Music Therapy with Adolescents

By Jukko Tervo

Of all the forms of therapy, music therapy holds a special place in supporting adolescent growth and development. The possibilities offered by the special features of adolescent growth and development - rock music and youth culture - should be taken into consideration when music therapy is used in adolescent psychiatry.

Music Therapy as a Part of Adolescent Psychiatric Treatment

The therapeutic community described in this paper was situated at the University of Oulu Central Hospital Department of Psychiatry, Finland, during the years 1979-1989. The ward consisted of eight beds, four for boys and four for girls. The basic emphasis in the treatment was laid on psychoanalytic psychotherapy and music and art therapies suitable for the stage of adolescent development. Adolescent community therapy (psychoanalytic psychotherapy, music therapy, art therapy, special school etc.) creates an environment which supports individual growth of the adolescent and youth culture. This, in turn, simultaneously supports psychotherapy.

The adolescent psychiatric team was composed on the staff of the ward and the outpatient clinic. All members of the adolescent community therapy unit continuously studied and regularly growth and development in adolescence and theory and practice of psychoanalytic adolescence psychotherapy in order to support adolescence development. The team leader and supervisor was the training psychoanalyst, Professor Tor-Björn Hägglund. The members of the team were under group supervision and each member was also under individual supervision. My work was supervised by the training psychoanalyst Vilja Hägglund. The criteria for including an adolescent in community therapy included adolescent psychic crisis except psychosis, addictive disturbances of personalities and borderline-type of disturbances with aggressive or suicidal behaviour.

In addition to psychoanalytic psychotherapy, the adolescents on the ward had the opportunity to participate in music and art therapy. By virtue of the fact that I was a member of the adolescent psychiatric team, I was provided with an excellent opportunity to concentrate on the development of adolescent music therapy. I was able to make use of all the materials collected by the team concerning background, development and the present problems of the adolescent. The music therapy sessions were tracked through use of written notes and video recordings which were regularly discussed by the team, thus making it possible for it to be integrated into the overall treatment.

Adolescent psychiatric treatment was voluntary, which also applied to music therapy as a part of this treatment. The music therapy described herein took place either in groups or individually, in the music room or on the ward. The hospital music therapy room, which was equipped with a wide variety of musical instruments, was reserved for the adolescents twice a week for two hours per session. The acoustic instruments on the ward were freely available for use by the adolescents in their rooms. In practice, the main approach to music therapy was to listen to, and above all, play the kind of music the adolescents themselves chose. The adolescents participated in music therapy two to three times a week for periods of between six months and four and half years. Most of the adolescents took part in music therapy during their treatment.

Adolescence and Rock Music

According to Blos (1962), puberty denotes the physical manifestation of sexual maturation. Adolescence denotes the psychological processes of adaptation to the condition of pubescence. Adolescence brings with it bewildering, new and often difficult internal struggles to balance out the strengthening sexual and aggressive impulses. At the same time, a gradual separation from home, parents and infantile forms of gratification begins. The changes are not only psychological but physiological as well. The adolescent struggles not only with adolescent development but also with issues of childhood development, which reappear as normative regression during adolescence.

Sigmund Freud (1905) described the phases of psycho-sexual development in broad outlines in his Three Essays on the Theory of Sexuality and applied the genetic principle to the period of puberty. Adolescence has been seen as a second chance for development after childhood (Freud A, 1958). Blos (1962) described adolescence as a second individuation, as a progress through different phases from early adolescence to adulthood. He stressed the importance of the generation gap for adolescent individuation. Laufer (1968, 1976, 1984) pointed out the importance of masturbation for the final sexual organization and for the separation and differentiation from the mother's body. Erikson (1956, 1958) described adolescence as a psycho-sexual normative crisis, i.e. a normal phase of increased conflict characterized by a seeming fluctuation in ego strength, and yet also by high growth potential. Tor-Björn Hägglund (et al. 1976, see also Hägglund & Hägglund V 1985) emphasized the corner stones of adolescent crises as a separation from childhood ties, an integration of the sexual body and the crisis of creating visions of one's personal future. He pointed out that "playing the fool" now and then could be a part of creativity in the adolescence progress and belongs in healthy adolescence because "...the oedipal and neurotic fantasies from early childhood are mixed together with fantasies of adolescence in normative regression" (p. 46) Winnicott (1965), asked "how can this ego organization meet the new advanced id? How shall the pubertal changes be accommodated in the personality pattern that is specific to the boy or girl in question? How shall the adolescent boy or girl deal with the new power to destroy and even to kill, a power which did not complicate feelings of hatred at the toddler age" (p. 80). The essential part of adolescence is that the personality is not integrated as a whole as in adulthood, but under a long vivid and deep progress of growth and development towards maturity (from 11 or 12 to 22 or 23 years of age).

I have stated that rock music is often a natural target of interest for adolescents (Tervo 1985, 1991, 2001, 2003). Music becomes rock music only when it is combined with the fantasies which the adolescent invests in it. This must take into account the sounds, rhythms, melodies, instruments, voice, lyrics and the combined effect of countless variations of tone. The significance of rock music is essentially connected with the fact that the adolescent has neither words nor commonly shared ways of expressing the new and never before experienced changes taking place within him- or herself. Music can emotionally affect adolescents at a deeper level than is possible with words alone. Rock music can enable adolescents to express, to be in contact with and to share amongst themselves feelings of anger, rage, grief, longing, isolation, psychological disintegration etc., as well as to experience closeness. It can safely lull the adolescent into regressive moods and - with its musical clarity, simplicity and high volume - give shelter to the distressed and may sometimes even be of help to confused adolescents.

