Dying Well

The Bonny Method of Guided Imagery and Music at End of Life

By M. Louise Cadrin

[Editors note: The article presented here is republished from the Journal of the Association for Music and Imagery Vol. 10, pp. 1-30, 2005-2006, with the kind permission from the publisher and the author.]

Abstract

This case study demonstrates the role of The Bonny Method in addressing psychosocial, spiritual, and existential issues particular to end of life, and in the subsequent peaceful death experience of a 47 year old palliative cancer patient. In reviewing her final 8 months of life, the case study demonstrates the patient�s willingness to explore her emotions of shame related to having cancer, fears of the cancer metastasizing, and the grief and sadness common to anticipatory grief and to a traumatic incident that she experienced as a youth. It demonstrates how she was able to reconcile relationships with family members prior to death, as well as acknowledge her part in this conflict. It shows how she drew insight from the sessions to direct her own course of treatment, resulting in an increased sense of control. Lastly, this case study demonstrates both archetypal imagery and imagery that reflects the dying process, augmented by poetry written by the patient as a further means of expressing and understanding her experience.

Key words: Guided Imagery and Music, terminal illness, palliative care

Introduction

In hospice/palliative care (HPC) dying is viewed as a natural process (Sanders, 1988; Twycross, 2002) that emphases quality of life until death (Harstade & Andershed, 2004; WHO, 1990). The HPC philosophy focuses on patient care rather than treatment of disease, and recognizes that although there is no hope of cure, there is opportunity to address and alleviate patient symptoms and the psychosocial and spiritual and existential issues experienced by both patient and family members.

This paper will begin by profiling frequent spiritual, existential, psychological, social and physical challenges experienced by terminal 2 Journal of the Association for Music and Imagery (2005-2006), Vol. 10 patients as they prepare for end of life. It will then review the existing Bonny Method of Guided Imagery and Music (BMGIM) literature relative to HPC. Lastly, the efficacy of this method in addressing several of the aforementioned psychosocial, spiritual, and existential issues will be demonstrated through the case study of a forty-seven year old palliative care cancer patient in her last eight months of life.

People facing a terminal illness have the opportunity to explore existential and spiritual factors. "Why me?" is one of several common questions pondered by persons with a terminal illness as they try to make sense of their situation (Rando, 2000; Rousseau, 2000). There may be a need to reflect upon their lives, questioning their human existence and the meaning of life and death, as they strive to seek value and purpose in their past and present experiences (Conrad, 1985; Puchalski, Dorff, & Hendi, 2004; Rando, 2000).

Issues of an existential nature relate to four ultimate apprehensions: death or existential obliteration; freedom as it relates to the absence of external structure; isolation, in that the journey of both entering and departing existence is ultimately alone; and meaninglessness, in that the dissolution of meaning can equate to the dissolution of the foundations on which ones life has rested (Yalom, 1980). Meaning and purpose are challenged as the assumptions and expectations of one's world and place in it's future are radically changed (Rando, 2000). A terminal illness may prompt the need to explore aspects of the afterlife, reinforcing present beliefs, or fostering hope that something exists beyond the grave. Or it may affect one's concept of God or other constructs of meaning, resulting in a sense of spiritual searching or abandonment.

To fear death is normal (Penson et al., 2005). In referring to a small group of case studies of patients at end of life, Penson et al. noted that fears of death were associated with uncertainly of what to expect in the afterlife, self-judgment of how one had lived his/her life and whether s/he would be punished or abandoned by God at time of death. Other concerns included the need to know what the death experience would be like, fear of how loved ones would cope once they had died, fear of their memory vanishing, and fear of meeting relatives who had already passed on but whom the patient had not had positive experiences with while they were alive. Persons may experience fear as it relates to a loss of autonomy, which can then become metaphoric of dying, as was seen in a study conducted by Adelbratt and Strang (2000) with brain tumor patients and next of kin. This study also demonstrated that sadness and existential pain may become more prevalent as the illness progresses and there is a realization that life is nearing an end. Lastly, trigger phenomena associated with cancer, such as symptoms (i.e.: headaches) or medical environments, may create death anxiety even if the disease is not currently progressing.

Although existential and spiritual issues are commonly experienced at one time or another throughout ones life, these questions are amplified with the diagnosis of a terminal illness, with existential dimensions being as important as other domains impacting quality of life (Cohen et al., 1996). In a study conducted with palliative care cancer patients, Chochinov, Tataryn, Clinch and Dudgeon (1999) demonstrated that the patient's will to live is highly unstable, and that infrequent or passing thoughts of a desire for death are universal among persons with terminal illness (Chochinov et al., 1995). In reviewing some of the psychotherapeutic interventions for patients at end of life Chochinov, Hassard, Kristjanson, McClement and Harloss (2004) Dignity Model identified that persons with a fractured sense of dignity are more apt to have heightened emotions including anxiety, hopelessness, depression, the loss of will to live and a desire for death. Breitbart, Gibson, Poppito and Berg (2004) have developed interventions for existential meaning and spiritual suffering for terminally ill cancer patients at end of life, noting that issues such as depression, hopelessness and wanting to accelerate the dying process were alleviated when a sense of meaning and purpose, and spiritual well-being were present. Kissane and Clark (2001) targeted what they term Demoralization Syndrome amongst cancer patients, suggesting the use of this diagnostic category in palliative care settings as a means of relieving distress and psychosocial morbidity. Demoralization Syndrome recognizes helplessness, loss of meaning, and existential distress as its primary features. It is different from depression in that it does not meet the formal diagnostic criteria. In addressing suffering at end of life, Byock (1996) also spoke to the anguish that arises from the loss of meaning and purpose in life, as well as from the fear of ceasing to exist.

