Music Psychotherapy and Community Music Therapy: Questions and Considerations

By Alan Turry

Editorial note: Upon Maria Logis' request the author has chosen to use her real name throughout the article (See Appendix 1).

In his article on community music therapy, Aigen (2004) recognizes the challenges that can emerge when a new form of practice develops and he emphatically states that when these changes take place, "new ethical, self-reflexive, and conceptual signposts" (p 216) are needed. My purpose in writing this paper is to contribute to the development of these signposts by sharing a course of therapy that has stimulated relevant questions in this newly emerging area of work. This paper does not present definitive guidelines, but attempts to identify important considerations when a course of individual music therapy includes the public sharing of the content of therapy sessions in the community in a variety of forms.

My clinical background includes graduate training at the New York University music therapy program, emphasizing a music psychotherapy approach, and advanced clinical training in Nordoff-Robbins music therapy. While my work is music centered, I recognize the importance of relationship factors in the music psychotherapy model. In sharing the following clinical material, I hope to provoke discussion about ways that community sharing potentially can feed into the music psychotherapy process and how the music psychotherapy process can be an essential component to community sharing.

Therapists who identify themselves as community music therapists may take issue with some aspects of my approach, as might some music psychotherapists. My hope is that the particulars of this material will help to stimulate further discussion. In this paper I will detail a specific course of therapy, focusing on the issues related to the topic, and then pose questions and articulate considerations that have grown out of this analysis.

One last point: in the case that follows, I did not undertake the therapy with the idea of applying a particular model or a theory. On the contrary, I was discovering a unique path that was being set by each step that the client and I took together. We veered into unknown territory, and the path we took was not pre-determined in any way. It is only with hindsight that I explore theoretical considerations in attempting to contrast ideas and at some points integrate the models relevant to work inside and outside the music therapy session room.

One Path, Many Communities: Coming Full Circle in the Therapy Relationship

Synopsis

Maria's path to music therapy was not a direct one. She was diagnosed with cancer in 1994. In her own account of her experience (Logis, p.2, 2004) she describes, "being paralyzed with fear.I was the general manager of human resources, a highly effective executive working 60-80 hours a week". An energetic and competent person, the diagnosis of non-Hogkins lymphoma, stage 4, shocked her. After hearing the unanimous consensus of six different oncologists she stated, "my hope vanished. The diagnosis forced me to decide if I wanted to live or not. Two irreconcilable feelings dominated my consciousness after the diagnosis, a deep trust in God and a wish to die (Logis, 2004, p 17).

Although Maria had undergone years of psychotherapy, which she had found very useful, she did not choose to return to that kind of support structure. A religious person, she describes praying to God for guidance. What came to her in response to her prayer to God was to sing. "This desire to sing was strange to say the least, considering my non-musical background" (Logis, 2004, p 4). She visited several singing teachers and came to see me, "not knowing the difference between singing lessons and music therapy."

In music therapy we began a music making process as we improvised together. Maria vocalized while I created music at the piano, at times joining in vocally. We both witnessed the power of music in allowing her to feel the fear that came with the diagnosis and had been difficult for her to experience and express.

I let out the fear in words and sounds. Alan encouraged me to make any sounds at all, loud guttural sounds, shrieking, moaning. I was not controlling my expression. It was pouring out of me. The words were simple, but the melodies expressed feelings for which I had no words. (Logis, 2004, p 25)

The music stimulated her dormant creativity; she never imagined herself capable of improvising not just sounds but melodies and also words that developed into lyrical forms and were often poetic.

They tell me I'm sick
They tell me I'm sick
They tell me I'm sick
And I have to learn to believe it
I have to stop saying it isn't true. (Logis & Turry, 1999 p. 99)

Music example 1

 

Much of the content of her improvised lyrics dealt with her diagnosis. But her cancer, it turned out, was, in her in her own words, "the tip of the iceberg." All of her life's anguish came pouring out as we began to create music together.

I was lonely, lonely, lonely.
I was lonely and afraid
I didn't say a word. I didn't say a word
I tried to do what I was told.
I didn't say a word.
I was lonely. I was lonely and afraid.

Ideas and images spontaneously emerged as she sang words describing her conflicts and her hopes. Maria often sang questions to herself, developing a way to reflect on the content of what she was singing. She sang words that expressed the oppression of her life yet, at the same time, the musical experience cultivated a sense of hope and gave her the courage to move ahead.

Be very, very quiet
Then no one will notice me
Perfecting the art of not being noticed
Spending a lifetime sleepwalking

What's underneath it all?

There is a dark rich place inside
Filled with songs, songs of all kinds
Oh how I long, long to sing them

Music example 2

 

The improvised music from the piano often contained unresolved cadences or tensions, qualities that related to the lyric content and the quality of Maria's voice as she sang. Driving rhythms and strong dynamic shifts enabled Maria to sing assertively, harnessing pent up energy that had previously been underutilized. The harmonic structures of the piano music also created the possibility for melodic direction and song forms. Changes in the music, such as harmonic shifts of tonal center and different harmonic constructions around the single tone she often sang, helped Maria to shift from singing with a self-critical, judgmental attitude about herself to singing with a more accepting, self-nurturing perspective. The anger that she had focused on herself was now being harnessed for musical expression and this energized her.

Maria described the piano music as giving her a sense of being listened to deeply, motivating her to continue, giving her a power and strength even as she felt vulnerable and confused. By intensely listening to the music Maria found the motivation to create, to enter into the momentum and flow of the music making process.

Her vocal range and dynamics began to expand. Even as the music resonated with her words that described her sense of being stuck and hopeless, Maria also felt hopeful about her situation because she was experiencing the momentum of the music propelling her to tap into her own creative energy. This was something she felt grateful for and in which she took pride. She began to look forward to creating improvised song forms even as she recognized her need to explore difficult personal issues.

Early on I suggested to Maria that it might be helpful to record the sessions and take the tape with her. "In this way, she could have something to hold on to - I hoped a way of expressing, identifying, and containing feelings that threatened her emotional stability. I hoped she would gain some sense of control over what was happening to her" (Logis & Turry, 1999, pp.100-101). Immersing herself in the music, Maria reflected on what happened in the sessions and began transcribing the words that she had sung. Eventually, with the strong support and advice from a close friend, she gave titles to music she felt was significant, discovering that in this music were songs that she wanted to be able to sing again and sing to others. In addition to working in the therapy room, she has found that performing for others and creating a musical product has helped her to stand up to the voice of the critic inside that would, in her own words, "silence and paralyze" her if left unchallenged. The process of gaining the confidence to share her music was an intense and difficult process. At first she needed strong support. After several public sharings, she became less hesitant, finding the performing process an important part of her healing. The critical voice within her has not been eradicated, but its strength and intensity has abated.

Why is Community Music Therapy Relevant?

Aspects of this music therapy journey are described in more detail elsewhere (Turry & Logis, 1999, Turry & Turry, 1999, Aigen, 2004). What I would like to focus on is the aspect of Community Music Therapy in this work. Ansdell (2002) describes community music therapy in part as,

an approach to working musically with people in context: acknowledging the social and cultural factors of their health, illness, relationships and musics.. It reflects the essentially communal reality of musicing.. The aim is to help clients access a variety of musical situations, and to accompany them as they move between 'therapy' and wider social contexts of musicing.. It involves extending the role, aims and possible sites of work for music therapists. (pp.120-121)

His subsequent revision (2003) described Community Music Therapy as,

an anti-model that encourages therapists to resist one-size-fits-all-anywhere models (of any kind), and instead to follow where the needs of clients, contexts and music leads. As such, Community Music Therapy involves extending the role, aims and possible sites of work for music therapists. (p. 21)

These descriptions are relevant in examining the music therapy that Maria and I have undertaken. Our work began within the confines of the music therapy session room. As Maria began to share her music therapy experience, first with close friends and family and then in wider circles, a community of support began to emerge.