Rock music may open up possibilities for the exploration of sexual fantasies and feelings in the adolescents' own body. The beat and firm pulse associated with rock music is at once both safe and exciting. A rock concert can be an erotic event at an auto erotic and masturbatory level. "The body, which until puberty was experienced as a passive carrier of needs and wishes, now becomes the active force in sexual and aggressive fantasy and behaviour." (Laufer & Laufer, 1984, p. 5). I have earlier described rock music as being a "caress without a touch" (Tervo, 1991). One might describe the musical experience as a state of mind where fantasy and one's own body join together.

Rock music is used as a defence against archaic impulses which belong to the regressive tendencies of adolescence. This is very evident among early and young adolescents. The urgent need of defences is the reason why there is not a lot of creativity in that stage of growth. In my experience, lyrics are more important for girls than for boys during the early adolescence stage, but rap- and hip-hop-culture may have changed this position. Later on, words of innocent teenage love and tenderness give way to expressions of fantasies of power, murder, hate and destruction in the form of phallic heavy rock or rap. On the other hand, adolescents use music to get in touch with their intense aggressive and sexual impulses and to cope with them. Elements of longing and love begin to take form under the shade of loud music, which extends through the adolescent development. The forms of adolescent music change rapidly, but the content remains the same. This could be compared to the relation between food and hunger; food changes in different times and cultures but hunger does not. This means that elements of adolescent process (puberty, sexual and aggressive strivings, and separation from childhood objects, developing towards adulthood and so on) are eternal. They will not change, but our ways in dealing with them may change in different cultures and at different times.

Improvisation in Psychiatric Adolescence Music Therapy

Based on my personal clinical experience, I have divided adolescent music therapy into three stages; interest, learning and improvisation (Tervo, 1985, 2001, 2003).

1. The Stage of Interest

A new adolescent on the ward becomes interested in music through other adolescents and through the support of both the music therapist and the atmosphere on the ward which supports self-expression and youth culture. The stage of interest is both very important but at the same time difficult to study due to the relatively short period of time the therapist has to work with the adolescent. The unconscious fantasies and hopes of the adolescent to discover a new developmental object to aid in adolescent growth and development and/or search for a person to complete relationships which have been interrupted due to his childhood traumas are central to this stage.

These two elements, the wish to develop and the trauma(s) - usually hidden - i.e. internal obstacles to growth, are present at all times in music therapy for adolescents and will force both the therapist and the adolescent into intense emotional interaction (Tervo 1996).

2. The Stage of Learning

In the learning stage, the adolescent begins to understand and master playing different instruments together with the music therapist. This may lead him to a feeling of being small and a very amateur player. This is usually a very difficult feeling in adolescence as one must face so many fundamental developmental issues which can't immediately be mastered or understood. If the therapist is able to find some means to help him with that experience, the adolescent will begin to have faith in the therapist.

More importantly this makes it possible for the adolescent to invest his fantasies in the music therapist as a good object, as well as in the music and instruments. Learning music provides new media to define new, even never before experienced emotions and fantasies and to cope with and express them. Well known musical structures create a feeling of safety as well as providing a frame for adolescent regression. As time goes on, the adolescent who is capable of playing common and well known musical themes might find the courage to play music with others.

3. The Stage of Improvisation

Improvisation is to music therapy what free association is to psychotherapy (Tervo, 1985). The secure and supportive atmosphere provided by music therapy allows the adolescent, even those with a limited musical ability, to freely experiment with instruments and sounds. Thus, the adolescent takes part in creating music with other adolescents. It is this which allows them to work spontaneously together.

In a dynamic sense, music therapy becomes more personal and intense as it progresses towards improvisation. The stages of interest and learning, the length and contents which vary with each adolescent, prepare them for actual improvisation. The improvisation discussed here is not jazz-improvisation in which chords, keys, scales and rhythmical changes are of great importance. The improvisation in question is a musical game in which the adolescents - or the music therapist - invent a drum beat, a series of chords or the phrase of a melody which is then worked on together. The improvisation is always new and different and expresses the feelings of the adolescents at the time. It can be free and furious "noise," a search for a gentle, common theme, or it can simply lead to listening to music and discussion.

Once the adolescent becomes really interested in music therapy, he begins to cooperate more with the therapist himself. When situations arise and develop naturally, and the therapist is teaching less and less, the therapy has reached the improvisation stage. It is at this stage when internal conflicts become apparent, with moments of anxiety, withdrawal, quiet sadness and anger. At first the adolescent attempts to avoid pondering his internal conflicts, but later might be able to better cope with them with the support of the therapist. During this time the playing becomes more instinctive and the players learn to anticipate each other, which are the essential elements of playing together. A shared sense of humour, the songs and the musical language created together all make for improved co-operation. The music no longer acts merely as a defence or as a performance, but rather becomes a deeper shared experience.

During the interest and learning stages, the therapist guides and supports the adolescent to the gates of self expression and creativity. When improvisation becomes possible, the roles change; the adolescent then shows the therapist and finds the way to the world beyond the gate, in other words, his own inner world. The music therapist must follow, to the best of his abilities, and explore this world with the adolescent by sharing it. To the best of my understanding, this is the area which the psychoanalyst Donald W. Winnicott describes as the "potential space." "The potential space happens only in relation to a feeling of confidence on the part of the baby, that is, confidence related to the dependability of the mother-figure or environmental elements, confidence being the evidence of dependability that is becoming introjected" (Winnicott, 1971, p. 118). One of the great challenges facing the music therapist and other members of the therapy team is the achievement of trust leading to a stable therapist-adolescent relationship. Through this the "potential space" can then be achieved and the inner process of change in the adolescent is allowed to be freely expressed.

