nature of the symbol, which comprises both an abstract meaning and a concrete quality. This idea is particularly important in music making, since music is considered to include both a physical event (an action producing sound) and an abstract phenomenon (form and meaning).

The idea that "the separation of virtual and actual is more subtle in music than in other arts" (Epperson, 1967) should be retained for a better understanding of the processes occurring in a music therapy setting. This leads to the assumption, in the music therapy field, that the actual music making with the client evolves in close association with its virtual meaning and the way it is experienced. In other words, "music is an objective symbol but it is felt personally: the alleged capacity of the art to stir emotions is widely looked upon as the source of its power and its chief significance to man" (Epperson, 1967, pg. 289).

Music and Human Experience

In philosophy, much attention is given to the dynamic character of the musical symbol. Langer (1953) proposed the analogy between emotional dynamics and music dynamics, stating that feelings - the underlying basis for music meaning - form the basis for thought-processes in general.

From this point of view, the emphasis is on "what happens", more than "what it means", and we can identify two inseparable elements - the factual event and the psychological meaning - emerging while the musical event takes place. Phenomenologically, music can be defined as an "artistic system of tonal events psychologically integrated into 'an experience'" (Pike, 1970). The music experience is therefore a "lived" one, marked by "an intimate link between sensation and consciousness, the space between Self and World" (Kenny, 1989, pg. 55).

Given what was said thus far, we accept that in music - like in all human experiences - there is a continuum between body-phenomena and the highest level of awareness, between factual events and the inner feelings of the participant. We can now move on to consider the implications of this statement in the field of music therapy, for they support my belief that actual music playing can foster personal change through the symbolic processes that it involves.

In his book "Playing and Reality", Winnicott (1971) discussed symbolism and its use in psychotherapy as an experience as well as an entity of meaning. The well-known psychoanalyst conceptualized an area of human experience where symbolism is a fundamental process and yet the phenomena occurring in this area are linked to actual experiences. According to Winnicott's theory, music can be conceptualized as a form of play and a cultural experience. In both cases, internal meaning and objective form evolve together, demonstrating that it belongs to this important realm of human experience.

C. Kenny (1989) matches Winnicott's description of symbolic play in the way she characterizes music improvisation experiences: "The musical improvisation is both subjective and objective - subjective in that it reflects the inner human life (feeling, thought and experience), and objective in that it creates an external object, i.e. the music" (pg. 98).

G. Stephens (1983) brings this concept into the realm of music therapy practice when she discusses the two simultaneous levels of relatedness occurring in music improvisation: "this (musical) interaction is actual in that it manifests the very relatedness of sounds moment to moment, yet it is symbolic in that all elements - thoughts, emotions and specific issues - are being expressed in a series of sounds" (pg. 33).

In the course of my work with a schizophrenic woman, we established an activity pattern in the sessions that lasted for several weeks and included a shared improvisation with two tone-bar boxes. I would play a rhythmic pattern to support her, while she would create a melodic/rhythmic pattern for me to disrupt, leading her to create a new pattern that she could maintain along with my sound. This "musical dynamic" was actually suggested by the patient, who wanted to work on coping with the disruptions of her current living environment at the time. My interventions would be arranged and then discussed between us.

This improvisation and its variations evolved into a cooperative building process that was in itself a metaphoric representation of her experience living in a shelter with chaos surrounding her, this time brought to life in a way that we could explore her participation in it and possible ways of changing the situation in real life. The fact that she could manipulate the sound characteristics of our interaction gave her an opportunity to address her need to establish daily structured activities and explore news ways of relating within an environment experienced as chaotic and oppressive, becoming a sort of "metaphoric laboratory experiment" for life and relationships.

Taking into consideration the difficulty of the psychiatric patient in processing his/her experiences and transforming verbal considerations into real life experiences, the therapeutic potential of music lies in the fact that music is symbolically experienced in a way that is analogous to the rest of the person's experiences in life. Therefore, it increases the possibility that positive change occurring in the long-term music therapy process will be paralleled in the client's life.

Metaphor and Music Therapy

Once we have taken the important step of acknowledging the nature of music as a symbolic experience, we are faced with a new challenge: how do we describe and discuss the music therapy experience itself?

