Ismaee il Musika - Listen to the Music

By Annette Whitehead-Pleaux

Introduction

I work at a pediatric burn hospital in the United States. Using music therapy interventions for pain and anxiety management during dressing changes are the bulk of my work and my passion. The children come from all over the world for care at the hospital, which is something I love about my work. Learning the music of each family, who are from different cultures and varied customs, and then incorporating it into my music therapy sessions is a key component to working with an international population.

For this case study, the names of the child and aunt have been changed. I received a referral for Sanaa, a pre-adolescent girl from Iraq, from a nurse who had cared for her the previous day. The nurse asked me to assess Sanaa for music therapy to address pain and anxiety during dressing changes and her range of motion exercises. The nurse described the child as exhibiting some trauma symptoms during her dressings as well as experiencing high amounts of pain and anxiety. Sanaa was injured by an explosion that also killed members of her family. Her aunt, Farrah, accompanied her to the United States for medical treatment. After reading her medical record, I chose to conduct my initial assessment of Sanaa at a time when she was not receiving any medical interventions while Farrah and an interpreter were present. This gave me time to introduce music therapy and its benefits, because the use of music during medical procedures can be an unusual concept to patients and their families. It also gave me time to answer questions, and to learn of their family�s beliefs about music, the childs music preferences, and music history.

Assessment and Procedural Support

It was a gray, rainy morning when I met with Sanaa and Farrah. The Arabic language interpreter and my intern joined me. The multidisciplinary team was cognizant of the cultural norm and the team was comprised mainly of women, including my intern and the interpreters. Despite a history of introducing music therapy and myself to people from many other cultures, today was different. I was unsure of what to say and how to phrase it. I was worried I would offend them with my western sensibility and appearance. I stood before Farrah and Sanaa dressed in short sleeve scrubs, with my guitar on my back, and very short hair. Farrah stood before us dressed in her long black robe, her head covered in a scarf, and with religious tattoos upon her hands and face. When asking the child and aunt about music they enjoy, the answers they gave were vague and noncommittal. I knew there was more to explore, but did not know how to proceed. The child and aunt did agree to try music therapy during the next dressing change. This was the beginning of our journey together.

After the assessment, my intern and I spent hours listening to the only popular Arabic music we had in our music catalogue at that time, Nancy Ajram. I focused on learning the characteristics of the melodic structure, the basic chord progressions, and rhythms. The next morning, we had our initial dressing change sessions, focusing on providing live music to support the child. My intern and I improvised music using the doumbek (a Middle Eastern drum), guitar, and voice. Our improvisations mirrored the musical elements we heard in the Arabic popular music. However, I felt our music was still strongly influenced by our western music training and sensibilities. During the dressing changes in which we provided the improvisations as support. These sessions consisted of myself playing the guitar and improvising vocal while my intern played the doumbek and harmonized vocally. The music echoed elements of Arabic music including melody structure, rhythms, and chord progressions. Sanaas wounds were extensive and limited her ability to participate to playing the tambourine once her hand dressings were completed. Although encouraged to join in vocally, Sanaa chose to not sing. The nurses, occupational therapist, and aunt reported Sanaa was much calmer and appeared to experience less pain. Sanaa said she felt more relaxed with the music therapy intervention.

As we met with Sanaa and Farrah over time, there were times that were free of procedures. During these breaks, we discussed with the family Sanaas experiences with music and how Sanaa and Farrah perceived the music therapy interventions. At these times Farrah spoke for herself and Sanaa. She explained that the music was nice but not what they were familiar with. She reported it helped Sanaa to relax and feel less pain during the dressing changes. She insisted that music is for the young and she, Farrah, is too old to enjoy music.

We continued to work with Sanaa and Farrah daily in her dressing changes. The nursing staff and physical therapist reported the child was calmer and more compliant. My intern and I continued to explore Arabic music elements and connect to community resources to improve the improvised music we were providing. Our utilization of Arabic musical elements as well as comfort in new vocal techniques increased. I tried to research Iraqi popular or traditional music, but with little success.