Some adolescents find their inner world safe enough to allow interaction to occur naturally and they are able to express feelings ranging from rage to deep sorrow. To others, this world may be very traumatic and full of loss, disappointment and rage. However, music created together with the music therapist can provide a means to express all of this. Beyond the gate some adolescents may find the emptiness which has been with them all their lives. On the other hand, they may find a place filled with the kind of fantasies which they may find impossible to accept due to the psychic pain they cause. This may prevent deeper interaction.

The following example illustrates how a phobic and depressive boy used phallic identification with the music therapist to find a new path in his adolescent development and how, with the support of the music therapist, he was able to express himself and begin to interact with other youngsters. The example also provides the possibility to observe a group of restless and anxious youngsters using music to get in touch with their hidden emotions. Some personal facts have been changed to prevent identification of the adolescents involved.

Example 1

John[1] lost his mother at the age of 5 when his parents divorced. Since then John lived in a foster family. His father, with whom he was in close contact, suffered serious mental problems and attempted to commit suicide. When John first came to the ward at the age of 13, he was very reserved and depressed. He was on the threshold of adolescence, drifting into an anti-social world due to his deep depression and serious learning difficulties. His treatment (on the ward and in music therapy) lasted three and a half years. It was difficult to settle down into the psychotherapy, which took place three times per week. He constantly broke the rules of the ward expressing in this manner his belief that no one cares for him. John's ability to verbally express himself was very limited.

In one music therapy session John became irritated and angry because the other adolescents, who were better players than he at that time, didn't let him play. The room was full of loud noise and nothing shared and common was found through playing instruments. I tried to discuss this but without success. For a time I allowed the youngsters to search for some form of relief, some way to make communication possible, but they couldn't find anything. I then asked John to play the electric bass and the others to play the instruments they were able to play best. I taught them very quickly the chords and lines of "The House of The Rising Sun."[2] John performed his part with serious concentration and without making mistakes. Suddenly the whole band begun to play with a good feeling of communication and with deep emotion. In the moments John was uncertain of his playing he received guidance from me and moved his body the same way as I did.

Later it was evident that the approaching Christmas vacation had affected the adolescents; the ward was to be closed for a few weeks and the adolescents felt that they were all being abandoned by the staff - including the music therapist. The loud, chaotic noise expressed aggression and worked as a defence against anxiety. The sad, but beautiful blues ballad, which I chose intuitively, touched them more deeply than words. Through the song the group was able to share the feeling of loneliness and to contain it.

The music of the song could be felt as constructive and secure but at the same time full of longing and disappointment. The words of this bluesy folk song describe a caring mother and a gambling, drinking father left behind.

The House of the Rising Sun
There is a house down in New Orleans
They call the Rising Sun
And it's been the ruin of many poor boys
And God, I know I'm one

My mother was a tailor
She sewed my new blue jeans
My father was a gambling man,
down in New Orleans

Now the only thing a gambler needs
Is a suitcase and a trunk
And the only time he's satisfied
Is when he's all drunk ...

This was very current in John's development in music therapy where early identifications began to rise up in relation to his transference to the music therapist and as well as in his progress as a 13 year-old boy; withdrawal of early object cathexis began. The work of mourning provides new needs to achieve new developmental objects. Even though the song that we created together was experienced as safe and secure, it was the music therapist whose presence made possible the discovery and sharing of the song. Later on in psychotherapy, John was able to verbalize his feeling about being left alone by the staff, his psychotherapist and music therapist among others, because of the approaching vacation.

Even though the song described above was a well-known song, the emotional content of it came from the adolescents. At the improvisation stage, there must be trust in the therapist and in the other players. The most important thing about improvisation, which differentiates it from many other musical forms, is that the expression or action is not prearranged or defined; the outcome is determined spontaneously by the adolescents themselves.

Transitional Objects and Phenomena in Adolescent Music Therapy

Winnicott (1971) described the early childhood "transitional phenomenon" and "transitional object" into which both the child and mother invest shared fantasies as the origin of creativity "...(if we study one infant) there may emerge some thing or some phenomenon - perhaps a bundle of wool or the corner of a blanket or eiderdown, or a word or tune, or a mannerism - that becomes vitally important to the infant for use at the time of going to sleep, and is a defence against anxiety, especially anxiety of depressive type" (Winnicott, 1971, p. 4). The transitional object helps the child to separate from the early symbiosis with his mother and at same time, it represents the fantasy which is invested in it, represents the shelter of being together as well as shared experiences when the mother is not there. Music itself or a musical instrument can also be a transitional object. In the following I shall comment on some aspects of the relationship between adolescent development and transitional phenomena through music therapy.

In clinical music therapy it can be observed how the musical instrument or music itself does not have transitional significance; instead the transitional phenomenon takes place through the fantasies invested in them. An instrument which is not cathected cannot express inner voices. The time spent with this instrument, the trouble taken with it and the fantasies invested in it turn it into "a friend who listens, understands and comforts." Playing is chiefly a psychic interaction with inner objects which can be expanded into an experience to be shared. In music therapy, playing is the result of co-operation and a feeling of belonging together.

Many adolescents project their desire to be powerful and skilful to electric guitars and drums. With the help of these instruments adolescent who feel insignificant and depressed can articulate dreams and thereby provide a medium for sharing fantasies. I have divided these fantasies into two categories: omnipotence and closeness. John's music therapy is an example of both types of fantasies.

