Bridging Music and Psychoanalytic Therapy
Introduction
This paper represents an attempt to separate, differentiate and meaningfully integrate two aspects of my personal and professional identities; musician and therapist. For 25 years I have merged these into the work of a music therapist, for the most part with dying hospitalized patients and their loved ones. My music therapy work has mined the rich affective, expressive, and soothing potential of music to elicit meaning and improve the quality of life of individuals facing death and dying. It is good work, yet at times music therapy has also felt like a compromise formation; not fully musician, not fully psychotherapist. While training in psychoanalytic psychotherapy increasingly informs my music therapy work, I suspect the opposite is also true; a life-long involvement with music and a long career in palliative care as a music therapist must similarly inform my psychotherapy work.
The "bridge" in "Bridging Music and Psychoanalytic Therapy" implies a connective space between two separate identities, symbolizing perhaps my ambivalent wish to both de-merge and sustain the two. In musical composition, however, a bridge passage is essentially integrative. According to the Harvard Dictionary of Music it serves "...to connect two themes." (Apel, 1972, p.112). In this paper I identify and explore five characteristics common to both music and psychoanalytic therapy, consider contributions from psychodynamic music therapy, and draw upon my own clinical experience as both music therapist and psychotherapist. Where the terms psychotherapy or psychotherapist are used in this context, a psychoanalytic orientation is to be assumed.
Music and Psychoanalysis
There are inherent difficulties in attempting to articulate that which is nonverbal, both in music and psychotherapy. One risks being reductive and doing injustice to the complex gestalt of each discipline. While music is a universal phenomenon, integral to all cultures throughout humanity, it remains impossible to fully capture the essence of music in words. Perhaps, as some authors have suggested, the difficulty in talking about music is due to its ability to reach "preverbal levels of human memory and to evoke the earliest forms of experience." (Noy, 1993, p.137). Gilbert Rose, (2004), elaborates that these preverbal internalizations "embody and encode affective memories that contribute to affect regulation" (p. 129). Alexander Stein (1999) describes music as
a primary process experience which defies absolute comprehension or satisfactory secondary elaboration... By naming the feelings felt while listening to music through a process of analogy and symbolization, we effectively translate the feeling into something else (Stein, 1999, p. 401).
Nonetheless language is what we have and the hope remains that by teasing out and linking threads common to the two, some further understanding will be gained.
Freud, who outwardly rejected music and insisted that he had an acoustic atrophy, also acknowledged his resistance to "being moved by a thing without knowing why I am thus affected and what it is that affects me" (Freud, 1914a, p. 211, cited in Cheshire, 1996, p.1131). Cheshire explores Freud's "problem with music", suggesting that in fact he was highly sensitive to music (Freud did admit to enjoying certain operas), but deeply conflicted due to early associations between music and a beloved nanny who left the family unexpectedly.
In contrast, Jung asserted that creative activity and active imagination could engage a healing power residing in the unconscious. Jung became interested in music late in life and wrote:
Music expresses, in some way, the movement of the feelings ... that cling to the unconscious processes... music represents the movement, development, and transformation of the motifs of the collective unconscious (Jung, 1973, p. 542 in Skar, 2002, p.632).
Indeed, motion and emotion are inseparably linked in music. Music is the movement of sound through time. We move to music and music moves us – to tears, to war, to states of reverence or joy.
In 1950, Heinz Kohut wrote about music from a classical drive theory point of view, arguing that the listener's ego tries to defensively master frightening auditory stimuli by organizing and attributing meaning to it. Emotions were deemed to be the by-products of that organizing activity (Stein, 1999, p.397). Other early theorists suggested a more direct link between music and human feeling. Suzanne Langer claimed that "music is a tonal analogy of emotive life" (Langer in Noy, 1993, p.127) and Carol Pratt similarly asserted: "music sounds the way emotion feels" (Pratt in Noy, 1993, p.127).