At some point, I started listening to the audiotapes from the sessions with Alan. I played portions for my sister and a few close friends. They often wept or stared at the floor, deeply moved. In the music they could hear what my speech did not express----my turmoil. They responded with even greater warmth and support. (Logis, 2004, p 38)

This community became more diverse as Maria responded to the suggestion to learn the improvised musical ideas as vocal compositions, rehearse them, and perform them for others. This was not an easy process for her:

Janet, my friend and vocal coach,[1] loved some of the melodies; she called them "songs" and encouraged me to learn and perform them for my friends. At first this suggestion struck me as ridiculous, but as I continued to struggle with the uncertainty of my illness, I agreed to approach Alan with the idea of a performance (hoping that he would say no and that would be the end of it). (Logis, 2004, p 49)

In response to her idea, I asked her to reflect on what it would mean to do this as we continued our sessions. How would it contribute to the therapy process? We explored the issue over several sessions, and, though I had reservations, I agreed to accompany her on this journey and she agreed to bring into subsequent sessions any material that arose out of the new direction we were taking.

After inviting family and friends to her home to celebrate being chemotherapy free[2] for one year, she sang songs which had grown out of the music therapy sessions for her guests. She found the experience exhilarating. It was

the happiest day of my life. I was alive a year after the diagnosis, and was what? Singing. Singing what? Original music from the music therapy process. It was too fantastic to believe. (Logis, 2004, p 53)

Maria was animated with energy and enthusiasm during her performance and received feedback from audience members that they were moved by what she shared. She had felt isolated and unable to convey to others what she was going through. Now she felt she had a way to communicate and emotionally connect to others about her experience.

Public Sharing Becomes a Component to Complement the Individual Music Therapy Sessions

This community sharing became a significant part of the therapy process. After this first sharing Maria sang about the experience in her music therapy session. She sang about her deceased mother, whom Maria experienced as an oppressive and domineering force in her life. She asked herself what her mother would have thought of her concert:

Do I dare imagine that she would rejoice for me
Do I dare, Do I dare, Do I dare imagine?(Logis and Turry 1999, p. 103)

Music example 3

 

Maria allowed herself to consider that her mother might have been supportive of and happy with the direction Maria's life was taking.

Because I began to feel more confident that it was benefiting Maria, I supported her efforts in extending the community with whom she could share her story while making sure to explore the process. Though she explained to me that she wanted to continue sharing publicly, Maria was also ambivalent. It was not easy for her to continue on the path of public sharing. "I was frightened. I'm not a singer" (Logis 2004, p 57). In her writing she describes that what propelled her to consider continuing public sharing was

a visit to the oncologist. His statements, of necessity, were full of conditional language. I left feeling frightened, wondering if I'd be alive another year. There was no way to predict how my illness would play out. Janet was delighted with my success at the first concert and was adamant that I plan a second one with a larger audience. With the uncertainty of my health and Janet's certainty about performance I agreed to take a small step. I spoke to Alan who supported this new direction. (Logis, 2004, p 68)

Her ambivalent feelings about doing another concert came up in the music therapy sessions.

The prospect of singing in public a second time was simultaneously thrilling and terrifying. 'Who do you think wants to hear you sing? Shut up,' said the voice of the critic inside me. This conflict was played out musically in my sessions with Alan. (Logis, 2004 p 58).

you're no good
lazy slovenly slovenly lazy
Self-indulgent selfish self-indulgent
Oh the struggle just keeps going on and on....agh..wagh

Several months after her first sharing, with the help and support of her friend Janet and her parish priest, Maria gave a concert in her church hall with more than 60 people in attendance. I supported her musically and also spent time with her backstage, offering support as she gathered herself to continue the second half of the concert. She was able to sing all the songs she had planned to sing. According to Maria, the performance "helped me to discover and express my belief that I did not need to hide/disappear/die" (Logis, 2004, Pg 72).

The sharing at church was well received and appeared to be significant for Maria but she seemed unsettled to me. At our next music therapy session, Maria shared that she was disturbed by the fact that people left so quickly. This led to an exploration of what she wanted to gain by organizing these public events. What was she trying to accomplish, what did she need from the audience? What was realistic to expect out of the event? She reflected on these questions. The processing of the performance experience became an important part of the therapeutic process.

What emerged was that Maria felt she needed and wanted to share the source of the songs, the "depth of feeling" that came from our work together. She wanted an audience that would be interested in hearing excerpts from the sessions. As we explored this further Maria explained her motivation to share the excerpts. She felt this was a way she could share her "vulnerable and tender self." Yet the raw material on the excerpts could be difficult to listen to. We discussed with whom she wanted to share this with, and she asked if I could help her to create a new audience. We came up with the idea of having music therapists as an audience for the next event.

After the second concert, Janet insisted that I perform again, this time for strangers. Although I trusted her judgement, I was turned topsy-turvy by the idea. Alan and I discussed it and finally decided that the benefits to our therapy process warranted another performance. He arranged for me to sing for a group of music therapists at the Nordoff-Robbins Center. (Logis, 2004, Pg. 70)

Finding New Venues: Therapist as an Agency for Performance Possibilities

When Maria asked if I could help find more opportunities for her to share her story, the question of who might benefit from the public sharing became relevant. Uncertain how to define this, I invited music therapists from the community for what I called "a special event." I considered the audience a potentially supportive one and felt confident that they would be engaged. However, I wondered if those trained in a more conventional psychoanalytic tradition would feel I was breaking the frame, or confusing the roles and compromising my relationship with Maria. In addition, I worried that colleagues would feel I was exploiting Maria, creating an opportunity for myself to be recognized professionally rather than facilitating her development.

My fears of being judged harshly by my peers failed to materialize. The event was particularly satisfying as the therapists in the audience related to Maria in a sensitive and insightful way. They asked her thoughtful questions and encouraged her to continue on her path, directly communicating their admiration and support. For Maria, this sharing seemed to confirm that connecting with the audience after the performance was a deeply satisfying part of the experience.

The dialogue that ensued after the performance--Maria receiving feedback, asking and answering questions about the experience of the audience members- "elicited a strong feeling of community" (Loewy, personal communication, 2004). Loewy, a music therapist with extensive experience working with medical conditions, remembers "everyone who attended had something to share or learn that could apply to their work as therapists." She felt that it was significant for Maria to be involved in a creative collaboration ", rather than struggle in solitaire, which is what researchers tell us patients with cancer often do." Perhaps the most outspoken in support of the event, Loewy felt that the musical experience was "amazingly potent" in creating within Maria a sense of acceptance of herself.

Though the general consensus was positive, I did receive feedback from one colleague who felt that it was important not to gratify all of a client's desires. She further stated that it would be important to say no to collaborating and to focus, rather, on exploring Maria's need to do this. Others felt mixed but acknowledged that it was a novel approach worth continuing.

As word of the work began to grow within the music therapy community, colleagues invited us to present at music therapy conferences.

The enthusiastic response of the music therapists at Nordoff-Robbins and further invitations to perform allowed me to breathe a sigh of relief and accept their invitations. It was at this point that I started to sing publicly of my own accord. (Logis, 2004, Pg 81)

Maria worked to plan these events with the knowledge that the audience was educated in this area and would be interested both personally and professionally. The success of these events led to more invitations. These presentations, like the previous public sharings, were also a part of the therapy process in that Maria found them deeply satisfying and stimulating and we could reflect on what had happened afterwards in our individual sessions.

As her therapist, I reflected on whether Maria's efforts to perform somehow impeded her in facing the challenge of having cancer. Was she avoiding the serious reality of her condition by working on performances? Was working on performance a way to avoid the feelings triggered by the diagnosis? In the sessions she continued to improvise vocally and create sounds and lyrics relating to the cancer, and how the cancer diagnosis triggered a resurfacing of long held life struggles. She did this in an emotionally powerful way. She sang that the sense of being stifled, of being rendered powerless by having cancer, was related to life long feelings of being stifled, of having "no voice."

woman why are you weeping?
woman why are you weeping?
why are you weeping?
they've taken away my song
they've taken away my voice
I have no voice
It's all gone
and I can't find it anymore. (Logis and Turry 1999 pp 103-104)

Music example 4

 

Paradoxically she sang this phrase with a strongly sustained tone at a loud dynamic level. I experienced her expression as being authentic in sharing her deep sadness while energetically tapping into a source of creativity.