Fantasies of Omnipotence

In spite of difficulties to verbalize his feelings John managed well in expressing himself through music. He usually played drums incredibly loud during the first year of music therapy and in this way was able to express his anger and rage. The loud noise gave John feelings of power and greatness. Although he hid behind the drumbeat, he was able to build a bridge of co-operation with me and the adolescents on the ward.

While playing fast, heavy rock music on an electric guitar, he was able to revel in his ability, his fantasies of omnipotence and his wish to become skilful and admired. Identification with the music therapist helped him to cope with his feelings of insignificance and of being only a beginner in playing instruments. This identification at the deeper level also helped him on his way towards manhood; the music therapist was a developmental object.

Fantasies of Closeness

After working in music therapy for a couple of years, a stage of closeness had developed between us. The same guitar began to cry; the sound of grief and intimacy was found in the weeping of the electric guitar and from the warm embrace of the acoustic guitar. John discovered this new level of playing the blues at the same time as he was approaching the fantasies connected with his mother in psychotherapy.

These central issues in John's inner world were given form in his music therapy. Close co-operation with the music therapist also opened doors in psychotherapy, where John dealt with his feelings and, as time went by, was also able to verbalize them. The touch of hidden emotions were first found and shared through music with his idealized music therapist. He idealized me as a developmental object, and as a man and a musician. The ability to express emotions through music led John to using symbols to express the thoughts behind his feelings. This transmission from music therapy to psychotherapy in his case was concrete; John, who had difficulties expressing himself verbally in the beginning of the treatment wrote a song called "Lonely man" and played it on acoustic guitar for his female psychotherapist. They were both on the verge of tears.

The major part of youth culture is based on shared phallic and omnipotence fantasies. They are used as a defence against regression and feelings of being small and helpless which are often very threatening in adolescence. Adolescents also need them to separate from early cathexis. These fantasies are used in music therapy as a shield guarding against intimacy, which in turn may be allowed to develop later on in therapy. A close relation between the therapist and the adolescent will subsequently open the way to deeper creativity and transitional phenomena as seen in John's case. Music acted as an imaginary world, both a defence against his own anxieties as well as a way of approaching his feeling of being completely alone and unloved.

Through music and the playing of it, adolescents can also approach issues connected with their sexual identity. The next example illustrates how music became a medium between a girl who uses phallic, aggressive and omnipotent defences as a cover of her fragility and the music therapist. She used the music therapist as a target for her aggression and sexuality as she worked on her ambivalent attitude towards femininity and masculinity.

Example 2

Tina was the youngest child and only girl in a large family. Her problems became evident at school as she approached adolescence. She was a constant disturbance during lessons and, in particular, picked fights with other girls and occasionally with the male teachers. In a culmination of her problems she was expelled from school for a period of time. Tina had a close relationship with her elder brothers and also her father, with whom she had spent a lot of time and even accompanying him on work trips. The atmosphere in the family was violent. Tina's elder brother was in prison for physical assault with a knife. She hardly had any female friends. Tina was going through an adolescent crisis and it was difficult for her to form her female identity.

Tina was happy to take part in music therapy, and was especially keen on playing the guitar, even though, like John, she had never played a musical instrument before. Tina constantly belittled me and complained about everything. She played electric guitar and drums with a bold and boyish touch. In one phase of treatment Tina wanted to take the electric guitar from the music room to the ward which I couldn't allow her to do. Angry disagreement over the electric guitar continued for weeks. She had written on her door a message: "I'm The Law!" When this highly emotionally-invested discussion had been worked through in many ways - and when the girl finally got the electric guitar on my terms - she switched her interest to the acoustic guitar and began to play it gently and sensitively. She learned to play simple but sensitive tunes and her previously hidden inner female voice was released. At the end of her treatment she wanted to learn to play a song called "I will stay."[3] We shared this song singing and playing it in a very intimate and touching manner.

I Will Stay
I will stay by your side now and forever.
I will always only be in love with you.
Is it true when you say that you love me
and is it truth that I'm the one?
And that day we'll walk together.
and that night I think of you.
I will call you my darling and ask her
if I can marry you.

It appeared that Tina was projecting fantasies connected with phallic power and control to the electric guitar. By maintaining a firm stand on the issue of the electric guitar, the therapist was able to create a line to communicate with the girl's aggression. In the end, she held the acoustic guitar in her lap with a special tenderness and played it carefully and well. Music became a way to deal with incestuous feelings. The tenderness which had arisen, as time went on, between her and the therapist, had been projected onto the acoustic guitar. Because of the way she played it one can hypothesize whether the acoustic guitar has a female inner space quality for her. Bold action, constant defiance, anger and defensiveness were transformed into close co-operation and creative interaction between her and the therapist. The contact established with Tina's own sorrow and insecurity enabled her to mature into a young woman. After her treatment Tina bought herself an acoustic guitar.

Winnicott also described the aggressive side of the relationship between the child and the transitional object. "It must survive instinctual loving, and also hating and, if it be a feature, pure aggression" (Winnicott 1971, p. 6). The following example of a music therapy group illustrates how destructive fantasies and feelings can be shared through music and be transformed into constructive rock improvisation.

Example 3

The ward staffs were going away for an educational visit which meant that the ward would be closed for a few days. The day before closure there was an affective atmosphere in the music therapy group session.