There has been growing interest in music and psychoanalysis over the years, with an increase in meetings, books and scholarly articles on the topic. A recent bibliography found on the internet includes over 800 citations (The Mind and Music Project, 2007). The writings reflect various perspectives; that of comparing jazz improvisation to free association (Rosenbloom in Raeburn, 2004), the study of musical compositions in respect to the mental life of their composers, considerations of affect, communication, creativity, and so on.
More recently, Stein (2004b) conceptualized the interaction between music and the listener as an object relation, comprising the totality of mental life:
An encounter with music triggers complex intrapsychic events or responses. The aesthetic/emotional gestalt experience of music's effects within us, then, can be generally understood as comprising perceptions, distortions, and condensations of time and memory, as well as archaically derivative fantasies, defences, and modes of internalizing, expressing, and responding to affects, all operating within an abstract primary process mode of registering, construing, constructing and reconstructing experience (Stein, 2004b, p.790).
The mind's ear is a fertile locus of interior listening where mental functioning can be translated into conjured sound having symbolic significance (Ibid, p. 802).
Common Characteristics of Music and Psychoanalytic Therapy
Music and psychoanalytic therapy do share certain characteristics. Listening is of primordial importance to both. Also, the boundaries and fluidity of time are central to each process. Both music and psychoanalytic therapy serve to contain and express emotion – they are affect-laden, and both may facilitate mourning. Finally, both are inherently creative, incorporating notions of play in the work.
Listening
Central to both musician and psychotherapist must be the capacity for engaged, attuned listening; to the form, content and feeling of the material, be it a piece of music or a client's narrative. Where does one hear consonant harmonies of ego strength, dissonances and tensions which call for resolution? What are the recurring themes and how are they elaborated? When are the variations of repetition compulsion being heard? The analytic therapist, like the musician, listens simultaneously on many levels; affective and cognitive, intra and interpersonal, focussed and floating, with an "evenly-hovering attention", or as Theodore Reik proposed, with one's "third ear." This kind of listening is "marked by oscillation between the conscious and unconscious labours of the intellect and imagination" (Reik in 1948, cited in Stein,1999, p.402). Further, it is through the capacity to listen deeply and tolerate the atonality, discord, "wrong notes" and silences that we come to better understand our clients' struggles.
Clients, of course, listen too, and many are exquisitely sensitive to the therapist's vocal timbre and inflection as they are to other nonverbal communications. Boyer (1992) relates two accounts of regressed patients hearing his voice as music. One "ascribed her improvement to the introjection of my 'sweet, purring voice' that 'babied' her in her mind and said also 'I don't care what you say, I just listen to the music'" (p.56). Boyer likens this to the infant's perception of contours in pitch which enable him to identify and respond to his mother's voice.
Indeed, a baby's cries quickly takes on a communicative function, calling for attention, care and contact. Lullabies, with their slow rocking rhythms, may help to create the feeling of infant-mother oneness and serve to form lasting imprints of safety. Caregivers cooing, laughing, and chanting of children's play songs often serve to safely draw the infant into a wider world of experience. These early communications, based in large part on sound, song and intonation, carry messages of affect and degree of attunement.
Stein (1999) uses the analogy of harmonic overtones – unheard acoustical frequencies which give tones their resonance – to elucidate the essence of listening in the analytic situation:
The music, then, is only sound, but becomes feeling by virtue of the harmonic overtones – what we hear is not what is said but what is implied. In the analytic frame, it falls to the analyst to assist in the process of decoding the hieroglyphs in listening to the analysand's (re-)telling of archaic experience, that is to say, to hear the feeling, not the sounds (Stein, 1999, p. 410).
Time
Music is intangible and ethereal, consisting of successive tones and silences moving through time. Sounds appear and disappear, one into the next. It occurs in the present and moves toward the future, yet music can also alter the perception of time, making it seem to fly, last forever, or even stand still. As in a psychotherapy session, vivid memories, associations, and feelings may be evoked; even giving one the powerful impression of returning to earlier times (Salmon, 1993, Stein 2004a). This capacity to condense and transform perceptions of time, place and state is also a feature of dreams, which themselves provide a window into the unconscious mind. Both a piece of music and a psychotherapy session are bound by a fixed amount of time which itself helps to create the containing frame within which time may be experienced as boundless.