Individual Sessions

As Sanaa healed and built trusting relationships with the nurses and occupational therapist, her need for support through her dressing changes reduced as she was able to effectively utilize her own coping strategies. The focus of music therapy transitioned to supporting the childs strong familial connections despite the distance to home, facilitating adjustment to the hospital stay through expression of emotions and thoughts, as well as facilitating her connection to her culture while she remained in a foreign land. At this time, the interventions switched to improvisation, song writing, and listening to music of the childs culture. Finding music from Iraq continued to be difficult. We listened to Arabic pop and traditional music, played instruments, and started some songwriting. Our interventions were limited by the availability of Arabic language interpreters.

An important shift happened when I attained music from Iraq that Sanaa and Farrah knew and liked. Another patient from Iraq had a cd of Hatam Al Iraqi, an Iraqi musician Sanaa and Farrah liked. When I brought the music to them and put it in the CD player, tears flowed down the cheeks of Sanaa and Farrahs eyes. When Farrah looked at me, I saw such sorrow and longing. I immediately called the unit assistant for an interpreter to gain an understanding of their reaction to the music and assess the appropriateness of this music. However, the interpreter was unavailable. I asked if the music was good, a word Farrah knew, and she said yes. We continued to listen to the CD. Sanaa spoke to her aunt who walked to her bedside. Gently, Farrah helped Sanaa to stand. Sanaa began to dance with her aunt and smiled. Farrah looked upon her niece with tears in her eyes as they held hands and danced. As this song ended, Sanaa laid down in her bed and said "tired."

Self-Analysis of Countertransference

Throughout this process, I continued to feel unsure of my interventions and my abilities as a music therapist as I worked with this child. What was I doing for Sanaa and Farrah? Why did I suddenly feel so out of place in a hospital I have worked at for nearly 8 years? I soon recognized these feelings to be manifestations of countertransference. I identified a similarity between how I felt with this family to experiences in my own life. My own feelings and experiences of being an outsider as a butch lesbian were being projected into my perception of my relationship to this family. Many times when I was with Sanaa and Farrah I felt out of place, unsure, and like a giant neon sign advertising all that is different between us were all feelings rooted in my countertransference. My own history of rejection and prejudice from my religious family members and community was clouding my ability to feel at ease with being my authentic self with this child and aunt. The memories of derogatory comments about my hair, clothing, and sexual orientation swirled about me. In addition, I found myself thinking about how I felt about my country waging war within Iraq. I felt guilty and conflicted that the actions of my country may have played a role in this childs injury. I wondered if Sanaa and Farrah saw us as helpers or something else. Did they feel safe here? My thoughts, feelings, and experiences crowded about me and kept me from being able to reach Sanaa and Farrah on a deeper therapeutic level.

As a Humanistic music therapist, I draw great clarity when I look at perplexing cases through the principles of Humanism outlined by Rogers. After identifying the roots of my hindrance, I turned to the foundations of person-centered therapy: congruence, unconditional positive regard, empathy, and the actualizing tendency (Rogers, 1961). Was I embodying these foundations in my sessions? I found congruence and empathy to be areas with which I was having the most trouble.

Congruence is the connection between the thoughts and behavior of the therapist. The therapist is genuine and does not employ a professional front or façade (Rogers, 1961). The therapist is aware of the emotions and attitudes that are present within her/himself during the session with the client. The therapist does not burden the client with his/her problems or feelings; instead, the therapist will communicate these feelings and attitudes to the client when appropriate (Rogers, 1961). The more congruent the therapist is, the greater the chance for change in the personality of the client (Rogers, 1961). Clearly, I was not congruent as my countertransference was inhibiting my ability to be genuine, to be myself. To connect to this family, I needed to be free of these feelings and thoughts in the sessions and to be more congruent.

As I re-read Rogers, I saw I was not fully embodying the principle of empathy. Instead of making the maximum effort to live the clients attitudes, I was observing, diagnosing, or thinking of ways to speed up the therapeutic process (Rogers, 1951). Rogers states it is important for the therapist to accurately understand the clients experiences to the point of willingness to accept correction (Raskin & Rogers, 2000). This appreciation and willingness allows the relationship between the therapist and client to deepen based on respect and understanding. I saw that my desire to move forward in music therapy was actually manifesting in rushing toward goals I had set, not goals that were important to Sanaa and Farrah.