Mike wanted to play a song he had written just a couple of hours earlier on the ward with the music therapist. The song was a sorrowful and hopeful country ballad. John suddenly expressed: "Oh shit!", and pushed Peter out of the drum seat and began to bang the drums as loud and as fast as he could. Mike jumped to the electric guitar and hit the one and only chord he knew as loud as John and screamed with a red face into the microphone words nobody could understand. I joined the boys by playing bass. This "heavy-metal-punk-chaos" lasted about 20 minutes with great enjoyment by the boys. After this outburst they were very satisfied and relaxed. When I asked John about his plans for the weekend, he answered: "I guess I'll go get drunk under the bridges."

Aggression was turned into creative effort without any real destruction. One could even say that in this situation they did not play punk, but created it! John used music as a defence; he imagined himself to be a powerful destroyer and master, not the one who was to be left alone. He also envied Mike due to the work I had done with Mike on his song. On the other hand, from his comment could be extrapolated: ". because you are leaving me, I'll leave you ..." Later he was able to discuss with his psychotherapist how he felt about being left behind. Winnicott pointed out the importance of the father (1964) and how a subject uses an object by destroying it (1971). The above example vividly illustrates the creative value of music; it could not be destroyed. The music therapist also remained alive while being able to share and reflect the boy's outburst emphatically by playing with them. This led to a better integration of aggression and to the ability to use it on an age-appropriate level.

The Importance of Music and Transference in Music Therapy

As I described earlier, music and especially rock music have a special significance in adolescence, but it's important to realize that music alone can't help an adolescent with serious difficulties to reach age-appropriate development. It requires psychotherapeutic interaction. In the music therapy described in this paper, the therapist is primarily interested in transference and developing self expression, not in musical skills or ability. The therapist is for an adolescent at the same time a childhood object and a developmental object. Music's property to activate early and primitive communication functions becomes integrative when an object is present. It is demonstrated in the following clinical example how a depressive boy with a poor capacity to play instruments was able to discover his creativity.

Example 4

Fifteen year old Mike had spent his childhood with his mother in particularly poor conditions, both psychologically and socially. His father had left the family when Mike was two years old. In adolescence, Mike fought with deep depression, which threatened his development in every way. Mike never really learned to play an instrument well, but he had a vivid imagination and in music therapy began to write lyrics for songs. I composed these lyrics to punk rock format for many years until depression and peaceful rhythms became shareable between us.

In one session Mike was singing a slow melancholic and monotone song he wrote himself; "A Ten Year Old Boy." It was about a deserted boy who is heading for destruction: "...a ten year old boy lays in the machine-gun fire, falls down and dies of the cold... there are millions of them. Ten year old boy..."

In its nakedness, this song is too touching and too personal. He both knows and at the same time doesn't know that he is singing about himself. Mike is unable, in this situation, to associate himself with this song. Even though Mike sang the song devotedly, he was not distressed. The music therapist, however, felt the song and the situation to be very touching. The song originated and was sung in one-to-one or intimate group situations.

In the example mentioned above, the music therapist used counter transference feelings when trying to understand the boy's psychic world. It's very important to emphasize that a creative product such as the song described in Mike's case should not be "understood" too quickly but rather the therapist should wait and learn from the transference and the process where it arises. A process and the product of creativity - the content and form - has its own mind, and represents the adolescent's own unconscious efforts to integrate different parts of his psychic world into the whole self. In the example above I felt I should only listen to, accompany and share his singing.

The therapist should be able to be emphatic and to respond to the adolescents' behaviours and musical expressions spontaneously as I tried to do in John's case when "The House of The Rising Sun" in Example 1 was found.

Example 5

"The House of the Rising Sun" started by cautious chords, while the players - the same restless youngsters - outlined the form of the song and a common tempo. I played the simple A minor melody very clearly. The restless and noisy adolescents calmed down and concentrated on their own instruments. The whole band sounded rich and colourful. I then begun to improvise the melody further and further from the original line, but I always came back to the root note at the end of each verse. Every second verse I played the familiar melody and then followed a verse improvised by me. Other players followed my solo by playing their part confidently. The song lasted about 15 minutes.

This is also a musical event which can't be translated into mere words. I bent the strings and let my electric guitar "cry, roar, and sing" as if playing a game with elements like "close - far away," "rage - grief," "loud - quiet," "secure - scary," "control - let go," "comfort - pain," "together - alone," etc. In music all these elements are naturally more or less subjective mix-ups of many different of simultaneous experiences. Asking them to play this song and using my guitar solo - both spontaneous responses - took place through my intuition. To be "in tune" is a music term but could also be linked into early emotional-physical (or body-mind) interaction.[4] Two years later after many phases in John's treatment and development - when he was capable of expressing feelings of grief in interaction - the guitar began to sound the same way in his hands as it did when I played; he got the blues himself.

There are two levels of using musical symbols:
1. The Level of Learning: This is an important but superficial "know-how" level which can be taught and learned. The facts of making music (as notes and techniques of playing) are received "externally" from the music therapist. 2. The Improvisation Level: This includes creative fantasies and important inner, deeply experienced and shared symbols. The emotional content of music played together comes into existence from transference. The origins of these symbols are extra- and preverbal. They can not be learnt but can be discovered.

Music therapy does not primarily depend on the music but on the co-operation and the interaction between the therapist and the adolescent. The feelings, fantasies and experiences which arise through the atmosphere of co-operation gained by the sharing of music become meaningful when they are projected into the same stable person, who in the terms of music therapy is the music therapist. Only after this has taken place can the therapeutic process become more meaningful and lasting. Even though some basic knowledge of playing is required for a shared musical experience, this experience doesn't originate from any sense of musical proficiency, but rather from being together with the music therapist.