Affect
Emotion and meaning are germane to both music and psychoanalytic therapy. Creating meaning from a wide range of feeling states; ambivalent, conflicted, manifest or hidden; and understanding how these express themselves in the life of the client is the work of psychotherapy. Music encodes affect in its melodies, rhythms and harmonies. It also serves to express a wide range of feeling states, even suggesting diverse emotions simultaneously (e.g.: a yearning melody soaring over a light waltz accompaniment). And like psychotherapy, music can function as a container for intense feeling
Akin to dream work, music elicits images and may give voice in a disguised but more palatable form to impulses or emotions too unsavoury to allow into conscious awareness. As in the psychotherapeutic process, one may sense relief, solace or greater freedom as the feelings are expressed, projected, contained, and survived.
Mourning
Music has a remarkable capacity to both elicit grief and provide solace, even doing so simultaneously. In palliative care music therapy one regularly witnesses the bitter-sweetness of patients choosing and hearing songs which invoke both attachment and loss. Tears may flow during the music, there is a sensation of coming apart, and then re-grouping, regaining a sense of calm and organization as the music ends. In psychotherapy too, the tasks of mourning and re-grouping are essential to growth, with the therapist facilitating the process in part by maintaining an environment where the complex emotions of mourning and solace can be held, experienced and worked-through.
By fusing with certain music, in particular music which evokes a state of rest, peace or timelessness, one may regress into a sense of oceanic oneness with "mother", so that one's internal experience is that of being temporarily held, understood, and consoled (Stein, 2004b p.807). This facilitates a recuperation of ego functioning, however transient, which had been diminished, split off or fragmented in response to loss or trauma. Rose (2004) adds that when the ego's integrative function is deficient, as in mourning, the arts may act as an external auxiliary ego, lending support to the continuous task of integration (p.119).
Creativity and Play
Psychotherapy can be conceived of as an ongoing act of composition between therapist and client. The psychoanalytic therapist listens to the client as well as to his/her own resonating inner responses while engaging in improvising in the creative space of the therapeutic encounter. Perhaps more analogous to musicians in a jazz combo, the psychotherapist co-creates meaning with the client, "playing" in the therapeutic work of associations, patterns and diversions from them, blue notes, bent notes, jagged syncopations and unexpected elaborations of the tune. The practice of psychotherapy is highly creative, calling on the therapist to be flexible and improvisatory.
Being a separate "other", the therapist provides accompaniment through empathic presence; promotes understanding and awareness by reflecting the client's leitmotifs, strengths and struggles; co-creates experiences of harmony or dissonance through interpretation and working in the transference; and offers counterpoint in holding a different perspective on what might be possible. The creativity of the psychotherapist's work, like that of the jazz musician's play, requires a capacity to tolerate, even relish the arousal and uncertainty of exploration...and both must be acutely attuned and responsive to the other's contributions.
Winnicott has contributed to our understanding of creativity in therapy through his concept of "potential space" between therapist and client in which, through "play", one acquires a sustained sense of subjectivity and agency in the world (Pavlicevic, 1997). This act of playing develops the capacity to perceive the world both subjectively and objectively, to distinguish illusion from reality, and to acknowledge the interplay between our inner and outer worlds. As we shall see below, these concepts inform musical play in music therapy.
Contributions from Music Therapy
Two of the most established psychodynamic music therapy models are Guided Imagery in Music and Analytic Music Therapy. The former, originally developed by Helen Bonny (1973) involves the client listening to carefully selected pieces of classical music in a deeply relaxed state and relaying his/her associations, images, feelings and/or physical sensations to the therapist. Unconscious material is often revealed through these dreamlike sessions which is then processed verbally and/or through other art mediums. A detailed discussion of powerful approach is outside the realm of this paper.