When Maria arranged a performance at a community center for people who have been diagnosed with cancer, I considered the choice of venue to be a healthy step, an indication that she was confronting her situation. Here she was singing directly to an audience filled with people facing the same challenge. I had the sense Maria was communicating "I am more than someone with cancer. Yes, I have cancer and it is frighteningly painful, but I am more than a condition. And you can be too."

What does Performing do for Maria?

Performing brought different aspects of Maria's personality together. A tremendous organizer and leader, she is extremely efficient and successful at putting events in motion in her professional life. As a general manager at a very large utility company in New York City, her professional responsibilities demanded that she be strong and decisive. In performing, she was able to tap into these skills while concurrently sharing her personal, fragile and vulnerable feelings and thoughts. An example of this was when she arranged a concert at her place of employment. Up to this point, each public sharing had offered something different, and the content had been influenced by whom the audience was. Maria took a significant risk and shared a personal side of herself with people who knew her in a very different way. This made a powerful statement. She no longer felt she had to hide her struggles, doubts and fears, and this was extremely liberating. It gave Maria an opportunity to participate and share with others more deeply what she was going through and that helped her to feel less isolated. As she connected with the members of the audience, they, in return, felt moved and wanted to connect with her.

Maria continued to attend individual music therapy sessions each week and improvise with me without a preconceived agenda. She often came in asking how or where to start. A typical session often started with Maria singing about the weather, making sounds, or singing a question asking herself what important personal issue was currently hidden but important to discover. The shape of the session often proceeded from lighthearted expression to intense turmoil and then a sense of closure, all through improvised exploration. As a performance date approached, she would use part of the session to reflect on what songs she wanted to sing and which excerpts she wanted to share. In this process, she examined the relevancy of the issues contained in the material and how intense were the feelings evoked, how meaningful the material still felt as she sang it, and how it fit into her concept of what she currently was going through internally.

By looking back at the improvised songs she had created in past sessions, she could recognize that she was indeed taking steps towards growth and feeling better about herself and her future. Each event offered the chance to publicly affirm the positive changes in her life, which, in turn, fed back into the music therapy process and the content and mood of the improvisations became wider and more varied in scope. While our music therapy sessions were predominantly focused on the music making, the preparation for and subsequent reaction to the public sharing triggered reflection and stimulated verbal processing of the material.

Each time Maria performed, she became more attuned to the audience response. The raw material contained on the audio excerpts from actual sessions was quite personal and emotional. For some in the audience it may have been overwhelming. Instead of bringing people closer to her, the struggles and conflicts heard in the excerpts may have triggered a defensive reaction. When Maria sang songs expressing conflicts that were unresolved for her, she could appear quite vulnerable and exposed.

Maria considered this, but at this point felt she had to continue to share what she felt was vital to her own process. It was an important stance to take in putting her own need first despite the risks it may have entailed. As the intensity behind this need began to dissipate and she gained more experience through reflection, Maria became more able to anticipate how audience members might react to certain material. She shaped the program by examining the qualities of each song or excerpt and the potential feelings they may arouse in others. Together we also considered how she might respond emotionally while sharing the music. Some songs were bolstering, even uplifting; others could trigger a sense of fragility in Maria. By intentionally shaping the beginning middle and end of the performance she created some musical containers, boundaries both for the audience as well as for herself. The containing qualities of the music had a lasting effect on Maria's internal process and generalized outside of the music therapy situation as she dealt with life outside of the performances.

The music therapy sessions also developed a shape. Maria could immerse herself deeply in a musical process that could be intensely painful at times, trusting that the musical container[3] of the session would keep her safe and that she would emerge feeling whole and more integrated at the end. This was certainly something I aimed for in creating the music and guiding the process, but the performances accelerated her ability to internalize this containing mechanism and use it as a resource for herself. She became more able to live with her emotions without feeling threatened that they might overwhelm and immobilize her. Her performance experiences were a key to this. The art form and the performance of the art form gave her a distance from the raw emotion without an ensuing disconnection. She could be involved in the experience and simultaneously keep it in perspective. Maria stated during a public sharing that when she shares her songs that are "dark," filled with content that can be challenging for her, she does experience the sadness again, but "it's in a song form so I experience it aesthetically, and as beautiful, and I change because the beauty of the music which Alan and I made together naturally, spontaneously" (Logis & Turry 2003).

These performances were very emotional. They were intended to be. At times, Maria cried while listening to an excerpt or while performing a song. She described experiencing a heightened sense of emotional expression and release while sharing publicly, and felt this was a healthy way to become unfrozen and allow herself to feel her feelings.

Yet Maria also wanted to sound good. She was motivated to share not only because she wanted to tell her story, but also because she loved music and valued the music as songs. The songs were comforting to her. She chose the songs based on their aesthetic power as well as their lyric content. She began to work regularly with Deborah Carmichael, a vocal instructor trained in the Bel Canto tradition, trying to improve the way she sang. This was quite significant because as she continued to involve herself in music, her image of herself began to change. Gradually she started to feel more comfortable presenting herself not only as an efficient professional trying something new, but also as a creative, aspiring artist. This had great psychological significance for Maria. Her mother had tried to force her to study the piano as a child and the subsequent struggle between them symbolized much of their troubled relationship. Now her relationship to music was changing. Could that mean that Maria's relationship to her mother was continuing to change as well, even though her mother was no longer alive? As stated earlier, Maria sang about this issue in the first session we had after her first community sharing. How would her mother feel about Maria's growing involvement in music if she were alive?

Would she be resentful, resentful of my success
Keep pointing out my failures
Would she ridicule me?
Would she ridicule me, put me down?
Or would she rejoice that I found my life at last

Reflecting on this she writes

I'd struggled all my life with sadness about my relationship to my mother. Her death left me with an open wound; the music provided an opportunity to heal the damage (Logis, 2004, p 42)

In a significant session later in treatment Maria sang about nurturing qualities that her mother possessed and wanting to embrace the feeling of her mother as a positive force in her life:

Can you hear me?
I need to say thank you Momma
It's hard to say thank you
I want to tell you I love you
Momma, I love you
let the past be done
We will make much music
That is how we will leave the past behind

Her sister had always been identified as the artist in the family. But now Maria, as she continued to gain confidence in sharing her story publicly, allowed herself to try out and internalize a new identity as a creative artist. And she considered this to have a healing effect on her relationship to her mother, and consequently with herself.

Aesthetic Considerations and Therapist Motivations

I had not planned to do 'community music therapy' with Maria. But, as Clive Robbins has often said, our clients are our teachers, and in a very real sense, Maria was teaching me the value of community in our music therapy process. We agreed to incorporate these events as part of the therapy process. Yet just as Maria did, I wanted the music to 'sound good.' I was trying to create music that would have shape, direction and form -- music that had aesthetic qualities. Perhaps, when we, as therapists, hold the belief that music, in and of itself, can be therapeutic and contain healing qualities, there is the possibility of creating products that have inherent value for the client and for others. It becomes complicated and potentially damaging when we allow the process to evolve solely out of a need for gratification as musicians[4] or a need to be heard or recognized as musicians. It is the therapist's challenge and our responsibility to differentiate needs and explore motivations, both conscious and unconscious, for accompanying a client on this journey.

It was Maria's idea to perform. However, was I subtly leading her to do this based on my own needs? How would I really know? How much personal gratification was appropriate? And, most importantly, how were these issues affecting my focus on Maria's process? In telling Maria's story I am also telling my story. In sharing the songs from therapy, Maria shares my music as well. Her success reflects on my professional standing. Could these benefits influence me to further encourage Maria, either consciously or unconsciously, to do something that may not be helpful to her? Who benefits from this? These were complicated and important questions I had to explore as the work continued to evolve.