Cassel (1982) suggested that "suffering occurs when an impending destruction of the person is perceived; it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner" (p. 640). His multidimensional theory of personhood outlines the many aspects of the self that may suffer, some of which encompass personal, social, familial, community, cultural, and transcendent aspects. In applying these dimensions of personhood to the end of life, certain of them become heightened and sensitive (Byock, 1996). Dying persons may experience suffering or a sense of loss that stems from the anticipated separation of loved ones, from the change of role identity that occurs when they are no longer able to contribute to the work force or to family in a way that they once could, or when their life routine changes and focuses primarily on doctors appointments and medical treatments. It may occur when they feel that their body has let them down and is no longer trustworthy, or when they reflect upon missed opportunities in the past and present. It may occur when their public self-image changes because they can no longer contribute to community projects or to a political life. It may occur when they realize that they will not witness anticipated events of the future such as the birth of a grandchild or the marriage of a child. Or it may be a grieving of their lost independence and diminished self-image as they become weaker and more dependent on others for their care needs.

In presenting an overview of palliative care literature related to psychiatric end-of-life care, Chochinov (2000) summarized psychological concerns expressed by persons with a terminal illness. These include progressive disability and changes to previously held sources of identity, fears of disfigurement and alternations to their body, and fears of a loss of independence and control. Further concerns relate to a loss of personal desirability, fear of becoming a burden and subsequent abandonment, and concerns with death and the way in which they will die. In a study conducted by Singer, Martin and Kelner (1999) in which 126 patients with advanced illness were asked to identify and describe elements of quality end-of-life care, five domains of significance were identified. These were 1) receiving adequate pain and symptom management, 2) avoiding inappropriate prolongation of dying, 3) achieving a sense of control regarding end-of-life care decisions, 4) relieving the physical and emotional burden that their dying would impose on loved ones, and 5) strengthening relationships with loved ones through open communication about their dying. In his model of landmarks and tasks for end of life Byock (1996) addressed the need for reconciliation and closure in the patients significant relationships. He noted how this opportunity can be offered within a progressive illness, and that it does not indicate discontinued communication or the severing of a relationship, but rather allows for the story of the persons involved to end well with nothing more to be said or done.

Persons diagnosed with a terminal illness are faced with the loss of all that they have known and loved (Periyakoil & Hallenbeck, 2002). Grief is a normal reaction to these losses and can encompass multiple domains (Rando, 2000). Kubler-Ross (1977) referred to the grief experienced by terminally ill patients preparing themselves for death as preparatory grief. Randos (2000) concept of anticipatory grief also recognized these reactions to loss, but in addition to the patient included the grief experience of others impacted by the illness, for instance family and friends. The role of appropriate grief work is important in assisting patients to find a sense of purpose and meaning as they process these myriad losses (Chochinov, 2000; Chochinov et al., 2004).

The dying period of ones life can be viewed as a stage of the human life-cycle, equivalent to other stages such as childhood, adolescence, or adulthood (Byock, 1996). As with each of these phases there are associated challenges and suffering, and an opportunity to work through and achieve a sense of accomplishment, meaning, and completion. Living through the suffering experienced at end of life can bring one to a heightened sense of well-being with new resolutions, insights, and a quality of life in which acceptance and peace are experienced (Byock, 1996; Sanders, 1988). In looking at this time period as an opportunity for growth, self-awareness and enhanced meaning, Puchalsky et al. (2004) suggested that having a terminal illness does not mean the patient has nothing to hope for, but rather that they may require guidance to know what is reasonable hope. This may include

hope that one will be able to cope with suffering; hope for remission, if not a cure; hope for enough time to achieve a particular goal (e.g., to attend the wedding of a grandchild or to complete a family history); hope for the future welfare of one's family; hope to reconcile with family members or others before death; hope to keep ones dignity; and hope for life after life. (Puchalsky et al., 2004, p. 703)

There is a need in human beings to transcend adversity and suffering and to find meaning that helps them to make sense of their situation (Frankl, 1992; Kellehear, 2000). This concept is the basis of Kellehear's multidimensional model of spiritual needs that recognizes three sources of transcendence (situational transcendence, moral/biographical transcendence, and religious transcendence) and the impact they have on spiritual meaning. The transcendent dimension often takes on greater personal significance as one nears the end of life, with the related aspect of meaning being instrumental in resolving suffering, and in the potential for personal growth (Byock, 1996). Kuhls (2002) book What Dying People Want is based upon stories of people who knew they were dying. Kuhl also noted that awareness of the transcendent dimension may evolve in people as their illness progresses, influencing their sense of self and relationship with others. For some this can impact their psychological and spiritual awareness, helping their ability to access new consciousness and foster an awareness and connection to something greater than themselves. Lastly, Cassel (1982) stated that "transcendence is probably the most powerful way in which one is restored to wholeness after an injury to personhood. When experienced, transcendence locates the person in a far larger landscape" (p. 644).