After this examination of my countertransference and the review of humanistic principles of therapy, I was able to acknowledge that my experiences and emotions were not coming from my relationship with Sanaa and Farrah. This allowed me to meet this family where they were and to be myself. The changes in the sessions were stunning.

Turning Point

During a session soon after I made these changes, an Arabic language interpreter joined me and my intern in our session. During the first part of the session, Sanna improvised on the xylophone, working on hand strength and grip. After, she was tired she rested her head in her aunts lap. Sanaa had previously spoken about how much she missed her family members. We presented the benefits of songwriting as a way to express feelings about the family members they were missing. Farrah began to speak and told us again how music is something for the young and she is too old to enjoy it. I asked her to explain what she meant, stating I did not fully understand, and she began to tell us about her life. Through the interpreter, she told us she feels she is neither here, nor in Iraq. "I am here with Sanaa but my heart is also home with my children and my family. I worry always about them. But I am here helping Sanaa and cannot be there. I am between two worlds," she said. She said there is no place for music and enjoyment in their lives as their lives in Iraq focus on survival. I sat there, listening to Farrah, and my only thought was "Of course." Of course, music was not a part of their lives. They were focused on survival through a war. The part of Iraq where they live is a very dangerous area with limited telephone and power. Their lives focus on basic survival each day. There is no focus on the arts and music. I told Farrah and Sanaa that I understood and was honored they trusted me to share this with me. The session ended soon after as Sanaa had to go for a medical test.

As we exited the room, the interpreter, who had worked with this family throughout their hospitalization, remarked that that was the first time she had heard Farrah say so much and share what was troubling her. By being cohesive and truly embodying empathy, I was with this family and heard their true state of being. This was a turning point in our sessions as I had finally let go and was fully present.

A week later, Sanaa was discharged when her wounds had healed. On the day she was discharged, I came to see if they needed anything and to say goodbye. Sanaa and I sat together and listened to music one last time. With no interpreter present, I used what little Arabic I had learned to say good bye and thank you. We hugged. I then went to Farrah to say goodbye. With tears in her eyes, she hugged me and said, "I love you."

Conclusion

To this day, I still feel deeply moved when I remember this family and the work we did together. There is so much power in being with someone where they are and not pushing for change. The day I stopped pushing and just listened, my relationship with both Sanaa and Farrah deepened, and a shift happened. Farrah was able to share her burdens of worries with someone and, through her, I believe Sanaa also shared her worries. I could do nothing but listen to ease their very real worries from the war, which is what they needed. My best intervention with this family was not based in music at all. Yet, to witness their worries for their family and how torn they felt allowed Sanaa and Farrah to move forward toward health and growth.

As I ponder this case further, I believe our efforts throughout Sanaas hospitalization helped to lead us to that pinnacle session. First, bringing Arabic music and later Iraqi music to their room helped to bridge their distance from Iraq to the United States, as well as conveyed our desire to know Sanaa. Our sincere efforts to learn Arabic music idioms and forms conveyed our respect for their culture and music. Our attempts, although not completely correct, conveyed our interest in "appreciating the world of the client" (Ruskin & Rogers, 2004, p. 147). And finally, becoming aware and then clearing myself of my counter transference paved the way for me to gain a true connection to this family.

I do not know if I will ever see this family again. When they returned to Iraq, I was both joyful that they would be with their family again and fearful for their lives. I hope to see them again and to dance with them. Until then, I carry the lessons I learned from Sanaa and Farrah forward, into all my sessions.

References

Rogers, C. R. (1951). Client-centered therapy. Boston: Houghton Mifflin.

Rogers, C. R. (1961). On becoming a person: A therapists view of psychotherapy. Boston: Houghton Mifflin.

Ruskin, N. J., & Rogers, C. R. (2000). Person-centered therapy. In R. J Corsini, & D. Wedding (Eds.), Current psychotherapies (6th ed.) (pp. 133 167). Itasca, IL: F. E. Peacock.