Learning new things enables new methods of expression, develops ego functions and yields experiences of control. One must be aware that the adolescent also needs to develop defences on the way to creativity and maturity; in music therapy the use of well known music pieces or riffs provides a feeling of safety and security when anxiety levels become too high and uncontrolled. The music, in the example described above, originated as a playful interaction between the therapist and the patients through improvisation.

Music can be used as defence and as means for interaction and communication, even though it is, in itself, neither. As an example, the expression "aggressive music" is inaccurate. It could narrate experiences of either the creator or the listener, but the music in itself contains no emotion; it is only vibrations which can be associated by psychic-physical perception to one's own experience.

Our personalities and our sense of security are not altered by music although we might feel momentary a sense of harmony and consolation. This is connected, in early development, with conaesthetic organization,[5] autoerotism, and sensitive, non-verbal communication with caring persons. Spitz (1965), Stern (1985), Hägglund & Piha (1979, 1980) and Rechardt (1988) have written on these subjects. The music we enjoy listening to seldom says directly "this is where you hurt," but rather "I will carry your pain over the river so that only your toes will get wet while you rest." Free improvisation with the music therapist enables the identification of the sources of hidden internal experiences and conflicts.

In music there are codes which will guide the listening experience in a certain direction, but in the end it is the mind of the receiver which makes the experience a personal one. In this way, it becomes possible to share things at a common level, even though everyone also has their own individual level. Music can act as an aid to achieving that state of mind in which the personal feelings and fantasies described above are given space and a base from which hidden fantasies and feelings can be experienced.

Music Therapy as a Bridge from Childhood towards Adolescence

From my point of view the essence of adolescent music therapy is the discovery of fantasies and fantasizing which promote adolescent maturation and development, finding an age-appropriate defence, and finding an area for possible creativity. This can help the adolescent to disengage from childhood gratification and create the space and psychic possibilities necessary to work on fantasies connected with adolescence.

The fantasies connected with the transitional object belong to the childhood symbiosis and to the first phase of individualization. In adolescence there is a second individuation (Blos, 1962). Transitional objects and phenomena may have temporarily vanished due to the rapidly changing process of adolescence, increasing the need for defences and possible traumas, as if they are "in dry dock." In adolescent music therapy, one tries to find the transitional world again in the service of adolescent development as illustrated in Eric's case.

Example 6

Eric was admitted to the ward at the age of 15. He was the only child of his family. At the age of 6-8 years Eric's childhood became traumatic, when his mother's alcoholism gradually increased and she became violent. Later on she was treated in a psychiatric hospital for paranoid psychotic symptoms. The parents divorced. Eric suffered from chronic abdominal pain for which he had been thoroughly investigated. After the parents divorced, Eric assumed the responsibility for practical matters at home and became, little by little, quite independent. In adolescence, Eric's abdominal pain recurred and he had acute attacks of palpation (somatic symptoms which may have psychological roots). Because of these symptoms he increasingly stayed home and did not go to school. He was investigated before hospital admission and his disturbance diagnosed as having a phobic fixation to pregenital psycho-sexual development. Symptoms were school phobia and somatization.

He played flute at ward parties and consoled himself with beautiful melodies before going to bed. He received positive attention from adults for his gentle ways. When listening to Eric's beautiful longing, harmonic play of flute one could get an impression that he was trying to recapture a past experience or was fantasizing on the harmony of his early childhood in contrast to this experiences of adolescence and to the generation gap between adolescents and parents (Blos, 1962). He also played the flute with me but wouldn't agree to go to the music room in another building.

During the first year, Eric was frightened by the noisy, excited and defiant adolescents. He finally dared to go to a rock concert, but - at first - loudly disapproved of the way the other adolescents danced to the music. After a while, however Eric's own head was bobbing highest in the group of dancers in front of the stage. He came back from the concert, sweaty and with red cheeks, praising how good the concert had been. Soon afterwards, Eric agreed to play an electric guitar and drums with John. Rock-and-roll began to be played both during music therapy and on the ward. He needed the music therapist at first to share his longings for childhood until he was ready to discover a new dimension of sound belonging to the struggles of adolescence and was able to experience it in interaction with both the other adolescents and the music therapist.

Winnicott's idea of the relationship between psychotherapy and play is also well suited in adolescent music therapy: "Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of therapist. Psychotherapy has to do with two people playing together. The corollary of this is that where playing is not possible the work done by the therapist is directed towards bringing the patient from a state of not being able to play into state of being able to play" (Winnicott, 1971, p. 44) and ".only in playing is communication possible" (Winnicott, 1971, p. 63). The music therapist must be able to play with sounds and instruments, in other words, he must know the methods and instruments, but more important, he must posses an inner ability to be playful.

With creative illusion, a child begins to perceive the difference between the "me" and "not-me." That which remains with the child, via the transitional object, is not an object or a thing, a sound etc., but rather the ability to use symbols to represent something real, something experienced in the psyche. The transitional object and phenomena are needed in order to maintain the feeling that the base of our personality, the early interaction with its various aspects, is part of ourselves and will guarantee sufficient inner integration. As an experience, creative illusion is strong and real. It creates a feeling of certainty in the same way that the lack of a creative illusion causes a feeling of emptiness. "Even though the basis of creativity is a regressive fantasy, the latter stage of it, a shared illusion, is a real feeling" (Hägglund & Hägglund, 1985, p. 38). The transitional phenomenon is a gentle reality of early individuation and separation; in other words, a memory of the interaction, closeness and separation, as was described in Eric's case, above.

The Finnish folk melody "Aa-aa allin lasta" describes how tradition has treated the concept of "belonging" and "differentiation" in the form of a lullaby:

Ah-ah little duckling, little baby bird,
doesn't have a mother, doesn't have a father
to look after the little one.