The Bonny Method of Guided Imagery and Music

The Bonny Method of Guided Imagery and Music (BMGIM; Bonny, 1978a; Bonny 1978b; Bonny, 1980) is a music-centered transformational therapy that allows self-regulating growth and development, opportunity for expanded self-awareness, and for physical, psychological, social, and spiritual integration. The very essence of this method offers tremendous opportunity to address the many issues, questions, experiences and the search for meaning and purpose that becomes integral or is heightened for persons at end of life.

The efficacy of this humanistic and transpersonal method (Bonny, 1975) in addressing some of the wide range of end of life issues listed above is evident in the literature that currently exists. In using a modified version of BMGIM with two hospice cancer patients, Wylie and Blum (1986) demonstrate how this technique assisted with matters such as relaxation, pain management, reminiscence, and in cultivating an increased sense of control. One hospice patient was successful in decreasing her pain when guided to imagine what was causing the pain, and then imagine how she could help it. This article also highlights the role of guided imagery and music in promoting creativity and a sense of exploration in persons encountering a loss of physical abilities and roles. The success of BMGIM in cultivating meaning and purpose, enhancing ones connection to spirituality, and expressing intense emotions was demonstrated by Marr (1998/1999) with an AIDS patient and a cancer patient in both in-patient and home-based hospice settings. This article profiled both the standard BMGIM as well as an adapted version. One patient in particular was motivated to prepare herself and those around her for her death. This paper also explores the appropriateness of BMGIM at end of life, how to modify this technique to be most valuable with hospice patients, and contraindications. Martin (1993) also questioned appropriateness and contraindications of this method, based on using the BMGIM in a hospital setting with advanced, terminally ill cancer patients who were at the very end of life. Based on her experience with this very specific population, she noted that the BMGIM experience may in most circumstances not be congruent at this point. Her view related particularly to the amount of physical and emotional energy this method requires and the psychological issues that can be stimulated, without sufficient time or energy to resolve them.

The significance of the appearance of deceased loved ones during the BMGIM process, as well as the impact it has on emotional and spiritual healing, was demonstrated in Bruscia's (1992) work with gay men living with AIDS. He demonstrated imagery from case material in which words of advice, assistance, or loving acceptance from significant persons who had already died assisted patients in dealing with feelings such as denial, loneliness, isolation, guilt, anger, and an unwillingness to embrace living and dying. Bruscia (1995) identified five themes and associated imagery that are often prevalent in the imagery of gay men with AIDS, noting that the themes are not always in sequence. These are identified as 1) being in limbo, 2) releasing feelings, 3) finding love, 4) emotional healing, and 5) embracing life and death.

Skaggs (1997) spoke to the advantages of BMGIM with those who have terminal illness from the perspective of one in private practice versus an inpatient hospital or hospice setting. Her case studies demonstrated imagery that revealed diagnostic information before it was determined by medical procedures; the role of transcendent images at end of life in addressing existential issues; how BMGIM was used to alleviate pain that was not being controlled by medication; and the benefits of BMGIM over an extended period of time for the person with a terminal diagnosis.

Lastly, Erdonmez (1995) illustrated the efficacy of BMGIM with a palliative patient with motor neuron disease (also know as amyotrophic lateral sclerosis or ALS), noting that in addition to the spiritual growth that occurred, the patients imagery reflected the progression of her illness. Although the patient maintained a state of denial until the last stages of her life, within the imaginal realm she was able to face the illness and prepare for her death, demonstrate a belief in life after death, and access archetypal figures.

The following case study will profile a forty-seven year old palliative community based patient in her last eight months of life. All sessions used the standard BMGIM and were given in her home. The case study will outline twelve sessions, ten of which involved BMGIM and two that focus on poetry written by the patient. Many of the sessions will be summarized, outlining only significant aspects and images, while several will demonstrate verbatim dialogue as obtained from the transcripts.

Case Study

Ellen was a forty-two year old woman when diagnosed with breast cancer and subsequent skeletal and lung metastases. When initially diagnosed she declined conventional treatment, opting for alternative forms. When further diagnosed with bone metastases a year later, she received both radiation treatments and chemotherapy. I met Ellen shortly after commencing my position as the Palliative Care Music Therapist. At that time she was forty-seven years old and living by herself, having come from a large rural family of many siblings. She presented as a bright, healthy-looking, gentle woman who was very aware of her illness process and actively trying to understand it. She was deeply frustrated that her body and health had not responded and improved as she had hoped for. She felt anger and disappointment towards her body, and towards her family and community for what she perceived as a lack of understanding of her medical condition. Ellen was especially angry at her mother. Ellens healthy appearance had contributed to a misunderstanding of her palliative state, which in turn had solicited pressure from family and friends for Ellen to work. Prior to Ellens diagnosis she had operated her own business, but since becoming ill had not been able to maintain it or work elsewhere. This had resulted in financial pressures. Also of significance, Ellen's father had died of cancer three years earlier.

Ellens reasons for pursuing BMGIM were because she felt that it was time to explore what she thought were deeper issues and emotions relating to her illness. She had attempted alternative treatments that had not been successful, and felt that the cancer was related to issues from within her that needed to be looked at. Her remarks were "I need to open up my heart, find my authenticity, my core being." It was her goal to release her grief and sadness so that she could find joy again. In addition to Ellens goals of understanding why she had cancer, I identified two other goals during our initial meeting. One related to exploring a feeling of oppression that Ellen had felt all her life in her health, finances, relationships, emotions, and choices. The second related to looking at the deep anger Ellen felt towards her mother whom she believed had not been a support in her life.