Quite often we are faced with discouraging statements such as "verbal descriptions are always prejudicial to musical meaning because the mind eagerly seizes the labels in glad recognition and comes to rest in them: the journey is over before it has begun" (Epperson, 1967). This particular statement emphasizes how difficult it is to find an authentic yet "shareable" way to describe musical experience. However, as I review the previously stated ideas about musical symbol and experience in an attempt to apply them to my own clinical work, I come to value the concept of Metaphor, which evolved to be one of the central ideas in this paper.

The word metaphor refers to "an expression taken from one field of experience and used to express something in another field" (World Book Encyclopedia, 1991). Taking this idea a little further, the Encyclopedia Americana (1984) defines it as "an analogy that imaginatively identifies one object with another and either ascribes to the first qualities of the second or invests the first with connotations inherent in the other".

Even though it is formed by a verbal expression, the metaphor is in itself an assemblage of symbols that contain the subjective elements of an experience that cannot be communicated by other means. It is no surprise, then, that we find it being widely used in the literature's approach to music, psychotherapy, and particularly in the music therapy field (Zuckerkandl, 1956; Barker, 1985; Snow-Austin, 1986; Kenny, 1995).

Reading through one of my colleague's papers (Garfinkel, 1992), I was struck by his capacity to use metaphors such as the growth of trees or a child's scraped knee to describe the elements of the music therapy process.

Being a kind of assemblage of symbols, the metaphor takes a step further in re-creating the non-verbal elements of the factual experience it refers to. Music being an experience with sensorial and kinesthetic components, our understanding of it benefits a great deal from analogies with other fields of experience, such as movement or visual imagery. Very often in my clinical practice, clients make reference to visual scenes as a way to express the symbolic meaning of the music they just played.

Different kinds of symbols can be used to describe music experiences. Since sound actually exists in space and its production (and even its reception) always implies physical motion to a certain extent, a whole symbolic approach can be elaborated on the spatial elements of music (Zuckerkandl, 1956). If we add to this idea the element of human interaction in most musical experiences, the "music space" is a metaphoric concept that has become increasingly pertinent in the practice of music therapy. In conceptualizing the therapist-client music making as a "work space" in which shapes, movements and scenes are (trans)formed , we come to develop a richer understanding of the therapeutic relationship. The use of metaphors in music therapy can also be seen in the opposite direction of the one explored thus far. Namely, the client's musical expression can be seen as a metaphor that contributes to the understanding of his daily life situations. Keeping in mind the previous definition of metaphor, we are now taking expressions that belong to the field of musical experience and using them to express some aspects of daily life experiences, in particular those relating to interpersonal phenomena. Music improvisation experiences can be a particularly fertile ground for this type of phenomenon: "The resulting material (of the clinical improvisation) are free to function as metaphor of the different types of themes central to therapeutic improvisation, (.) which are also significant in the therapeutic context" (Ruud, 1998, p. 120).

Garfinkel (1992) presents an elaborate example of metaphoric use of musical terms when he approaches the therapeutic process as a "polyphonic and polyrhythmic one", given that 1) various themes and issues emerge or recede, and 2) the cycle of working through the issues can occur within an activity, a session or a longer period within the therapy process.

Metaphors have been mentioned in the literature as a valuable tool in psychotherapy work. Barker (1985) discusses the use of metaphoric stories, anecdotes and questions in verbal therapy, which refer to verbal accounts of life episodes, which relate to the clinical situation through their metaphoric meaning. The author mentions other types of metaphors that are often used in psychotherapy, such as illustrating analogy statements, relationship metaphors, tasks and objects with metaphoric meaning and artistic metaphors. The last category includes "drawings, paintings, clay models and other artistic productions which symbolize other things" (p. 45).

Metaphors seem to be increasingly used in those models of psychotherapy where the therapist plays a more intervenient role and the interactions between therapist and client become more active, with reciprocal participation (Wilson, 1994). However, it seems that a lot more is to be explored regarding the use of artistic material and activities as therapeutic metaphors at the non-verbal level of experience.

With the development of the Creative Arts Therapies, art, imagery, music, dance, drama, rituals and expressive activities have become an intrinsic part of therapy sessions, actually bringing into the clinical setting the non-verbal meaning and the dynamic processes that take place in most of the client's life experiences. Given that music making is an active experience that unfolds in time, the musical progress that takes place along this journey becomes a constructive metaphor that the client can actually translate to his life outside of the session. There seems to be a way in which music connects with words as well as the other fields of human experience (Kenny, 1989). The description and understanding of music therapy experiences through the creation of verbal and visual metaphors may actually open the door to an engaging and meaningful journey.