Analytic Music Therapy, developed by the British music therapist Mary Priestley (1975, 1994), is based on clinical improvisation, where the therapist and client create music together and both the instruments and the music itself can be understood as transitional objects, holding projections of the client's inner state. Pavlicevic (1997) describes the process as follows:
When a music therapist and patient are able to create a shared musical space between them, within which both express themselves by playing, then an intimate and dynamic intersubjective relationship is possible.... (This) is an act of playing in the Winnicottian sense... Together, through a highly spontaneous interchange of musical phrases and rhythmic patterns, the therapist and client negotiate how the musical space is to be used between them, while at the same time continuing to create and extend it (Pavlicevic, 1997, p. 151).
Patricia Skar (2002), a Jungian analyst and pianist with training in clinical improvisation, notes that playing instruments allows some clients to experience feelings and physical sensations more freely and to express certain emotions, such as anger, without guilt.
[Clinical improvisation] frees the energy formerly bound up in the unconscious symbols and makes it available for conscious use... words are often [then] more readily accessible (Skar, 2002, p. 635).
In fact the use of words in music therapy has been a point of controversy, with some believing that the music therapist's response to the client should remain purely within the music itself (Ansdell, 1995 in Pavlicevic, 1997, p. 157). Paul Nolan (2005) distinguishes between "the musically-experienced self" and the "verbally-experienced self", stating that "the musical self often reflects a higher functioning person than the verbally-expressed self." He nonetheless supports verbal processing of the musical experience proposing that a main goal of verbalization is "to help further integrate these two experiences of the self" (p. 22).
Benedikte Scheiby, another analytic music therapist, asserts that "we can actually listen to the unconscious – manifest in the form of music – [and]... one of the roles of the music therapist could be to help clients translate unconscious processes... into conscious ones" (2005, p. 9). Skar adds that unconscious material which emerges in clinical improvisation "can be a powerful form of communication, deepening the relationship between (therapist and client) and opening new pathways for the process of individuation" (2002, p.636).
Engaging in musical creation with clients is a highly subjective and intersubjective endeavour, and one must be prepared to work with emergent transference and countertransference material. Scheiby embraces an intersubjective approach: "The music in music therapy is a joint creation and so therapists should ... [look] at how musical countertransference techniques can be helpful for the music therapist in the treatment process." (p. 10).
Music is powerful and music therapy can also be seductive in its nurturing and gratifying potential... both for therapist and client. One might be wary of assertions that music can bypass defences, reach the unconscious, and perform integrative magic. When the therapist's own direct expression, with its inherent hopes, desires, and needs, gets thrown into the musical creation, therapy can become murky. What belongs to the client, what to the therapist, and what to the therapeutic couple in this co-creation? Music therapists are increasingly addressing countertransference issues, musical and otherwise, and attempting to study the phenomena (Dillard, 2006). Supervision, clinical training, one's own therapy and a capacity for reflective thinking all contribute to helping therapists recognize and use both transference and countertransference phenomena.
Clinical vignettes
What follows are two clinical vignettes involving music. The first illustrates how psychoanalytic thinking may inform music therapy work in palliative care. The second shows the spontaneous use of a song facilitating mourning and intimacy with a verbal psychotherapy client. In both vignettes, the identities and certain details have been altered to protect confidentiality.
Mrs. H.
It was my first meeting with Mrs. H., an emotional, alert 79 yrs. old bed-ridden patient on the Palliative Care Unit. During our visit she wept and despaired at what she described as a loss of culture and predominance of destruction in society. She then requested two dramatic pieces of music; the Kol Nidre; a solemn Jewish prayer of atonement, and Bach's Tocatta and Fugue in D minor. She never spoke of her painful and conflicted family relationships or of her approaching death. She rather seemed to project her pain outward, resonating with the suffering and injustice of the external world.
Admittedly feeling somewhat taken-aback by the intensity of Mrs. H's emotion, I also wondered if her failing body could sustain the energy of her ranting. Was it best to meet her there or attempt to calm her? Further, I didn't have those pieces of music immediately at hand and wanted to make a musical contact. I offered to play a solo Bach piece on my flute (the Sarabande in A minor), one which is at once melancholic and intellectual, like the patient before me. My goal was to establish rapport with her through music, and to assess her response to the music. She became completely calm during the Bach piece, and expressed appreciation for the beauty in the music.