Ellen said that her faith, the Bible, healing studies, and the support of two churches were instrumental in helping her to trust and contain her worries and anxieties related to her cancer. At the time of our initial visit Ellen was undergoing radiation treatments, and was receiving a bone scan that same day to determine whether there were bone metastases in her spine. She also was experiencing continual pain in her right breast. In conjunction with BMGIM sessions we discussed the possibility of poetry writing and/or song writing as an additional means of creatively expressing what surfaced during the sessions, with a final goal of recording and creating a CD of her work.

Treatment Process

Session #1: "Lost"

The first two pieces of the Quiet Music Program (Bonny, 2002) were used in this initial session to determine Ellens ability to engage with the BMGIM method. In lieu of Ellens goal of wanting to open up her heart, I started this session by having her focus on an image of the heart while listening to Debussys "Dance Sacred and Profane." [Note to the reader: The italicized sections below are verbatim from session transcripts, with bracketed non-italicized excerpts indicating the author's interventions or observations, or the titles of the music being listened to. Further, unless otherwise specified, all music programs listed in the sessions have been used in their entirety.]

I was hesitant to touch the heart. I see its movement - it is beating. I timidly touch it. It feels okay - like it likes it. Yes, it does. It makes it happy. The heart is kind of sad though. It quivers. When I viewed the heart it was a beautiful brilliant red. When I touch it and it quivers, it turns grayish. It is turning colors - from gray to a darker red. It has a hard time keeping its shape. Im still holding it. The bottom is going to the ground... [Q: How does it feel to hold your heart?]... Different - something I havent done before. Im nervous. The heart wants it too, but is hesitant... {Debussys "Prelude to the Afternoon of a Faun" begins}... There is hesitation for both of us. The center of the heart has a dark spot in it about the size of a fist. Its a black, dark spot. Theres a black center surrounded by red... [Q: Are you able to touch the dark center?] Yes, I can put my hand there but there is nothing there - its hollow... I can put my hand right through - it is like a black tunnel ... with hard walls and it goes right through my heart. I can walk through this tunnel. It goes on - Im looking for light - for a way out. In the tunnel I get defeated. I crouch down. I dont know what to do. I know there is light but I cant find it. There is no one there for me. Im trapped, all alone, not knowing what to do. Its a hopelessness - its black - Im even black. Its all black, except for a star in the top right hand corner of the tunnel. Its far. When I am crouched with my head against the tunnel it makes my head rise up.

Afterwards Ellen said that she thought this session showed her the state of negativity she was engulfed in. She remarked that "sometimes life is so stressful we dont know where were at" and titled this session "Lost." The feelings of aloneness and hopelessness that surfaced continued to be significant themes as the sessions progressed.

Session #2: No title.

We met one week later at which time Ellen had completed radiation treatments. She had not slept well during the treatments and had been experiencing ongoing pain in her right hip. She expressed feeling stressed and said that she was tired of worrying about the cancer spreading. Ellen wanted to address a goal from our initial interview, which was to look at the anger and bitterness she felt towards her mother and others. She felt that her mother was not able to look at Ellens illness with any depth of understanding. As a result Ellen kept her mother at a distance. She expressed a need to find resolution with this issue, sensing an intuitive time frame of 4-6 months within which to talk to her mother about the anger and to forgive her. Ellen then talked about the tumor in her breast, which she described as red and hot, stating that she felt it was related to issues of anger and forgiveness. She said that her initial tumor of several years ago had looked like a volcano but that it hadnt erupted. Her newest tumor had subsequently taken over the location of the original one, covering the center of her breast. She described it as "red, raised up and broken open, bleeding heavily and letting stuff out." Although the goal of this session was to focus on Ellens feelings toward her mother, this did not occur. Rather, the subsequent imagery reflected her fears of the cancer metastasizing. She also accessed an archetypal figure who gave candid, yet reassuring advice about the unpredictability of the cancer, while also reinforcing the growth and nourishment that could happen even if death occurred.

The Quiet Music Program (Bonny, 2002) was again chosen in this session. As the session began with Debussys "Dances Sacred and Profane" Ellen found herself on an island with an active volcano that was situated near the water.

The opening - you can look in and see its a real hot red. The volcano is large - it spreads out. It takes in quite an area. It is dark in color. The surface is rough with crevices going down the side, letting the red out. Its quite beautiful - red coming down making paths. It is so alive, so brilliant... Now its night it's dark...around the tumor is more darkness. [NOTE: Ellen interchanges the word volcano for tumor.] Its spitting out little chunks of red...

{Debussys "Prelude to the Afternoon of a Faun" begins}... I am standing on volcanic lava. This volcano is not as dangerous as it used to be. I can stand here and know it is safe. I feel safe even though there is smoke rising behind me. They told me not to worry. The people of the island...They said it used to be a bad volcano but it has played itself out. I turned and looked at the volcano and wondered about the others beyond it - if they will act up or erupt. [NOTE: In keeping with Ellens concerns of the cancer metastasizing, there are now four volcanoes.] One is noticeably higher than the rest. Then there are two others. I can ask the village people... There is a man back at the village that I can ask... I think that I need to know whether he thinks that is a volcano that could erupt. Hes lived here a long time. Im with him and taking a deep breath. Im worried about what hell say, but Im going to face this anxiety. Im not going to back away...We have small talk. I tell him I was walking, looking, watching the volcano...

