She Looks so Beautiful
We reach and touch each other
Sharing a moment of ecstasy
As the light of spiritual truth
Enters that Holy place
Deep within
Peace that surpasses all
Love that knows no boundaries
And then we move on.
(Unknown Source, taken from The South African journal of Natural Medicine, 2008 Issue 37)
Introduction
The observation: "She looks so beautiful," would normally be made when looking at someone who is physically attractive, possibly dressed in an outfit for a Matric Dance, sporting a new hairstyle after a visit to a salon or by a parent watching over their sleeping child. Whatever the context, you would not expect to hear these words when looking at a self-mutilating, psychiatric client who has taken out her pain and frustration on her body to an extent where she is bandaged, bloodied and swollen. These were, however, the words uttered by Nonhlanhla, a care-worker, during my last music therapy session with Angelica[1].
The Client
Angelica, aged 34, was a client at the Residential Home for the Profoundly Intellectually and Physically Disabled where I have been working for five years. She was housed in the "psychiatric section" of the home which caters for the dual diagnosis of mental illness as well as intellectual disability. This section is separate from the rest of the residents, as this group of 40 residents are prone to endanger themselves and others. There are instances of residents within this group becoming psychotic and most are very heavily medicated.
Angelica caught my attention from the outset. Her hands were always bound behind her back and she never made eye contact. She always kept to herself, sitting in a corner on the floor, away from the rest of the group. She did not respond to anything I offered during group music therapy sessions. When I enquired as to why her hands were tied, the nursing sister on duty explained that Angelica was severely self-injurious. The state psychiatrist had recommended that her hands be tied after she had almost succeeded in severing one of her ears.
On entering the psychiatric section in November 2007, I was very shocked to find that Angelica’s head was thickly bandaged and her eyes were swollen shut. She had repeatedly smashed her head against a wall to the point where her head became a bloodied mess. The dosages of her medication had already been elevated to the maximum in order to minimise her destructive behaviour and alleviate her discomfort. This posed the question: "What next?" I decided to offer Angelica individual therapy. I thought at the time that she might benefit more from sessions when taken out of the bigger group, which she did not seem to be part of.
The Sessions
The first phase of my individual work with Angelica was exhausting and exasperating. I tried everything I could think of to elicit a response from her. A care-worker always accompanied her to sessions. We untied Angelica’s hands so that she could play an instrument. This was disastrous as she immediately started scratching herself. Angelica’s participation with instruments was impossible with her hands bound and vocalisation was non-existent. In the second phase of our work together, Angelica still did not participate, but started to look at me once or twice as if to say "I know what you are trying to do, but I am not interested."
As our sessions progressed, we moved into a third phase where I noted an increased sense of agitation and discomfort from Angelica. She tried unsuccessfully to move her chair towards the wall. When I enquired about this, the nursing staff confirmed that she does this in order to bump her head repeatedly against the wall. For the most part, our sessions seemed to benefit the care-workers more than Angelica as they got a half hour "time-out" from the ward. They seemed more relaxed after each session which made the sessions not feel like a total waste of time. This did not make me feel any better though, as I felt I was not yet able to reach and mean something to Angelica.
The next two sessions were gruelling as Angelica had reached a stage outside the sessions where she was trying to inflict pain on every possible part of her body. Her shins were bloodied as she scraped them with her shoes. They were then bandaged to stop her from reaching them. She still tried and blood was oozing through. Her eyes were swollen as she bumped herself against walls when staff weren’t watching. During our sessions, she started crying with a deep rooted quality of pain which resonated deep inside of me. Everyone, including myself, seemed to feel powerless as to what to do next as Angelica’s medication had reached a ceiling. One of the staff nurses broke down in her shift as she could no longer cope with the crying and the blood flowing from this very tormented body.