The following week, I brought in excellent recordings of both requests. Her daughter was present and as Mrs. H. listened she reached for our hands. She raged, wept and marvelled at the genius and beauty possible in this terrible, unjust world. "This is rageful music", she roared during the Bach, "It is a weapon!" And of the Kol Nidre, "this is the cry of the heart!" The music seemed to contain, mirror and affirm her intense emotion – some mix of rage, impotence and suffering, the history of which I will never know. She seemed to me to be held in a kind of rapturous suffering.
Her daughter then read a letter she had written, expressing adoration for her mother. Mrs. H. dismissingly silenced her: "that is a selfish letter... now let your mother speak." Then she told the story of being a small girl, bringing flowers, purchased by her father, to her mother. "My father had me write a note", she said, "saying 'this is a gift from God, delivered by your wise little prophet." "I am the god-sent child with a precious gift for my parent", she seemed to be saying to her daughter, "and you are nothing!" I was aware of a tightening inside me; I experienced her as narcissistic, hostile, and regressed and was aware that this countertransference response might have something to do with my own experiences of being a mother and daughter. At the same time, I saw before me a dying woman struggling with a fragmented sense of chaos and destruction. I wondered if the childhood memory of her loving parents, possibly evoked by the ancient Kol Nidre prayer, served to provide, at least momentarily, a wished-for sense of wholeness and safety. As a music therapist, coming into this complex family at the end of Mrs. H's life, I knew well that my impact was limited. I was grateful for the music, which could provide a powerful affective vehicle, enabling me to stay with and tolerate her intense emotionality.
My third and final visit to Mrs. H occurred almost a week later. She was semi-comatose, medicated, in a deep sleep. Her daughter welcomed me and accepted my offer of live music, requesting "nothing too light or relaxing, she hated that!" I played the Kol Nidre – this time on my flute – a gentler sound than that of the operatic version on the recording, single melody without words, but the same lamenting tune. My hope was to acknowledge something of her essence, wherever she might be in her consciousness. Unable to respond verbally, Mrs. H still appeared to hear the music, squeezing her tearful daughter's hand. I offered the Bach "Sarabande" which Mrs. H had previously enjoyed, beautiful in the coherence of its balanced architecture; a winding minor melody followed by its contrapuntal elaboration, then the comforting return of the original melody. Here the music served several functions; it created a physical, auditory and affective link between mother and daughter, it elicited and contained the daughter's grief, it seemed to symbolize layers of meaning, and it soothed.
The emotions accompanying trauma are a complex mixture. Rage and helplessness are central, including rage at feeling helpless and unable to trust one's own body and mind to see one through and continue to feel whole. The various ways in which the ensuing crisis is expressed are unique to the individual (Rose, 2004, p. 120).
Mrs. H's somewhat grandiose angst at the suffering of the world, with her concurrent avoidance of her personal crisis was unique to her. The music she chose mirrored and held her emotional state (as would a "good-enough" mother) and seemed to provide some modicum of comfort. It further helped this therapist to understand something of the quality of her internal experience.
"Tom"
Tom, 30 yrs. old, came into psychotherapy with relationship issues; his great need for autonomy impeded his ability to sustain a committed relationship with the woman he loved. Tom had been the only child of a single mother. His father left when he was a baby. His mother adored him but worked full-time, often leaving Tom with his elderly grandmother or to fend for himself. He became self-sufficient at an early age.
Tom's mother had died four years prior to him entering therapy and although he missed her, he felt that he had grieved this loss. Tom used writing, drawing and guitar-playing as expressive outlets, but sensed that he needed to speak with another person at this juncture. He loved to hike and bicycle alone, had many friends but trusted few, and fiercely guarded his independence in all facets of his life. With his girlfriend, Tom alternated between periods of intense intimacy and times of distance and withdrawal. This was mirrored in therapy where he'd bare his soul, then cancel a session or suddenly talk about ending therapy. We began to understand how frightened he was by feelings of intimacy and emotional dependence, as he had been unable to count on having emotional needs met as a youngster.