{"Venus" from Holsts The Planets begins}... He says "it used to be a bad one, but dont think it will cause damage in the future." What about the others, I ask? They look ominous. He says, "We dont anticipate problems with the others. We can never be completely sure, but they seem to be tame. Even with the one giving us problems it is always unpredictable. Thats the way life is. You can come here anytime - its a pretty safe place... Even though people have lost their lives, theyre not afraid of them [the volcanoes]. They respect them and have learned from them. We grow great food because of them. We appreciate them."

Ellen described this man as in his seventies, as someone who had lived outdoors, was well spoken, and dark and lean with white hair. His family had lived on this island for a long time. He had nice, dark brown eyes filled with compassion and gentleness, and his name was Horus. While listening to Vaughan Williamss "Fantasia on Greensleeves," Ellen says

This music makes me cry. Im floating in the air, still in the area of the volcanoes and the ocean, with the quaint village on the other side. There is a sadness to leaving but I am also moving forward anticipating the next placethe next part of the journey. . . . .[Q: Are you able to be with the sadness?] It is already past. Maybe because it has become a part of me, and so I realize I can take it with me.

After the music ended, Ellen again expressed the amount of fear and worry she had been experiencing. She said that this session reinforced that she was to relax, to not worry, and to know that she was safe, no matter what happened. She felt that the village figure Horus, had also reinforced the need to live more in the moment and not to worry herself sick.

Clark (1995) noted that through "the experience of BMGIM, persons can begin to search out what myth it is that they are living" (p. 51). Ventre (1994) observed the power of archetypal images as found within myths and fairy tales in exploring crucial issues of the person. In Egyptian folklore Horus is found within the myth of Osiris, as the son of Isis and Osiris. This legend portrays themes of life, suffering, death and resurrection (Budge, 1967). Horus plays a role in Osiriss resurrection in that he holds the Ankh, or sign of life, before his fathers face (Campbell, 1968). Ellens unconscious accesses this mythological pattern to give understanding to themes of life, death, and life after death. In this session Ellen receives guidance of how to find meaning and a way to co-exist with her terminal illness. She is able to integrate feelings of sadness and a sense of safety as she faces her mortality, and then voice anticipation for the next leg of her journey.

Session #3 Poetry

When we met a week later Ellen asked that we look at some poetry she had written one evening when she was unable to sleep and felt in despair. The first poem, entitled "Words, Words, Words," spoke to the anguish Ellen was feeling within; the need to express herself to others, particularly her Mother; and the fear of hurting them in doing so. It also exposed a theme that had begun to surface but became more prevalent as the sessions continued; the image of darkness as it related to feelings of fear, hopelessness and solitude, and the image of light as it related to feelings hope, beauty, and freedom. Although Ellen did not expound deeply on the content of the poems, their meaning became clearer and more relevant as the sessions progressed.

Words, Words, Words

Words, words, words
Are there words in my deepest being that need to be set free?
I hold them in and I wont let them out.
I wont let them out for they might hurt someone.
But Ive held them in so long I dont know how to express
them.
The dark, the dark, the dark.
The words are darkness to me, they are secret, they are hidden.
They hurt me, they make me sad and full of sorrow.
Words I should speak or should have spoken, I keep within.
Always thinking I can do it, Ill be all right.
Mother, Mother, Mother
Do I speak to you of words from my deepest being or not?
If I do, do I risk hurting you?
Can I speak with gentleness, openness, humbleness, and
honesty to release the secrets that I have held in my body for so
long?
Light, light, light
I have flickering moments of beautiful, brilliant light.
I shall keep seeking that light until it permeates my whole
being.

The second poem spoke to her need for healing her heart, of her feelings of grief, sadness and loneliness, and of the support she received through her faith in God.

Today is my day for healing.
Jesus, himself took my infirmities and bore my sickness.
So the time is now.
I am made whole.
Nothing missing, nothing broken.
I speak to my sadness and my grief.
You have covered me like a thick black blanket.
I have lived in the dark so long.
My soul aches for release, Ive been so lonely.
But still the tears dont come.
Refusing to listen to my heart.
My heart says its not too late. Its never too late for new
beginnings.
As God heals my heart I see that sadness and grief have no
power over me.
For I dwell in the secret place of the Most High and abide
under the shadow of the Almighty.
I will say of the Lord, He is my refuge and my fortress.
My God, in Him I will trust.

Session #4: "The Struggle"

Ellen and I met one week later for another BMGIM session. The theme of the second poem became the focus of this session, with a goal of looking at Ellens long term feelings of sadness and grief. She spoke about how her emotions seemed to squeeze or suffocate her heart, commenting "I think its always having to be strong; not allowing the emotions to show." Ellen was asked to focus on an image of her heart as she had described it in the pre-session talk. The music chosen for this session was the Explorations Program (Bonny, cited in Grocke, 2002). As the session began with Ravels ballet, "Daphnis and Chloe", Ellen described herself as two beings. One was a heart, enclosed and trapped in blackness; the other was her with wings, and a sense of freedom. She subsequently returned to one person, but the theme of duality continued to present itself as an image of two sides split down the middle by a line. One side was dark and contained a cement wall with her heart encased and squeezed within it, and a picture of her mother over top it; the other side was spacious, well lit, and again contained a sense of freedom. Ellen spent much of this session on the centerline, first as a young girl and then as her present self, wanting to forgive her mother and family but not being able to. She subsequently was able to tell her mother and family how resentful she was that they had not acknowledged her pain or supported her. While listening to the "Sirenes" from Debussys Nocturnes, Ellen was encouraged by the voices to forgive, reassuring her that she was not alone and was surrounded by a heavenly presence. At this point the heart that was encased in the cement began to beat. It was only at this time that Ellen realized it had not been beating before. Her words were

It has some lifebefore it was so dark. Its still enclosed in the cement but maybe the walls arent as dark, as grim. Its changed. I was always able to see the heart though it wasnt a nice shaped heart. It was being squeezed by these ropes. Now its freer, it has a beat, a movement to it.