Ah-ah little duckling, little baby bird,
does have a mother, does have a father
to look after the little one.

If the transitional world does not originate, even in favourable circumstances, it can indicate an early disturbance as in Tom's case.

Example 7

Tom had been brought into a children's home when he was a few months old and was placed in a foster home at the age of two. Tom was admitted for adolescent psychiatric treatment due to violent aggressive outbursts at thirteen years of age. Tom approached his peers by copying their youth culture styles with no idea of their inherent meaning, and very little of significance was ever born out of these attempts which might have been shared with others. Tom beat the drums and played guitar in music therapy for several years, even though very little that was original or shared ever came out of it. Playing never really progressed beyond the level of defence. Instead, his playing served primarily as an outlet for his libidinal aggression and destructive thoughts.

In one session (after many years of work) I was finally able to stop continuously trying to share a playing and noise-making with Tom, and simply sat down, wordless. Tom also stopped playing. As we sat, I felt as though we sat on a brittle roof very distant from each other with a cold wind blowing between us. For the first time something of that emptiness and coldness which he might have experienced as a child came out in transference. As I anxiously considered this experience, Tom stated calmly "Even you don't want me to stay on the ward..."

It was possible for us to share that silent moment after long and distressful work. After "killing"-banging on the drums, he was able to let down his massive defences for some time and share what's behind them; inner emptiness and desolation. I also did a great deal of work not only in sharing but also - before the session started - in protecting myself from his internal pain. That he could use words to doubt my ability to stand his anxiety was an important step in his development; a feeling of rejection was between us and he was able to talk about it.

In my work as a music therapist, I am not only looking for objects (an instrument, a song, music etc.), but for the world of personal creativity behind the object with the music as a media. Music created together, in enough freedom, will take us into that world in its own time, or obstacles for creativity will appear, as in Tom's case. Early damage to his personality meant a limited potential for creativity and a limited capacity to use the symbols necessary in development and in the psychotherapeutic communication. In music therapy, he communicated his early losses as noises of destruction, emptiness and chaos. In Tom's case it is easy to see how musical communication brought him again and again to childhood traumas and how difficult it was for him to reach adolescence developmental phases.

In favourable circumstances, adolescent music therapy enables us to get in touch with, and understand, the present stage of adolescent development as well as the different facets of the adolescent's early childhood development. There is a level of musical communication and state of mind which can not be translated into words but can only be communicated through music.

The significance of musical activity for earlier psychological organizations is derived from its capacity to allow subtle regression via extra verbal modes of psychological functions. It appears to contribute to the relief of primitive, preverbal tensions that have found little psychological representation and it may provide for the maintenance of archaic object cathexis by virtue of its relationship to an archaic, emotional form on communication (Kohut, 1957, p. 405).

Music Therapy and Team Work

An expert team can greatly benefit from music therapy, for example in the assessment of the degree of an adolescent's disturbance. Music therapy has a special significance in developing co-operation between adolescents, as well as between adolescents and adults. This must especially be taken into consideration when working with younger adolescents, withdrawn adolescents and adolescents who are unable or unwilling to co-operate.

Music therapy can aid the adolescent in getting in touch with youth culture, and this in turn helps them to create their own area in which they can share the fantasies and actions of their development phase, outside the control of adults. In their account of the development of an adolescent psychiatric team, Hyttinen & Tervo (1985) described how youth culture began to live on the ward along with the music therapy. "Youth culture helped us to understand what the building and maintaining of the generation gap means to an adolescent. It was also important to the staff that they recognized their own sex and adulthood" (p. 117). Music therapy can provide the adolescent psychiatric team with important information not otherwise available.

Music therapy is especially useful when it is given in conjunction with psychotherapy. In time, the interaction achieved through music therapy helps the adolescent to express his feelings verbally and in this way integrate this ability to express feelings into the personality as a whole. Those adolescents who have difficulties progressing in their adolescent process or those who behave anti-socially may receive great help in finding creativity, communication and close co-operation through music therapy. Music therapy may lead to a normative adolescence process and maturity in itself, or, if necessary, may motivate adolescents to begin psychotherapy later, or in conjunction with the music therapy.

Summing up

Creative therapy must find its content in creativity itself, even if the techniques and instruments used are from derived different art forms. Creativity is hidden neither in techniques nor in instruments, but rather in the fantasies connected with transitional phenomena. These fantasies originate in human relationships and in therapy in transference relationships. "Creativity cannot be taught in the same way as knowledge and skills. Our whole personality is involved in a certain developmental path, when creativity is allowed room" (Hägglund T-B, 1984, p. 139). Adolescent music therapy aims to promote adolescent growth and development. A multiplicity of musical experiences, the regression-progression position in adolescence and firm and reliable therapeutic relationship are an effective combination in aiming at that goal.

Adolescents usually have a good capacity to use this "musical regression in the service of adolescent growth and development" as I have named it applying Kris's (1953) expression "regression in the service of ego." "Whenever regression has to be avoided, the internal process is played out on the stage of present actualities. In that case, the adolescent externalizes and concretizes what he is unable to experience and tolerate internally as conflict, anxiety, guilt, and repression" (Blos, 1979, p. 1). There is no progression in adolescence without regression and without regression there is no creativity. It's possible to speculate why some adolescents might be able to face early childhood experiences of longing through music, although they might have experienced them as very unsatisfying. A great deal of analytical work is required before we can better understand this aspect of adolescent regression.