Carolyn Kenny (1989) elaborated on the use of metaphors to approach the music experience and created a model for the conceptualization of the music therapy process that involves a complex but enlightening metaphor: the interplay of fields. The following quote seems to justify the use of symbols and metaphors in music therapy from a phenomenological point of view: " If music can in fact be considered a language of immediacy, it seems to be obvious that any efforts in the design of language and construction of models describing the process of music therapy be closely connected to methods which keep us in touch with direct experience". (Kenny, 1989, p. 48)

The Music Psychotherapy Experience - "Being With" and "Looking In"

In the last section of my paper, I will briefly present some basic principles that can be applied to the practice of music psychotherapy. The music therapy model that supports the ideas presented in this paper is based on the observations taken in the context of doing long-term music therapy with reconstructive goals (Wheeler, 1987).

In the lives of some people, there comes a time when, for a variety of possible reasons, one takes on a journey of reviewing one´s experiences in life and re-creating his functioning patterns in order to follow a more wholesome and fulfilling way of being. For that long and challenging journey, one needs a "companion" and a "mind that's not his own", that is, someone who will be present and supportive throughout the good and the bad moments, as well as someone with a different point of view who can help him be more objective about the issues that may arise. This poetic way of thinking about the therapy process and the role of the therapist contains some important ideas that require a more technical explanation.

First, this will only be a true journey if we're actively engaged in it, from all aspects of our being. It is my belief that any form of psychotherapy is the most effective when the clinical setting provides the client with the opportunity to work with and integrate sensations, feelings, thoughts, actions, interpersonal dynamics and spiritual experiences. In other words, for a real change to occur, the client must go through an experiential process, with active participation in the sessions, more than just talking about and reflecting upon his/her behavior as an outside observer. Regarding the nature of the therapy experience itself, one can actually think of it as the client's journey within an evolving relationship with the therapist. But what is this relationship like and what is the therapist's role in it?

The reference to "a companion" implies that one will have someone to be with and share his/her experiences as each important step of the transformative journey. The therapist will hopefully support, acknowledge and accompany the client, letting him know that he is not alone and providing him with a helping hand at the most challenging moments of change.

A "mind that's not our own" implies that we will have someone giving the client a different perspective of his own experiences. It's as if the therapist would be following the client´s path while walking on a nearby hill. This way, he can see where the client is coming from and where he/she is going from a broader perspective. Psychotherapy is, to some extent, a process of looking at ourselves, in the context of our past history and environment forces, toward a future way of being. The role of the therapist in this process is one of giving feedback and providing the client with a more comprehensive and clearer approach to his/her life-situation.

This short analogy covers the two main areas of work represented in the psychotherapy process: the therapeutic relationship - "being with" - and self-exploration - "looking in".

The expression "being with", represented in the title of this section, refers to the importance of the therapeutic relationship. It is accepted in this paper that our way of being in the world is greatly influenced by the relationships we establish through our own history. When pathology occurs, there are invariably dysfunctional patterns in the person's relational experiences.

In the beginning stages of the psychotherapy process, the therapist's first concern will be the establishment of a safe and empathic relationship within which the client is going to experience and eventually transform his interpersonal patterns. Several therapeutic factors are involved in this interactive growth-process, such as empathy, consistency, playing space and containment. Above all, I must state my belief that the client-therapist relationship remains as the foundation for the client's transformation process and it exercises the connection between the client's growing Self and the environment in which he is bound to exist.

Self-exploration is the other main aspect to be emphasized in the psychotherapy process and it is represented by the expression "looking in" in the title of this section. As we progress through life, we all need to have a certain understanding of ourselves, who we are, and how we relate to others. When big changes, stressful experiences or pathological development occurs, one's ability to perceive oneself as a person who is whole and different from those around him is lost or diminished. This can happen due to the interference of external factors, the intensity of our emotional processes or a disruption of internal organization.