Performances and the Therapeutic Relationship

I also had to continue to consider Maria's motivation in choosing to perform and how it affected our therapeutic relationship. Was she motivated in part by her desire to be important and special to me? Did she feel she had to be special in order to be valued and cared for? Was it easier for her to consider me as her musician/accompanist rather than her therapist? Did she prefer to perform publicly as a way of sealing off painful feelings rather than exploring with authenticity her emotional struggles? I supported the community sharing in part because I recognized Maria's capacity for working on an even deeper level after a public sharing. I sensed the performances functioned as a form of refueling and allowed her to immerse herself more completely in the music therapy session.

Each public sharing took place after a substantial period of time during which we met regularly. As I listened to the quality of her voice while she improvised in the sessions, I heard more power, more anger, more tenderness and more despair. If I sensed she was holding back, I could help her to go deeper by improvising music that had qualities of her present state yet held hints of where she could go. For instance, if her lyrics described a painful idea yet her vocal quality seemed incongruent with the lyric, by contrasting her dynamics, adding dissonant minor seconds within an open voiced inverted chord I might lead her to becoming more congruent with her feelings. If the content of her words were overwhelming her, I could play music with more stability and rhythm -- root position chords with a steady pulse, for instance -- to help support and contain her. [5] I experienced the sessions as a place where Maria authentically explored a range of emotions, not just painful feelings but exuberant ones as well. The community sharing seemed to contribute to this process.

Still, in my experience it was unprecedented for the direction of the therapeutic relationship to go beyond the four walls of the music therapy room and out into the community. Accepting this direction necessarily meant giving up a great deal of control that therapists typically take for granted. I realized I would have a limited ability to influence the course of events that a community sharing might take and this awareness provoked a substantial amount of anxiety for me. What if the audience members were not supportive? Was adding this new component to our relationship dissipating my role as therapist? Did the public sharing compromise my ability as her therapist? How would I be perceived within my professional community? Did my anxiety prevent me from being attuned to Maria as fully as possible?

Examining the Process

The two best ways to address these complicated issues are therapy and supervision. In supervision I was encouraged to observe carefully the relationship and to process the partnership as it evolved. I knew that it was empowering for Maria to feel that our therapeutic relationship would not limit the possible directions the future would hold in terms of collaboration. She felt powerful guiding the new directions of therapy as I allowed the traditional therapist-patient relationship to expand and transform. But this was also a risk for me. In allowing Maria to shape events and following her lead, I gave up a significant amount of control. I recognized the need to consider whether I was somehow exploiting Maria by participating in these events. But it was also important for me to consider how Maria's desires to perform affected me as her therapist. Was she seeking to change our relationship from therapist-client to vocalist-accompanist in order avoid necessary but painful issues? Taking it a step further, was I allowing this to happen due to an unconscious preference to not be her therapist? My own therapy was vital in discovering my unconscious and how it might be influencing the therapeutic relationship.

It was important to remind Maria that it was my responsibility to consider the novel directions our musical relationship was taking us and help her to reflect on the meaning and purpose of what we were doing. Maria and I continue to process our relationship as our collaboration evolves and takes us in new directions. We recognize that our therapeutic relationship benefits both of us. However, it is my responsibility to help Maria to reflect on this public collaboration. What was the experience like for her? She consistently described it as satisfying and powerful. Were there things I did or said or played during our public performances that she didn't like or felt a strong reaction to? When I asked, Maria clearly stated no. Did she feel attended to when I was playing? Maria felt she was. How was playing together publicly different from creating music in the privacy of our sessions? Having others listening often intensified the emotional experience for Maria. How did she experience our sessions afterward? Usually the sessions immediately after a public sharing would include processing the event, and included singing about her experience.

Overall, Maria was sure that the direction we were taking was a positive one. She felt that by continuing to share her music, she was affirming her changes and fighting her tendency to give up.

She sang about this in the sessions:

And why not choose to live?
Why not choose why not choose to live?
Why don't you choose to live?
So much to learn
Why not why not choose to live?
Why not why not choose to live?
And why not choose to live?
Stand up for yourself stand up for yourself
Why not choose why not choose to live

Her diagnosis had triggered a profound question Maria consistently asked herself in a variety of ways. Would she choose to make the most of her life, or fall prey to the hopelessness? She writes, "Through singing and sharing the music with others, I chose life" (Logis 2004, p98).

Public Sharing as an Intensifier

As an improvising therapist and a Nordoff-Robbins clinician, I have been immersed in a culture that values entering into the unknown. The sense of diving into the process is further amplified and intensified when it is shared publicly. Though the program is predetermined, our reaction to it, as well as that of the audience, is unpredictable.

Perhaps one motivation to share this material publicly for Maria is that she wants to create a sense of empathy within the audience by feeling the music and living the experience with a depth that a simple narrative explanation cannot enable. I can understand this. When presenting, it is invariably more powerful and effective to include actual music from a session than to try to explain what occurs in the session. Hearing the musical process as it unfolded allows the audience to enter into this experience, and allows Maria and I to re-enter it, as the intensity of sharing it with others brings it to life.

In fact, during one presentation at a conference, we had to change our original plan and, not only did Maria sing songs she hadn't planned, but we improvised to illustrate the process. This appeared to have the dual effect of enhancing audience members understanding of the music therapy process and feel more drawn to connect to Maria. Several members of the audience sought her out afterwards to convey their support and appreciation.

Measuring the Potential Benefits of the Direction of the Therapy

One way to determine whether the performances helped Maria or not was to consider how she felt immediately afterward. Early on, I had a sense that even though the events were thrilling for Maria, she still was hoping for more. She wanted more response from the audience, more involvement. But with time, the performances seemed to be more completely satisfying for her, and she felt nourished by the audience response. I suggest that this is more a result of an internal change within Maria rather than one audience being more or less responsive than another. She seems to have gained an inner sense of self worth and does not require as much external validation.

Creating a Musical Product as a Way of Developing Trust and Confidence

As Maria continued to explore new avenues for sharing, she explored the possibility of creating a CD of the song material. She found that she enjoyed finding yet another community with whom she could feel a sense of belonging. Being with professional musicians and working with them on the project solidified her blossoming new identity that included being an artist. She arranged the bookings of the recording studio, hired a musical director, and chose the musicians that worked with her. Though it was not easy facing her own inner critics and trusting her judgement in making decisions, she was very satisfied by working towards a product in this way.

As a result of this project, an important therapeutic opportunity arose for me to nurture her ability to trust her judgements. Rather than simply answer her questions as to whether one recorded track sounded better than another, I encouraged her to listen and make the decisions independently. When Maria asked my opinion on how to structure or organize these public events, I initially felt it was important that I help her reflect and answer the questions herself rather than give her my opinion. With time Maria began to develop stronger opinions and preferences herself. She became more aware of what she wanted to hear in the recorded music, how she sounded and what her preferences were. I was able to give her feedback and trust that she would consider it and then independently make a decision. This was a good indicator that there was a benefit to working on these projects within the therapy process. A natural evolution was taking place in our relationship in which a sense of equality was beginning to emerge. She shared with me how proud she was that she could tell the musical director that she had a clear opinion on the music, enjoying the fact that she could trust herself.

The ability to trust herself and listen closely also fed back into the therapy process as well. At first Maria gave most of the credit to me in terms of where the musical ideas came from when we improvised in the sessions. And it was true that I provided musical form and harmonic alternatives for her melodies in an attempt to widen her tonal choices and create musical momentum and structure. My musical ideas helped to stimulate Maria and encourage her to continue even when she was unsure of where to go. With time, though, Maria was able to initiate more and she began to realize that she had a great deal to do with the creation of the music. She could eventually take credit for musical ideas. This manifested concretely in her willingness at my suggestion to give herself co-authorship of the music when the music was credited on the CD.