In a session after Mother's Day, Tom described how he had chosen to spend the day alone, hiking in the mountains. During that session I kept hearing in my own mind the refrain from the plaintive spiritual "Sometimes I feel like a motherless child...", and eventually shared this with Tom. He brightened and reported: "I sang that the whole day as I was hiking!" The next week Tom brought in his guitar to sing and play for me his version of the song. Something shifted in the therapy at that point and Tom became more able to explore his fear of dependence, vulnerability and loss, including his fear of becoming dependent on me for emotional support. In the following year, Tom became increasingly able to sustain intimacy in his relationship, eventually proposing marriage to his girlfriend and ending therapy.
In this example, I believe the song contained a split-off part of Tom's psyche; a lonely boy, abandoned by his father, yearning for his mother, yet needing to be strong and independent far too young. The song held the condensed lament of the both the "parentless child" of Tom's boyhood and of his adult self grieving the real loss of his mother. The repetition of the lyrics "sometimes I feel like a motherless child" in the song, and Tom's repetition of the song itself while hiking alone on Mother's Day provided a means of self-soothing, paradoxically feeling like a motherless child while connecting with an internalized sense of comforting mother. Rose (2004) contributes the following on singing to oneself:
Drawing comfort from being both singer and listener – single but not "alone" – permits an analytic inference: it likely taps into the primal safety of an early precursor, namely, the infant-caretaker pair. In that dual unity, mutually responsive cooing and expressive vocalization between the two partners long antedated verbalization and being able to distinguish oneself from a loving Other (Rose, 2004, p. 115).
In intuitively sensing this song, I communicated an empathic attunement to Tom's affective state, evocative of the well-attuned aspects he may have experienced in the infant-mother bond. Tom then sang the song to me, risking sharing the tenor of his pain with another (symbolically another mother) who did not need him to be a strong little man. This seemed to help him connect to his internalized loving mother, to grieve the loss of her, both past and present, and to risk reinvesting in love and life. In the safety of the therapeutic relationship and partly through the expressive venue of this song, Tom began to reintegrate his split off vulnerable self enabling him to achieve greater intimacy in his relationship.
Music in mourning proposes a creative solution to an intolerable reality (and its consequent affects)... Music consoles... in temporarily relieving or diminishing feelings of pain by providing an illusory response ensconced in rhythm and sound to the dominant wish of the bereaved – reunion with the lost object (Stein, 2004b, p. 807).
Discussion and Conclusion
This effort to bridge music and psychoanalytic therapy has proven meaningful and rich in concept, metaphor and experience. Each is both science and art requiring attuned listening, and each the repository of thought and feeling. Music, like emotion, is an integral part of life which nonetheless is ephemeral; as such it reflects something of the vulnerability and impermanence of life. At the same time music, like the psychotherapeutic process, provides a flexible and creative container; able to hold, express and console, to carry one to breathless heights and darkest depths, and to offer possibilities of increased integration and freedom.
Nonetheless the question of words continues to beg further attention. Where might the music express what words cannot, and where might words articulate, externalize and communicate that which music cannot? Should all music therapists be trained to do in-depth psychotherapy work or is this only useful for those working with higher functioning clients? How might we best train music therapists to recognize and make use of unconscious processes such as transference and countertransference, both within musical interactions such as clinical improvisation, and within our verbal exchanges? What can psychoanalytic theory and technique contribute to music therapy, and where might other therapeutic orientations prove fruitful?
To my view, music therapy work deepens and the profession continues to develop with the incorporation of psychodynamic concepts (e.g.: Bruscia, 1998; Hadley, 2003; Scheiby, 2005; Dillard, 2006). I believe that training in psychoanalytic psychotherapy has profoundly enhanced my music therapy work. As well, I feel certain that years of experience working in the not-knowing-explorative-improvisational-play-space of music therapy at the end of life has brought greater openness and creativity to my psychotherapy work.
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