Ellen then became a child of about ten years old. The heart, still encased in the cement, moved to the centerline and stood beside her. It had developed arms, enabling her to hold its hand. At this point Ellen realized that Jesus Christ was present and had taken the other hand of the heart. She was stunned at His presence saying, "I cant believe somebody would be there for me." Her mother, now present in physical form, continued to be on the dark side of the centerline, beckoning for Ellen to come to her. She then moved to stand in front of Ellen at which time Ellen was able to say "I forgive you Mommy," and to thank her for being her mother. Ellens mother then took her other hand. Ellen felt carefree and happy at the end of this session, titling it "The Struggle" but saying that it could have also been called "Letting Go."

After the session Ellen commented that she felt some of her anger towards her mother had been releasing, but coupled with the belief that her mother was not there for her, it continued to surface in certain situations. Again Ellen felt a need to talk and make peace with her mother, committing herself to finding the right time and the right words.

In this session Ellen used the imaginal realm as a place to successfully voice her feelings of anger and resentment to her family and mother, and to find resolution with her mother. She accessed religious imagery that assured her of the support available within her faith and affirmed that someone was there for "her." The significance of this session will be demonstrated as the case study progresses, as will the relevance of Ellens self in this session as a young girl.

Session #5: "Journey to the Top"

When we met two weeks later, Ellen had recently consulted with medical staff as the tumor in her breast was bleeding continuously. They had suggested a series of radiation therapy treatments, five days a week for three and a half weeks. Ellen was in conflict with the treatment plan being suggested and was uncertain whether to agree to it. She didnt want to receive aggressive treatment that she felt would exhaust her and possibly result in lung damage. She stated, "If youre going to add three months onto my life, don't bother. Let me have my energy now." Ellen felt that this was bringing up issues of expressing herself in relation to her treatment process, and of being heard by medical staff. She also articulated feeling a lack of control over decisions that she felt a need to be in control of. Ellen then revealed that at the base of her angst was unresolved anger towards the medical profession around her fathers death. Ellen strongly believed that her fathers struggle with chronic leukemia had ended prematurely due to over toxicity from his treatment plan.

The goal of this session was to help Ellen decide whether or not to accept the prescribed treatment plan. The music program chosen to assist with this was Mostly Bach (Bonny, 2002). Bachs "Passacaglia and Fugue in c minor" set the mood as the session began and Ellen was asked to see herself standing in a forest at the foot of two separate paths. Ellen described one path as gentle, lovely and relaxing, while the other path caused her fear and was more of a difficult, upward climb. She eventually decided to walk the path that caused her fear, stating that she felt a need to do so. Although she initially described this path as dark, she later remarked that it never was that dark, it had just appeared to be. Ellen was then joined by supports and allies in the images of Jesus and angels, and felt a sense of victory over facing her fears, recognizing that she could be in victory even as she climbed. In her imagery there were chains bound around her feet. These were subsequently removed during the Bach "Concerto for 2 Violins" by angels who reinforced the need for her to let go of her unresolved anger and unwillingness to forgive, assuring her that they would assist with this.

When later reflecting upon this session Ellen affirmed that she needed to "undo the shackles" that werent allowing her to receive from others or forgive them, and for the first time she talked about feelings of shame that were associated with having cancer. She said, "I feel ashamed of my health, of being sick and for so long. Its been five years." She spoke to her need of privacy and how it had affected the relationships of those close to her because she was unwilling to talk about her cancer. She also recognized that the fear she had felt on the path was about expressing and honoring herself, no matter what people thought. Ellen ended our time together by disclosing that these sessions made her stronger and gave her a sense of strength. She called this session "Journey to the Top."

Session #6 Poetry

We had not met for six weeks as Ellen had been sick, then visiting family. She started the session by saying that she felt a break-through had occurred. Ellen was able to voice her concerns about the radiation therapy treatment plans, which had resulted in her doctors agreement to postpone them. In addition, the visit with her family had prompted more insight into the patterns of rejection that she played out with them, fueling her desire to change her patterns and act differently. She suggested that the theme of self-rejection or rejection of others be a focus in a future BMGIM session. She also shared two poems that she had written since our last visit. The first poem, "Moment by Moment," was about seeing the beauty in everything even when life wasnt good. It had been prompted by a dull, cloudy March day that had caused Ellen to be overcome with a sense of heaviness and despondency related to the length of time she had been living with cancer. It had also caused her to question when it would end. By the end of the poem she was filled with a renewed sense of hope and faith and a belief that new opportunities would present themselves.