On the day of our "breakthrough" session, Angelica came in a wheelchair and looked absolutely dreadful. She was bandaged from head to toe and her face was swollen, with blood seeping through the bandages. My gut response was that I did not have the stomach or strength for this and that there would be no point in this session. Before I could communicate my feelings to the care-worker, however, Angelica was wheeled into the room and the door was closed. The decision had been made for me and I would have to continue. I immediately dimmed the lights because I honestly felt queasy at the sight of the blood, but also to soften the atmosphere in the room. I felt as if I was on "auto-pilot" and had no idea how I was going to proceed or even what I was going to do in the session. All I had was an overriding intention of wanting to make a difference, even if this was just a brief respite to Angelica’s torment on the day, at the time.
I motioned to the care-worker, Nonhlanhla, to take a set of bongo drums on a stand, while I started humming, strumming softly on the guitar. I looked up, almost in relief, as Nonhlanhla immediately tuned into the rhythm of my strumming. The quality of her playing on the bongos matched my strumming perfectly in tempo, dynamic and energy. I started vocalising vowel sounds after a while and we improvised in this manner for a few minutes. Angelica started getting very agitated, crying with the same deep-rooted pain of previous sessions. Nonhlanhla and I carried on in our subdued manner to provide a musical container for her. In retrospect, this also enabled us to be with Angelica in this state. Angelica’s crying and agitation became louder and more visceral and we instinctively tuned into this, without looking at each other for cues. Our music became louder and more intense to provide continued support for Angelica’s intense feelings of pain. I suddenly felt an overwhelming need to cry and my voice quivered while I was singing. I looked up to find Nonhlanhla’s eyes swimming. The quality of Angelicas crying intensified, as we increased the quality of our music to a climactic bursting point. She suddenly stopped crying and became very still. I closed my eyes for a moment and heard Nonhlanhla say very softly: "She looks so beautiful". When I opened my eyes, I was surprised to find Angelica’s eyes open and intensely blue. Her expression had a softness and gentleness which was far removed from the pain she exhibited before. She almost seemed to be smiling. I reverted back to humming as I did in the first part of the session while Nonhlanhla provided a soft beat. After another minute or so we instinctively faded out together. We sat in silence, experiencing the calm for a while. As she was wheeled out, I made a mental note of the marked difference in Angelica when she left the music therapy room in a calm state as compared to the agitated state that she had arrived in.
When I was alone in the room, I had a premonition that this would be my last session with Angelica. This was confirmed when she passed away five days later, due to the severe head injuries she sustained after banging her head for the final time.
The Care-Worker
Nonhlanhla, aged 32, lives in a squatter community and is the only member of her family that has a permanent income. Like many of her colleagues, Nonhlanhla has to battle daily with the realities of a soaring cost of living, keeping dry in a rain-soaked squatter camp and fearing for her life when arriving home after dark. To step into the role of care-worker where the physical and emotional demands are often strenuous and repetitive cannot be easy when there is so much need at home.
Reflections
Nonhlanhla’s Experience
Nonhlanhla and I did not have an opportunity to reflect on this last session and she went off duty the next day. I later realised the extent to which the session had impacted on her when she came back on shift the day before Angelica died. We were conducting a workshop for staff on dealing with "challenging behaviour", when Nonhlanhla got up to talk about her experience. She told the group that on the morning of the session, she had tried to dress Angelica, who was fighting her every effort. She was screaming, kicking and crying when Nonhlanhla decided to put her in the wheelchair for her music therapy session. Everyone in her section seemed to sigh of relief as she was removed. At the time, Nonhlanhla questioned whether she was doing the right thing because Angelica continued to be distressed. The ride in the wheelchair, which is quite a distance from her section to my room, seemed to calm her a bit.
Nonhlanhla’s first language is SiSwati but her command of English is adequate. She explained in a very endearing manner how the music that we made stirred her inside and how Angelica became first very sad and then very calm. She said that afterwards she told her own mother that my music had power and that it made Angelica calm. I corrected her and said that our music had power and that we together provided much needed support and containment for Angelica on that day.