The production of the CD was quite an accomplishment. Maria recognized that the musicians who worked with her were personally moved by the experience. Yet she struggled to internalize that what she had created had value to others. Because she had become more aware of her strengths and challenges as a vocalist, she could easily find ways to denigrate the music on the CD. One way she found to combat this tendency was by asking others to contribute in describing the material. Gary Keenan, a writer, poet and musician, helped her to see the CD material in another light. In his liner notes he writes:

This is soul music of the highest order. The songs are acts of witness to the ordeal of living.... All of them express a transformation of the soul, from passive victim to creative artist, and of the body from sickness to health. Her discovery of her true voice is recounted in these songs, and their real power is not that they portray a personal confession but that they enact a fundamental spiritual process. In order to be whole, each of us must find our true voice, whether we are singers, poets, accountants, or bus drivers. By so boldly stepping forth in an act of faith, Maria not only changes herself but is the agent of change in her audience. She has chosen to face death singing-her peculiar duende, the flamenco singer's fierce devotion to life in spite of loss-and by doing so transcends the fear that silences too many of us daily. (Keenan 2002)

Maria felt that this project -- working on the creation of a musical product -- was a major contribution in helping her formulate a new answer to one of the overarching themes she asked herself while singing. Particularly early in treatment, she sang herself a question -- was she

worthy to live?

Her musical experiences both in and out of the music therapy sessions led to a change in her self-image, reflected in these improvised lyrics sung later in treatment:

I am a gardenia
I flower in the night

Music example 5

 

Building Musical Skills Contributes to the Therapy Process

I could not have imagined the world that would open up for me. My identity started to shift. For a few years, I would not call myself a singer, but Alan and Janet encouraged me to recognize that I was changing. I started working with professional jazz musicians on music theory, rhythm and voice, learning to read the songs that Alan and I created. Music was filling up my life. In 2000 I made the very difficult decision to give up my position as general manager and started working part time as a consultant. For the first time in my life something was more important to me than my job. Music, creativity, expression. My artistic identity was emerging. (Logis, 2004, p 101)

The musical awareness she gained from working on both the CD project and in learning the music for performances contributed to the development of Maria's willingness and ability to initiate music within the music therapy sessions. Her trust in her musical ideas also grew as she improvised freely. This was a cyclical process and one experience fed into the other as she learned what she improvised in music therapy sessions for public sharings, and then returned to the sessions to improvise again with enhanced confidence and enthusiasm.

More live performances continued. Invited to give a presentation for psychotherapists at the Training Institute of Mental Health in New York City, I felt a professional obligation to explain music therapy and the improvisation process in general terms. I gave a brief introduction including some ideas about our process. I wondered how Maria felt about this and asked her about this in our next session. She started by saying she found my remarks interesting, then laughed and said, "English is your second language." She explained further that she thought my verbal description was adequate but paled in comparison to the experience of music therapy.

Dependence and Independence

During our therapy sessions, I asked Maria to consider how it would feel to do a community event without me. Her reaction to this was emotional and it seemed to arouse a fear that I was trying to terminate the relationship. I wondered if she might be feeling a strong sense of abandonment. She experienced me as a powerful person in her quest to express herself and help her become more of the person she wanted to be. She feared that if I left, she would no longer be able to continue the positive directions she had begun. I explained that rather than abandoning her, I thought that performing independent of me might be a way to gain a sense of ownership and independence. Gradually, as we continued to work together in our individual sessions and after working with other musicians, she gained the confidence to do an event without me. And she continued to gain confidence as she experienced my support in the sessions afterwards. She has since developed working relationships with many musicians, arrangers and instrumentalists, and has participated in various projects based on her music therapy experience. She has done this without my participation but with my support. One of the most recent events was an actual theatre piece that Maria organized and in which she performed.[6] She hired a musical director as well as a stage director and the piece was favorably reviewed in two different publications.

From Performer to Facilitator

Maria always had a sense that she received a great deal from these experiences. She wanted to give back to the audience and hoped that her community sharing would move people and have personal meaning to them. Most recently, our collaborations have evolved from concerts to workshops. Calling herself a performance artist in her biography, she and I facilitated an experience for cancer patients, survivors, and caregivers. Part of the Expressive Therapy series offered by the Friends Health Connection, the workshops were designed to help the participants "express the emotions experienced during treatment, coping and healing regimens." (Friends Health Connection, 2004)

At first a collaboration such as this might seem questionable. But, in addition to her many years of experience in music therapy and psychotherapy before that, Maria studied and received a graduate degree in counseling. Her life experiences have given her a unique ability to connect with others in this situation. And our therapy relationship had evolved to the point where working together in this way could confirm our equality. Maria knew what kind of musical experiences she wanted to bring to the participants. In a sense, as she continued to work in music therapy sessions and improvise with more initiative, she became her own music therapist. She cued me more directly about the music she wanted me to play and her musical ideas became more varied and flexible. Now she looked forward to having the opportunity of sharing this experience with others.

Still, I felt this was another step in expanding our already multi-faceted therapeutic relationship. And I was aware that I had the ultimate responsibility in terms of the musical experience. I thought it might be helpful if another music therapist were present to observe and assist if necessary. I expected that there would be even more variables than our previous public sharings. Participants would be interacting with both Maria and me throughout the workshop and I imagined it would be difficult for me to attend to audience members while observing how the process was going for Maria. Having another therapist participating, yet ready to intervene if necessary, created a safety net. This kind of structure had already been successfully utilized in the Caring for the Caregivers (2002) workshop series organized by Joanne Loewy. In that structure, nine music therapists participated with 50 participants who had been affected by 9/11. I had asked my colleagues in this community if any of them would function as "gatekeeper" [7] during Maria's and my workshop. This person can be particularly helpful in large group sessions, and it was not possible to determine beforehand how many participants the workshop would have. By doing this, I felt I had a safety net, another pair of professional eyes on the group and myself as I participated with Maria in yet another new context -- facilitators of a therapeutic workshop.

Benedikte Scheiby, one of the music therapists who had participated in the Caring for the Caregivers series, attended the workshop for both personal and professional reasons[8]. She had a close friend who had been diagnosed with cancer and wanted to bring her to the workshop. She recognized that this was an opportunity for her friend, who is a wonderful singer, to experience the power of music as a therapeutic tool and join a supportive community. Later Scheiby stated that she did not see the need to intervene as a therapist but had been prepared to do so if necessary. She discovered that the workshop helped her personally to take space and time to be in music with her own process of how to support and be with a friend who is facing a life threatening illness.

I suggested to Maria that we utilize a similar format to that of the Caring for the Caregivers workshop that I had led months earlier.[9] In this format, we introduced the participants to the instruments, conveyed the benefits of improvisation, and suggested how to incorporate our ideas about vocal work. Maria had several ideas and we brainstormed together in preparation for the event. The workshop began with name singing introductions and moved to instrumental improvisations in the first part. After a break, we came back together to sing as a group. During this, each person took an improvised vocal solo and the group acted as a backup chorus.

Benedikte later described it in this way:

You let the responsibility for the actions in the workshop be taken care of by Maria in terms of verbalizing the instructions and her connection to the music therapy and her cancer experience. You took the responsibility for musically holding the group, providing musical backup for the process, supporting and amplifying the emotions, helping to create flow, and made interventions to take it into a different direction by playing music that created an anchoring effect or a reflecting effect. You also picked up upon the transference in the group and reflected that in your music. When a participant needed support after going very deeply into her sadness, you changed the music you were playing from minor to major and played more rhythmically while keeping the same tempo and dynamics. (Scheiby, personal communication, September 2004)

Maria suggested that each participant consider a word or phrase that they wanted to sing. Some of the words chosen by participants were states of mind that were sought after, such as "solitude," and improvised music emerged as the idea was repeated. After the solo participant sang the word, the group would respond musically, singing it back or continuing to sing as a kind of backup as the soloist continued. Benedikte later described this singing:

The spontaneity and support from the improvised chorus was just fantastic. Somehow it felt like a timeless archetypal experience - a group of women singing out their pain. It could have been anywhere in the world.