Moment by Moment

My thoughts fill my mind,
But when I go to write them on paper
They seem to flit away on the wings of butterflies.
One moment I feel so hopeful.
The next moment I feel so barren, so dry, so lifeless,
just like this drab March day.
As I gaze out my window, I know the world around me
will blossom into a world of
beauty and color.
And soon I will see the greens, reds, oranges, yellows, purples
explode everywhere.
So I am thankful to this March day,
for out of it will come forth beauty.
But then perhaps if I look again at this day
with a different perspective,
I will see the glory of the newness and beauty of this day.

Her second poem entitled "Yesterday" acknowledged the pioneers and their indomitable spirits and resilience that helped them to continue moving forward. She was inspired by the stories that demonstrated these peoples perseverance and courage, and prayed for that same inner guidance to help her with her cancer.

Yesterday

I like to think about the people of yesterday,
The people I call pioneers.
I sometimes think that I had been born in the wrong era,
And that I belonged in my Grandparents time.
I have heard some of their stories first hand,
or read them in books,
And find them so inspiring.
They had this indomitable spirit in them that never gives up,
And a resilience to keep moving forward against all odds.
In my season with cancer I have prayed
for an inner spirit like they had.

Ellen was enthused in this session, sensing the need to re-establish what her life goals and passions were. She voiced hope that she would receive clarity on how to direct her life and start generating an income. In the past her commitments to the family farm had held her back from following her own passion. This visit home had brought up issues relating to family expectations and the difficulties of trying to break away from her connection to the farm. She realized that the gradual decline of her health was relinquishing this role, filling her with a renewed sense of freedom. In this session she expressed "Im breaking free, I want to be free, and Im going after it. I want to have that joy back, my own life, my own person."

Session #7: "Climb Every Mountain"

We met again two weeks later. From this period on Ellens health began to change. She was experiencing increased back pain and a loss of energy and was fearful that it meant additional bone metastasis, hence more radiation. She was also discouraged and depressed, as she believed that the tumor size had increased. Ellen was upset by the changes that were occurring in her body and the impact they were having on her functioning abilities. She said that her thoughts within the last few days were negative, stating that she felt hopeless and despondent.

Ellen's thoughts and feelings became the focus of this session using the music program Emotional Expression I (Bonny, 2002). Ellen was asked to focus on a sense of the changing seasons, in particular that of fall. As the "Adagio" from Brahms Piano Concerto No. 2 in B-flat began, Ellen found herself climbing to the top of a mountain. Her imagery subsequently reflected her present situation and her struggle to make sense of her progressing illness. At times she felt victorious and that she was making progress, while at other times the path was treacherous and a struggle. At one point she questioned whether to continue on, saying, "Do you stay? Go on? Go back? Stay put? Go on fighting or go back fighting through what youve gone through. Its such an uncertainty." Ellen expressed a need to have someone join her that could offer some understanding while on this climb. Of significance, four of her family members appeared. Not only did she have a meaningful time with them during the remaining music program, but her family also allowed her to reach the top of the mountain first, moving at her slower pace. During the final piece of music Ellen also was reminded by Jesus Christ to deal with her feelings of grieve, pain, despair, and despondency by leaning on him.

This was the first time that Ellen's family was present in her imagery in a supportive role. She later remarked that this session had given her encouragement to continue on with what functioning abilities she had. Time also was spent validating the normalcy of the feelings that were manifesting with the changes in her life and the importance of grieving those changes. To this she replied, "There is definitely a time to go to the Wailing Wall. I dont know if Ive really grieved over my illness. Ive been more ashamed of having cancer and trying to get rid of it." Ellen titled this session, "Climb Every Mountain."

Session #8: "Tug-O-War"

When we met again 2 weeks later Ellen was experiencing increased fatigue due to low counts of hemoglobin. She did not want to undergo a blood transfusion and asked that this session focus on cleansing her inner body. She wanted to see her red blood cells as "pure, healthy, vital and hardworking, and willing and capable of destroying the foreign cancer cells that were in her body." As the music program Imagery (Bonny, 2002) began, Ellen was asked to see herself standing inside her body, holding a broom. Ellen found herself in the area of the tumor within her right breast. In surveying the rubble all around she noted that cleaning up would be a lot of work, but that she felt up to the task. She noticed one pile of red rubble that she described as a red mountain. It was a taller pile than the other rubble, had heat coming off of it, and hissed at her to get away. She described it as mean and vicious with red slanted eyes and that it was very angry. In trying to interact with it, she was told to "back off, get away, not to get any closer, and to leave it alone." When asked if it had a name, the response was "no one's here." The rubble subsequently began to lose its sense of hostility, allowing Ellen to move closer to it. At that time she realized that although it looked real, there was no physical form to this being. During Tchaikovsky's "Scherzo" Ellen continued to survey and clean other parts of her body, whistling as she worked. As the music continued, the mountain of rubble subsequently changed to a red of "love." It now had a sense of victory to it and felt alive, vibrant, cheerful, and blissful.

In the post session Ellen identified the hostile mountain as herself and how she had felt at periods all through her life. Again she talked about her shame of having cancer and how unresponsive she could be to others because she didnt want to admit it. She had thought that on some level if "nobody was there", maybe the cancer would go away. This session caused her to reflect on the consequences that these feelings had had on family relations and for the first time she admitted that her reluctance to open up to her family had limited their understanding of her experience, often contributing to their inappropriate comments or responses. In this session she also questioned whether she was going to have the staying power to carry on fighting the cancer, which continued to present as increased pain and lack of mobility. She titled this session "Tug-O-War" and suggested that our next session focus on her shame of having cancer.