I urged Nonhlanhla to write about her experience as I realised it would help her in processing what had happened in the session. It was also of value to me as I did not record the session. She gave me a three page document and I once again realised how deeply moved she was by the experience. The following excerpt is part of her reflection:
When I was alone I was thinking about what happened in the music room that was the experience of a lifetime. We were all connecting to each other. We clicked.
The Music
When I think back to the beginning of this session and compare it to the end, I realise once again the power of music and its ability to transcend our physical reality. I had dimmed the lights because I found it difficult to face the swollen, bloodied Angelica. Towards the end I did not see that which I could not stomach initially. Through the music I was able to reach Angelica’s humanity and beauty. The music enabled us to connect, to "click". I was also reminded that as therapists we sometimes get too focused on wanting a visible response from our clients. When we stop trying so hard and just offer our compassion and support through the music, a shift often occurs.
My singing and vocalisation in the session started off with universal humming and "oo-ing" sounds which are well documented as sounds that mothers and caregivers use for calming and soothing their babies. This was done in a pentatonic key which is more open-ended and enables the singer to carry on for an extended period without a necessary resolution. This open-ended quality of the music provided a platform for Nonhlanhla and I to find each other in the music and connect in order to provide support for Angelica and each other. Once we had established a mutual ground through the pentatonic scale, we were able to move to the ebb and flow of major and minor tonalities to match the increasing intensity of Angelica’s crying.
It struck me that Nonhlanhla remembered me switching from singing in English to Afrikaans. Nonhlanhla noted that it was at this moment that Angelica looked up and for the first time in the session, made eye-contact. I could not find any reason to have switched to Afrikaans at the time. Perhaps I did this because Angelica has an Afrikaans name (Angelica is not her real name). Though she had been abandoned at birth and spent her infant years in a sanctuary for orphaned babies, she might have originally come from an Afrikaans family. At the risk of sounding presumptuous, it is possible that at some point in time, perhaps in utero or early infancy, someone had spoken to her gently in Afrikaans and the sound of this language thus provided comfort to her. The switch to Afrikaans appeared to have brought about a shift in Angelica and she became very calm. Leading to this point, the music had provided an outlet and support for her expression of pain and suffering.
By trusting each other and the music, Nonhlanhla and I were able to venture out into unexplored areas, for example singing in Afrikaans. Although Nonhlanhla did not necessarily understand the words, she was able to give sustained rhythmical support and showed sensitivity to tempo and dynamic changes in the music. The fact that she could not understand the language did not interfere with her playing: in contrast, it heightened her sensitivity to Angelica, noting her calmness and how beautiful she looked.
Conclusion
There is a lot that I can analyse, contextualise and theorise about this session on an interpersonal, musical and spiritual level. Perhaps I will do that at a later stage. For now, this story has once again highlighted the power of music to transcend difference and pain, to become a vehicle for expression of our innermost turmoil and distress.
At the start of my last session with Angelica, I felt unsure, not knowing how I would proceed or what I was going to do. All I was clear on was the intention of wanting to mean something to her on that day. My experience was that when I lost "control" of the conscious therapeutic process, I was opened up to a much deeper and more meaningful unconscious, non-verbal communication between client, careworker and therapist. Whilst I do not fully comprehend how this unconscious communication functions, through music I have experienced the power that this communication holds to provide a client with the necessary shift that they need to move beyond their physical discomfort.
I am also humbled by the insight and compassion of Nonhlanhla. To rise above her onerous personal conditions to be able to provide the support and compassion that she did in our session, gives me immense hope for this country where there is increasing negativity at the moment. It also gives me renewed faith in what our profession and the medium of music can offer, despite our constant struggles to prove and validate what it is we do.
To Angelica: Thank you for allowing us in, God Bless your soul.
Figure 1. Excerpt from Nonhlanhlas’ letter
Notes
[1]This client’s name has been changed to protect her confidentiality.
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