Each person took a turn, and each musical event was unique to his or her expression. Benedikte describes her turn:

It was definitely a deep and spiritual and lasting experience. I felt that it bridged me to the cancer women. When one does not have cancer oneself it feels like you are an outsider. The fact that I sang and played myself as one of them made the bridge for me. I saw the strength of the women and the suffering in a clear authentic form. I felt that there was a lot of support individually and group wise facilitated by the music. It almost felt like the women with cancer were a special tribe. The spiritual connection between us was also facilitated by the music. I was in awe that people from so many cultures -- Korean, African, American, Jewish, Danish, etc. -- could be together and understand each other and empathize so much and I am sure it was because of the music. It was a very freeing experience to sing my feelings and have that tremendous backup in your playing. I do not know what you did when you backed me up in the singing. But I felt that I could open up my voice and just let it become big and sing whatever came to my mind -- and you picked up the emotional quality in the voice and backed it up with your piano.

Coming Full Circle-is it Time to Complete the Circle?

As the relationship between Maria and myself continues to evolve into a different form, a major issue continues to be that of roles. Because of the variety of experiences we have shared together it is important to maintain clarity in defining our relationship in order to avoid any confusion. We need to be able to maintain a clear relationship with music therapy as the overall umbrella to all the activities we are doing. What if Maria starts to struggle? In order to maintain our success story and continue our collaboration as workshop facilitators, will I unconsciously avoid seeing that or deny it? Is there anything about these activities that somehow has impeded Maria's ability to continue to explore in her music therapy sessions? It might be more difficult for her to explore her inner world and share her vulnerabilities in session if she is focused solely on creating music with an audience in mind. These are questions that, as her therapist, I must repeatedly consider and explore with Maria as we work together.

The community performances began as a way for Maria to share her music, her story and her experience. Now the experience has become a way that Maria and I can facilitate musical exploration for others. Maria has sung about this issue, her hope that she would relate to the community around her,

Recognizing the needs of others and reaching out to people

This was a clearly stated goal that her participation in the project met quite successfully.

Our partnership has expanded and Maria has come full circle as she offers this experience to others. This is something she finds satisfying and plans to continue in the future. There is a quality of reciprocity both between us and between Maria and the many communities to which she now belongs. And this new way of working together may signal the beginning of the end of our original contract. In a way, working together as facilitators is a way for us to experiment beyond the traditional roles of therapist and client. Maria witnesses my attention to participants other than her and she assists with this, offering what she herself has internalized. It is a way of confirming and anchoring the changes she has made, in a large part due to her continuing relationship to music. And she carries this relationship to music outside of the work we are doing together. Since these collaborative efforts in facilitating began, Maria has improvised music with children at the Sunday school at her church, and facilitated a music workshop for public school teachers seeking ways of utilizing music for personal growth.

At this point in our therapy relationship a new contract is necessary. Have we met the goals of therapy? Certainly Maria is more connected to others and involved in several new and diverse communities. She is more able to connect with her feelings when relating to others. She is also more aware when she is disconnected and knows how to address this conflict. She has a healthier image of herself, and has developed an ability to find creative outlets that are emotionally satisfying for her. She is singing. And she sings with more freedom and awareness and less critical judgement than before. Her vocal expressions have greater range and variety.

Sharing the music she created in music therapy sessions has helped her to reclaim her voice. The act of public sharing gave her the experience of overcoming her feelings of isolation and she has described that she has more options than merely hiding in a private world of self-criticism. By continuing to share her process in different ways to the community, Maria feels that she has found direction and a meaningful purpose. She describes her transformation in simple terms: "The change that has occurred in me after all this work with Alan is remarkable. I who was comfortable only in a corporate setting am now living in an artistic world of creativity and plenty" (Logis 2004 p 67).

Music Psychotherapy and Community Music Therapy: Bridging Two Streams of Music Therapy Practice

The case material I described above may appear unconventional to some; to others it might mirror their own experience. I realize that it generates more questions than answers. Is it music psychotherapy? Is it community music therapy? By attempting to tune in to the specific needs Maria had, I did find myself in different roles with her, though I always maintained my overarching role of music therapist. I do not present it as an example of how to integrate music psychotherapy and community music therapy. Rather, it is the particular path that I took with Maria and I hope that this additional public sharing can be useful to others. In the clinical story, I have described the potential benefits as well as identified crucial questions to consider. I would now like to examine these considerations more broadly, from a theoretical standpoint.

In the practice of music psychotherapy, there is general agreement that the client has a need for authentic self-expression. By accepting this expression unconditionally, the therapist can help the client to accept aspects of his personality that he previously rejected or felt shame about. The self-expression of the client is considered important in and of itself for the client's self-discovery, self-acceptance, and emotional contact to the therapist. The ability of the client to discover meaning and worth based on self-reflection is cultivated.

Performance based activities can place an emphasis on the aesthetic product and encourage the client to consider how audience members will receive this product. The client may focus on how the product is received and censor or inhibit his or her expression in order to achieve a successful performance. The client may experience that acceptance of his expression is conditional, based on its pleasing aesthetic qualities rather than its authenticity and meaning. This may be one reason why practicing music psychotherapists have been reluctant to embrace the value of performance for clients.

Austin (personal communication on performing with clients,1999; 2003) has performed with adolescent clients but has chosen not to perform with her self-referred adult clients as part of the music psychotherapy process. She feels that there are certain clients who are too fragile and are unable to tolerate experiencing their therapist in different roles. Austin is also concerned that with some clients she might be re-enacting the role of the client's parent who promoted and/or identified with the talents of his or her child while neglecting the emotional needs and the vulnerable, wounded parts of the child. For Austin, the authentic feelings and needs that make up the "true self" are the most important parts of the client that have to be attended to if genuine healing is to occur.

Austin described one client who thanked her for saying no after the client asked to perform together. The client wanted Austin to perform with her and tried to persuade her, but realized later in discussion that she really needed her therapist to keep the boundaries. This was a significant moment in the therapy relationship, as Austin felt the client could now trust her and experienced a sense of safety that was necessary for their continued work together. She makes a point to distinguish between collaborating and colluding with clients, noting that sometimes the client may have an impulse to do something which ultimately may not be in his or her best interest, and that the therapist needs to work with the client to discern this.

Scheiby (personal communication, September 2004) works in a rehabilitation facility and has integrated community music therapy practices into the overall music therapy program. She identifies performance as an effective component within her process oriented music psychotherapy sessions. She believes that the wish to perform has to be expressed first and foremost by the client and, if there is a risk of compromising the treatment, it should not be encouraged. She admits that due to her psychoanalytic training she had to work hard to overcome her reluctance and resistance to go in the performance direction with her clients. She now realizes the gratifying experiences for the clients is of great value and can be integrated as an important part of the healing process as long as the music therapist is conscious about the pitfalls and receives ongoing supervision.

She described her work with one particular patient who during his individual course of therapy suggested that he arrange an opera concert and asked for her help. The client was diagnosed with Bipolar disorder, and Scheiby was concerned that focusing on an event like this could feed into the client's feelings of grandiosity. She found herself functioning in the role of "a coach channeling his energy into something productive and also being a handbrake when things would go too fast and escalate for him" (Scheiby, personal communication, September 2004). She felt his manic energy was successfully channeled into the creative act of singing and the preparation for the performance offered challenges he had to deal with in a realistic way. Scheiby contributed to the project by helping him to plan and making arrangements for the event. The client actually worked hard in preparation, the performance was well received and the client became more integrated into the community. He has gone on to coach young opera singers.

What are the Potential Pitfalls when Performing with a Client?

Role Abdication

In order to avoid addressing difficult issues or feelings, some clients may defend themselves by abdicating their role as client and ignoring the role of the therapist. This can happen when both therapist and client perform together and experience each other in a new context. It is important for the therapist to emphasize that he is still observing and guiding the therapeutic process even as he collaborates as a performer with the client. The therapist needs to be aware of taking on a role that may compromise his focus on the client's development.