The psychotherapy experience provides the client with a space and a time just for him/herself, an opportunity to focus on his/her own needs and to get a better understanding of his own existence. Psychotherapy as a process involves looking at ourselves with the help of the therapist´s feedback. We look IN, listening to our own needs and discovering the authentic parts of our Self. We look AT our Self from the outside, trying to understand the way we come across to the others, our Public Self and the roles we play within different contexts and groups. We look BACK in time, in order to become aware of the circumstances and past experiences that provide us with an explanation for the way we are today.

We can refer to the ideas of Anthony Storr (1988) about solitude and apply them to the therapy experience. To a certain extent, the process of psychotherapy involves a "metaphoric solitude" experience, since the client sets himself aside from his daily environment and engages in a "looking in" process, as if he would be involved in an actual solitude journey. The uniqueness of the therapy process is that such solitude is relative, for the client is supported by the therapist, who accompanies, stimulates and sometimes guides him in that self-exploratory process.

" At a metaphoric level, one can think of psychotherapy as an accompanied or supported "retreat", that is, one in which the client places himself in a circumscribed setting, isolating himself from his daily environment, activities and relationships in order to develop a process of self-exploration and change" (Leite, 1992, p. 8).

However, solitude and loneliness are a predominant issue and a frightening experience for most psychiatric patients. Therefore, the therapist should always make it a priority to make the therapy session a safe ground for exploration and to accompany the client throughout this journey.

Why is self-exploration important? Because, as we become aware of how we function and who we are, we will eventually establish a connection with our Authentic Self (our healthier one, too, especially in the case of psychiatric patients). Once this hidden Self is awakened and connected to the functioning Self, a process of re-integration and re-adjustment is to be experienced, back in the context of our daily environment and relationships. This work is aimed toward a more balanced, coherent and fulfilling way of being, the ultimate goal of all forms of psychotherapy.

In summary, the experience of psychotherapy can be seen as an interweaving of two dynamic processes - self-exploration and relating. It all starts with the therapist´s support and acknowledgment of the client´s self-expression. Once a state of "rapport" (Ramsey, 1983) and empathy is achieved, the client will develop his self-exploratory work, along with the therapist´s feedback and continued support. If the process is successful, later down the road the client will begin to extrapolate the "relational experiments" that he carried in the therapy session onto his daily life. The growing self-awareness of the client will then lead him/her to a process of transformation in and out of the sessions.

In music psychotherapy, the same process occurs in the music making as the therapeutic relationship occurs. The process begins with an invitation from the therapist for the client to play music and a concentrated effort on the part of the therapist to match the musical preferences of the client, as well as the main features of his spontaneous music playing. Once the accompanist-soloist rapport is established, the client will begin to notice the main issues around his music and to explore alternative ways of playing that will match a healthier and/or more satisfying way of living.

Conclusion

It is proposed in this paper that music can be understood as a form of human interaction, and that the music experience, in its process, more so than in its product, is charged with symbolic meaning that can be extrapolated to other experiences in the life of the person who is involved in the music therapy process. Based on these principles, music can be used as a form of long-term reconstructive psychotherapy for emotionally disturbed adults who would otherwise have significant difficulties working through intra and interpersonal dynamics at the verbal level. The work with psychiatric patients requires a long-term undertaking in which the therapist plays a quiet intervenient role and the sessions include an active re-experiencing of the real-life interpersonal patterns of the patient, then occurring at a symbolic level, in the therapeutic relationship.

Most patients present interpersonal difficulties to a significant degree and a life-style that is mostly focused on overcoming the negative repercussions of their illness. The work in music therapy with such patients should be geared towards the following goals:

• The establishment of more effective and gratifying relationships

• The development of their potential for adaptation and creativity, as well as the healthy parts of the Self.

This type of work must include the establishment of active music-making experiences and an interactive relationship between therapist and client through the use of improvisation. Both the music experiences and the relationship itself will become a developing metaphor that will eventually be translated to the experiences and relationships of the patient in the outside world.

In the music-making experience factual and symbolic elements are inseparable while it is taking shape. Therefore, the act of making music in a therapeutic context provides the patient with an opportunity to stay related to the environment and the people around him, while simultaneously displaying the dynamics and symbols of his inner life.

The idea behind this approach is that Music is - at the same time - a factual experience and a symbolic process, both of them involving creativity, self-expression and relating. The process of creating music as a shared experience helps us integrate its meaning into our Self-concept and connect to others in a more effective way, that is, a way of inter-relating that is satisfying for us and adjusted to the demands of our social environment.

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