In the following list I will describe how the music therapy process may progress under favorable circumstances. I have came to these conclusions after working with adolescents on a psychoanalytic team for nearly 30 years both on the adolescent psychiatric ward and as a freelance music therapist. I find it very important for the music therapist to realize the length of time it usually takes to see and understand adolescent development, how adolescents use the music therapist and music and especially the nature of transference in adolescent development.

In music therapy, the progressive use of music and transference between the therapist and adolescent may typically take place as follows:

• Idealization of the music therapist
• The music therapist teaches the adolescent to play instruments. At first the therapist's main task is to help adolescent to cope with feeling of inadequacy. This is usually difficult in adolescence.
• Music as a phallic defence is created and shared and rock improvisation becomes possible. Music and active playing help to find a new connection with the body.
• Long interaction brings the elements of closeness to the forefront. Music is used as a means to get in touch with sexual excitement and aggression. The adolescent may be afraid of it and try to leave the therapist.
• The therapist maintains the therapeutic contract. Music turns to be more intense and contains elements of the expression of anger and rage.
• Close co-operation enables feelings which are expressed not only in the music but also very intensely between the adolescent and the therapist. This can be very painful for subjects with a traumatic background. The fear of rejection by the therapist may be very intense.
• This will be projected to the therapist and the adolescent tries to "kill" the therapist (who represents early identifications) through music; "musical fights" take place or the adolescence tries even harder than before to irritate the therapist or to leave him.
• These fights later take place in "reality" not only on the symbolic level of music. The music therapist is deeply involved in these experiences of transference and counter-transference.
• If the therapist can stand this, aggression becomes part of the communication and is then shared and symbolized in music.
• This leads to mutual trust, which has now been tested. Improvisation achieves levels of creativity varying from deep sorrow to rage. In Winnicott's (1971, pp. 119) words: "continuity is giving place to contiguity".
• The music calms down with elements of sorrow which lives between the therapist and the adolescent. Phallic music is also used as a means of disguising closeness and coping with aggression and sexual impulses, but used only when needed. The capacity to use musical symbols leads to better touch for emotions, body functions and for the symbolization of words.
• Getting in touch with inner sorrow and mourning means creativity, as T-B Hägglund has pointed out in his studies (1974, 1976). Creative integration becomes possible; early childhood experiences and adolescence progress merge and an age-appropriate present and future are opened up.

During music therapy, the patient will first regard the therapist as an idealized object, later as a sensitive, caring mother / severe father and finally as a partner on the therapeutic journey. As the therapy draws to a close, the therapist will have been integrated and become an internal object and can then be left through a process of grief and sorrow. Music may remain as a means to achieve transitional experiences.

Music therapy can progress further than an art experience by itself because the therapeutic relationship allows us to share experiences, actions and fantasies. In my opinion, music therapy - as described above - can be placed as somewhere between psychotherapy and art; it receives its tools and language from music but it takes its clinical working methods, theoretical viewpoints and its aims from the concepts of psychoanalytic psychotherapy.

This paper leaves many important questions open for future research. In particular how can music therapy help in serious disturbances such as psychosis in adolescence? I'm convinced that it can provide new perspectives in the treatment of asocial adolescents with serious difficulties in finding their capacity to co-operation and personal creativity.

The reason I find my work very rewarding is that the potentiality for creativity is very strong in adolescence. In this contest creativity means "good-enough" capability to experience emotions in ones own mind and body which will lead a better integration of the maturing sexual body. Creativity also opens up possibilities to express feelings and tensions spontaneously via non-destructive media, to share internal fantasies and to join the age-mates. Creativity in itself represents growth and development.

In practice, adolescent music therapy should be regular, intensive and usually long term. To carry out music therapy in this manner, one should be well trained, have a broad knowledge and experience of adolescent growth and development, as well as knowledge of other treatment methods, for example psychotherapy. The possibility for team work and supervision is also necessary.

Closing Words

In the end of my paper I shall return to the case of John and to the song of "The House of The Rising Sun." The song contains many elements which touched John personally in the transference; he lost his mother at the age of 5 and his father tried to commit suicide. But the song is also full of images of adolescence in general; there is longing for an idealized mother and an image of a father who is no good and distant. The result is that they can no longer be used for growth and development as they were in childhood. The song can be played in many ways; as melancholy blues ballad or it may turn at times into a loud, creeping and dark heavy-metal version, and everything between. An internal surrender of one's childhood parents takes place in "The House of The Rising Sun," a place where the new day of hope and personal future may rise through mourning. But "The House of The Rising Sun" is also full of sexuality; it is a song about a whore house. The adolescent can no longer let his mother build up his body, as she did earlier when she "sewed my new blue jeans." The ambivalence of leaving (the second separation) is evident: "one foot on the platform, the other foot on the train..." This is the essence of adolescence.

Acknowledgement

I'm grateful to psychoanalyst Donald L. Campbell for his great help in finishing this paper. All psychoanalysts mentioned in this paper are members of International Psychoanalytic Association (IPA).

Notes

[1] All names and details of the youngsters' background are changed to protect their intimacy.

[2] This is an old traditional folk song recorded by many artists. The most popular performance is a version of Eric Burdon and The Animals from 1964.

[3] Recorded by the Finnish rock trio Hurriganes (oh yes it's written with g, don't ask me why) 1974. The original name is "I'll Stay by Your Side" by T. Lundgreen and J. Lundgreen, recorded by The Lollipops in 1964.

[4] See also Daniel Stern; The Interpersonal World of the Infant (1985).

[5] The general feeling of inhabiting one's body that arises from multiple stimuli from various bodily organs.

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