Exploitation

There is the danger of exploitation as the therapist benefits from the client's public activities. If success is measured on how the performance is perceived rather than on its effect on the clients overall progress, it could be harmful to the client. This is obvious in theory but can be difficult in practice when the therapist has his own personal investment in the success of the performance. Under the guise of helping the client or promoting the field, a therapist may be unconsciously acting out his or her own hidden agenda such as self-promotion, the need to feel important or the need for recognition and acknowledgement. He or she may want his or her music to be heard and manipulate the patient's participation in order to achieve this end.

Perhaps the therapist is also a performer. He may assume that since he enjoys performing that the client will also. Perhaps the therapist has always wanted to have his own band. These unconscious dynamics are not necessarily troublesome for the therapist but can be potentially damaging for the client. The basic problem is this: if the therapist is acting on his or her own unmet desire to be a performer or professional musician, who is watching out for the client? Unconscious motivations can impede the therapy process, preventing the therapist from working on a deeper level with clients, whether the therapist acknowledges the importance of these motivations or not. Some questions to consider are:

• Who is benefiting from the performance? [10]
• Is the therapist aware of his or her own issues around performance?
• Has the decision to perform been an informed one on the part of the client?

Loss of Attunement

When including a focus on performance as part of a therapy process, there is a risk that the client's issues or needs will be missed or ignored by the therapist. Particularly during the performance itself, the therapist has to cope with the external conditions of creating the performance as well as his own internal issues around performance. If a therapist is focused on his own performance, he may not be as focused or aware of the client's process during the performance. Of course, this could contribute to the process in a healthy way if the client can live through this and re-connect and experience that the relationship is still intact. It might be important for the therapist to assist the client in expressing his feelings about the loss of attunement.

Personality Attributes that May Make Performing Problematic

It may be that the client who desires to perform is driven to do this due to a particular constellation of personality attributes. For example, if early in life, a client's basic needs are unmet by a distant parent who needs the child to be special in order to feel self-worth themselves, feelings of abandonment and rejection can become primary motivating dynamics in the child's life. The child may grow to be an adult who desperately seeks recognition and "special-ness" through performance as a way to defend against feelings of inadequacy and powerlessness. Though he may have an exaggerated view of his talents and accomplishments, this is a fragile state and is considered a defense. What drives this exaggerated self-importance (which may or may not be easily discernible) is a deep feeling that he or she is hopelessly unlovable and defective. He or she then seeks to create an ideal self through the pursuit of celebrity and external success. He or she constantly depends on others for approval and recognition. It is very difficult to establish trusting, intimate relationships for a person struggling with these issues.

The act of continued performing can be a destructive cycle when the therapist does not tune into the client's needs and the client continues to yearn to perform in response to the therapist's lack of attunement. Even if the therapist attends to the client during the performance, the client may not feel valued for who he or she is, but for what he or she is doing. If this dynamic is present, the client may continue to perform in order to please the therapist, but ultimately will not feel satisfied. He or she will continue to feel driven to perform to try to gain some level of internal satisfaction that is not attainable.

So for some clients, receiving the external validation that comes from sharing publicly may not necessarily have a beneficial effect. Even when others acknowledge the performance or product as successful, the client may not be satisfied. For some clients, the desire to perform and receive public acknowledgement is an attempt to fill an emotional need for nourishment and connection that was never met interpersonally. No matter how much public sharing and acknowledgement, the client may continue to feel unsatisfied and driven to perform again. It may be that they are unable to share the spotlight with their peers. Their relationship to others in every day interactions may be problematic and fraught with conflict. Psychoanalytic theory has described the person who consistently seeks external notice by performing and who achieves public acclaim yet continually feels an underlying sense of emptiness and shame, to be suffering from "narcissistic personality disorder" (Kohut, 1971).

Assessment Questions

Important questions when considering the performance process include the following:

• How does this client relate to others?
• Is he or she able to establish intimacy?
• Could the client's desire to perform be a way of compensating for a lack of intimacy and trusting relationships with others?
• Can the client work constructively toward a successful performance or expect it to occur without effort?
• How does the client relate to the therapist and/or peers after the performance?
• Does the history of the client give any indication of the possible effect of performing as part of the therapy process?
• Does the performance process enhance the therapeutic relationship?

Strategies on Performing with a Client

Despite the fact that the external validation that comes from public acknowledgement does not vanquish feelings of emptiness and inadequacy in certain clients, performing nevertheless may be an effective component of music therapy treatment with this particular kind of client. Kohut (1971), who identified this dynamic in his patients, considered that "useful, creative work, which confronts the individual with unsolved intellectual and aesthetic problems" was a particularly successful way to try to help these patients. He felt it was important to try to mobilize the "narcissistic impulse" on behalf of activities outside the self. The creative act of music making can be seen as a step in this direction. The music therapist could utilize performance as a way to engage the client who felt the need to perform. For clients struggling with this core issue, processing their feelings after the performance or completion of the project product could help them to feel valued as a person, worthy not solely for their external achievements but for who they are in totality. In other words, in psychoanalytic terms, there is a healthy narcissistic impulse in all of us that can be addressed constructively rather than merely pathologized.

Another important reason to share thoughts and feelings about the performance process with any client is to maintain the therapeutic alliance. During these kinds of public events, the therapist may reveal parts of him or herself that the client had never been exposed to before. This can have a powerful effect on the relationship. When the client sees his or her therapist not functioning solely as the container and caretaker of the therapy process, but also as a performer focusing on his or her own performance or producer working on a product, strong feelings may arise. Feelings of abandonment, and anger toward the therapist may manifest. This may occur if the therapist makes a mistake as a performer. The client may feel that they let the therapist down if they make a mistake during the performance. They may feel that they have disappointed the therapist and react in a self defeating way. Competitive feelings may be triggered if the therapist gets more applause. Perhaps the event will trigger a stronger idealization of the therapist on the client's part, causing the client to become more dependent on the therapist, and feel less capable on his or her own. If the therapist becomes personally invested in the product they created with a client they may be less aware and sensitive to the client's needs. The client may not recognize the therapist's contribution to a product, and this may be an important dynamic to understand and explore. Issues over who controls the product created in a therapy session after they are created may occur. All of these possibilities are potential issues when working with any client, and are opportunities for exploration that can actually enhance the therapy process if the therapist is ready to work with them.

It is vital for music psychotherapists who are psychodynamically oriented to avoid limiting one's understanding of performance solely as a compensation or sublimation. The desire to perform can be driven by natural, healthy impulses and there are examples of this in the current literature on community music therapy (Stige, 2002, Pavlicevic & Ansdell, 2004, Aigen 2004).

Conclusion

Publicly sharing the results and accomplishments of the music that is created privately in a music therapy session can be a way of cultivating a sense of achievement within the client. It can be a way of validating changes the client has made internally. Performing can create a sense of accomplishment and self worth within the client. Recording music created in therapy sessions can allow clients to share personal feelings and expressions with others in a meaningful way and build trust within the therapeutic relationship.

For Maria, community sharing gives her the opportunity to have a sense of feeling more fully within a social context. She described early on in treatment being emotionally frozen, walking around like a zombie, isolated emotionally. Performing was a dramatic way of breaking past this isolation. Rather than feeling paralyzed and helpless, organizing a musical sharing in the community helped her to take command of her situation in a novel and creative way.

Also, the process of community sharing is a way of affirming that the pain of her life is something that does not overwhelm her in the present. She does this in part by organizing the shape of the concerts so that there is an overriding form in the presentation of the songs and excerpts. They do not remain in chronological order but in category. In the first section she places her pain songs -- songs and excerpts "about the darkness." The next section of the sharing includes songs and excerpts containing elements of the struggle to overcome her personal turmoil. The last section includes the hopeful songs, even celebratory ones. The performance gives her a way to shape her process the way she would like it to be. By doing it she is attempting to reinforce her understanding that she is more than her painful feelings and that there is hope for the future.

It is worth noting that for Maria, sharing her music publicly allows her to communicate with others while at the same time to be inside her own experience. A theme she has often sung about in sessions is her desire to shrink, to not be noticed. Yet she is trying to combat that by sharing her songs publicly. During the concert experience she can be heard by others yet does not have to interact directly with the audience during her musical experience. She can immerse herself in the music, feeling protected and nurtured in a world she has helped to create for herself. Sharing publicly in this way helps her to feel safe and helps her to overcome her desire to shrink and hide even as she sings about those desires. Even when Maria is singing about giving up, the concert experience -- her public affirmation -- gives her the feeling that "I'm not giving up at all. The music gives me another power" (Logis and Turry, 2003). Doing this publicly amplifies that feeling for her. Describing her songs and her experience in between each musical sharing during the concerts allows her to communicate directly to others and affirm her perceptions. Her own explanation about the songs and excerpts is a way for her to process her experience and gain support and consensus from others.

Acknowledgements

Dedicated to the memory of Jill Azzolina.

Notes

[1] A few months after we started working together, Maria became clearer about the differences between music therapy and singing lessons and wondered if she should pursue singing lessons. She spoke with friends and found a vocal coach, Janet Savage who became an important ally for Maria and her relationship to music. Janet worked with Maria for several years.

[2] There were two oncologists who agreed to wait before beginning chemotherapy, with the plan that each month Maria would be re-evaluated. Maria had a partial remission and has remained chemotherapy free for the past ten years. The tumors are indolent but could, in Maria's words, "grow back at any time."

[3] For more on the concept of container and its relevance to music therapy, see Aigen (In press).

[4] For more on this see Austin and Dvorkin (1998), and Turry (1998).

[5] I do not mean to imply a prescriptive relationship between these particular elements and emerging emotional congruence. I did want to briefly share my ideas about my intentions in improvising. The musical choices were not made prescriptively, but intuitively and then built upon in a conscious manner. For more detailed descriptions of this see Turry, A., & Turry, A.E. (1999), Logis, M. and Turry, A. (1999), Turry, A. (2002) and Turry (In Process) The Interconnections Between Words and Music in Clinical Improvisation., Doctoral Study, New York University.

[6] For more on this see Aigen (2004).

[7] A Gatekeeper is a therapist who participates in the workshop, observing the process and helping to maintain safety, ready to intervene if necessary. For more on this see chapter 1 in Loewy, J. and Frisch, A. (2002).

[8] Errin Epp functioned in the role of gatekeeper when the workshop was done at another location. Her participation was vital in setting the appropriate environment and in generating support for the workshop.

[9] For a detailed description of this workshop, see Turry (2002).

[10] Emma O'Brien has recorded songs of clients with terminal illnesses and these songs are produced on CDs that raise money for the music therapy program she directs. These clients have described the recording project as giving their life purpose, and helping them to feel less isolated. O'Brien has been under pressure from those within the profession who feel it is unethical for a therapist to be economically supporting her program with the profits of recordings made by patients and herself. She has stated that the idea of giving the proceeds to the music therapy program she runs came from the patients themselves. At issue is the potential conflict if the proceeds of the CD are a primary source of funding for O'Brien-how will she sort out the needs of the clients with her own financial needs for survival? Will some clients feel exploited even if they initially agree to participate? Are they recognized as a person in an equal fashion with O'Brien or labeled a patient first in order to increase sales?

References

Aigen, Kenneth (In Press). Music-Centered Music Therapy. Gilsum NH: Barcelona Publishers.

Aigen, Kenneth (2004). Conversations on Creating Community: Performance as Music Therapy in New York City. In Pavlicevic, Mercédès and Ansdell, Gary (Eds.). Community Music Therapy (pp.186-214). London: Jessica Kingsley Publishers.

Ansdell Gary (2002) Community Music Therapy and the Winds of Change-A Discussion Paper. In Kenny, Carolyn and Stige, Brynjulf (Eds.). Contemporary Voices in Music Therapy: Communication, Culture and Community (pp.109-143). Oslo Norway: Unipub Forlag

Ansdell, Gary (2003). Community Music Therapy: Big British Balloon or Future International Trend? In Community Relationship and Spirit: Continuing the Dialogue and Debate. London: BSMT Publications.

Austin, Diane S. (2003). When Words Sing and Music Speaks: A Qualitative Study of In-depth Music Psychotherapy with Adults. Doctoral Dissertation, New York University, New York.

Austin, Diane S. and Dvorkin, Janice M. (1998). Resistance in Individual Music Therapy. In Bruscia, Kenneth E. (Eds.). The Dynamics of Music Psychotherapy. Gilsum, NH: Barcelona.

Friends Health Connection (2004). New York Expressive Therapy Series Registration Form. New Brunswick, NJ. Retrieved from http://www.friendshealthconnection.org

Keenan, Gary (2002). Liner Notes for Do I Dare. New York: Gardenia productions.

Kohut, Heinz (1971). The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders. New York: International Universities Press.

Loewy, Joanne and Frisch, Andrea (2002). Caring for the Caregiver: The Use of Music and Music Therapy in Grief and Trauma. Silver Spring MD: American Music Therapy Association.

Logis, Maria, Turry Alan (2003). Presentation to Funabashi Music Therapists at New York University. New York University: Gardenia Productions.

Logis, Maria (2004). Singing My Way Through It. Unpublished manuscript.

Logis, Maria, and Turry, Alan (1999). Singing My Way Through It: Facing the Cancer, the Darkness and The Fear. In Hibben, Julie (Ed.). Inside Music Therapy: Client Experiences (97-118). Gilsum, NH: Barcelona Publishers.

Pavlicevic, Mercédès and Ansdell, Gary (2004). Community Music Therapy. London: Jessica Kingsley Publishers.

Stige, Brynjulf (2002). Culture-Centered Music Therapy. Gilsum NH: Barcelona Publishers.

Turry, Alan (1998). Transference and Countertransference in Nordoff-Robbins Music Therapy. In Bruscia, Kenneth E. (Ed.). The Dynamics of Music Psychotherapy, (pp. 161-212). Gilsum, NH: Barcelona Publishers.

Turry, Alan (1999). Performance and Product: Clinical Implications for the Music Therapist. Paper Presented as Part of a Panel Discussion at the World Congress of Music Therapy, Washington DC.

Turry, Alan, & Turry, Ann E. (1999). The Use of Improvised Songs with Children and Adults with Cancer. In Dileo, C. (Ed.). Music Therapy and Medicine (pp. 167-178). American Music Therapy Association.

Turry, Alan (2001). Supervision in the Nordoff-Robbins Music Therapy Training Program. In Forinash, Michele (Ed.). Music Therapy Supervision. Gilsum, NH: Barcelona Publishers.

Turry, Alan (2002). Don't Let the Fear Prevent the Grief: Working with Traumatic Reactions through Improvisation. In Loewy, Joanne and Frisch, Andrea (Eds.). Caring for the Caregiver: The Use of Music and Music Therapy in Grief and Trauma (pp. 44-53). Silver Springs MD: American Music Therapy Association

Appendix

Appendix 1.: Permission letter from Maria Logis

August 18, 2004

Dear Editors:

I am writing to advise you that I have given Alan Turry permission to use my actual name in a manuscript he is submitting to you for publication. In fact more than giving my consent, it would be more accurate to say that I have requested that my actual name be used in this article, and in any future publications.

As the article describes, I have benefited enormously from performing and presenting my experience in music therapy to numerous professional and public audiences. I am also in the process of writing a book about my experience. Therefore, the usual conventions of confidentiality do not apply to my case. My story is in the public domain.

With my full consent and enthusiastic encouragement, Mr Turry has included direct quotes and identifying information about me. I am honored to be able to contribute to this endeavor.

Should you require a formal release or any further information please feel free to contact me.

Sincerely,
Maria Logis