Session #9: "Free to Be Me"

We met again 2 weeks later at which time Ellen said that her blood counts had increased since our last session. Ellen's mobility was continuing to decrease and she was having increased pain in her stomach. She had been trying to find joy and purpose in her life and asked that this session focus on patience and endurance. When asked what gave Ellen a sense of joy, she said, "walking on a beautiful evening and viewing a beautiful sunset." This became the focus of the session, coupled with the Quiet Music program (Bonny, 2002). During Debussy's "Dances, Sacred and Profane" Ellen experienced a tremendous sense of peace while sitting in nature. This feeling subsequently shifted to a feeling of fear which overshadowed the sunset, causing it to turn to a dark gray. During Debussy's "Prelude to the Afternoon of a Faun" Ellen was confronted by and danced with a man shrouded in black. She identified this man as death and evil, and said that he reinforced feelings of doubt and fear in her, destroying any sense of joy and peace. Consequentially, she was able to stand up to this man and say to him,

Im getting stronger and you cant push me around or make me afraid. I wont live my life like that anymore. You have no control over me. Find someone else to manipulate and torture....Even through my many losses in this 5 years I am finding some purpose, something good is coming out of it. This is a dark period of my life but it does not mean that it will control me.

Ellen felt confident and empowered at the end of this session and titled it "Free to Be Me."

Ellen then disclosed for the first time how she was sexually assaulted at the age of 9, adding that she had never revealed this incident to anyone until a year before she was diagnosed with cancer. She advised that she and her brother had been approached by a man who had offered them a ride home in his car. Once in the car he had forcibly groped her body, before allowing them to leave. She remembered how this, combined with failing a grade, being bullied at school, and feeling that she couldnt reveal her emotions to her family, was a turning point in her youth and a time when she stopped laughing and began to withdraw from her family. She said that she was filled with emotions of anger "towards God, myself, and possibly my parents." She also admitted feeling that there was a relationship between these feelings and the breast tumor.

Ellens disclosure gave insight to the long-standing feelings of grief and sadness that were voiced in her first two poems as well as in many of our sessions. It gave clarity to her sense of solitude, the anger felt towards her mother and the difficulty she had in expressing aspects of herself that had been cloaked in silence for so long. It spoke to the anguish that was noted, in particular, in her poem "Words, Words, Words," acknowledging the "secret" that had been held in for so long and the impact it had had on her. Also, her connection of this incident to her illness spoke to one of the primary goals she had identified in our initial session.

Session #10: "Through the Valley"

We met again in 1 month. At the time of this session Ellen was experiencing nausea and increased pain. She was also undergoing numbness in her foot and face and was scheduled for a magnetic resonance imaging scan the following day. She was afraid of becoming paralyzed and regretted that she had not dealt with the cancer earlier on in its progression. Her predominant feelings were despair, hopelessness and a heaviness that she could feel in her lungs and chest area. She was also having problems breathing. It was still important to her that she strive to be independent and live alone, but she was finding it increasingly difficult. When asked for an image of what the feelings of despair and hopelessness might look like, she replied "a cement wall."

As the Emotional Expression I Program (Bonny, 2002) began with the "Allegro non troppo" from Brahms's Piano Concerto No. 2 in B-flat, Ellen was asked to focus on an image of a cement wall which she subsequently described as enormous and unbelievably thick. She commented on its ancient qualities and how long it had been there, saying that she was not certain that it could be scaled. She subsequently realized that the length of the wall was not long and that it was actually a square box sitting on the grassy field. She questioned why people had tried to scale the wall when they could have gone around it, and commented on how limited their vision was. When Ellen peered behind the wall which was now only a foot thick, she found a steep valley. She realized that it would not be easy getting down into this valley as there were no trees to hold onto, so she would have to slide down into the darkness.

Ellen subsequently visualized transpersonal imagery that reflected her dying process and the supports available to help her through it. Prior to dying she reflected upon how her life had unfolded in ways that werent what she had expected. While building up the nerve to descend into death she drew upon the strength and courage of her ancestors, encouraging herself to continue moving forward in the same way the pioneers had in her poem, "Yesterday." In completing the dying process she continued to review her life and significant persons who had impacted it and supported her. As the music ended she was filled with a transcendent awareness of her trust in God and a sense that all was well. Although she wasnt certain what was to come next, she was comfortable with the uncertainty.

{"Allegro non troppo" from Brahmss Piano Concerto No. 2 in B flat}... Im taking deep breaths and trying to build up courage. It wont take long to go through the valley but it seems I have to go through it. There is no one to go through with me. I dont always feel understood. I have to go through the valley alone. As a child I didnt have anyone there for me, or helping me... Giving up isnt an option. You can move through this. Never give up. Keep moving forward. Then become thankful for the strength and courage instilled in you as a child. A few minutes ago my head was bowed, shoulders stooped. Now I am standing up straight... Ive got that from within - from my parents and my heritage. I am on the steep side of the wall waiting to go down. Wondering how long it will take to go through the valley and what one might see. I would like to run through it in a few seconds. The way my life is who knows what I might find? I should muster up courage - I am a worrier -I make big things out of little things. . . .

{Brahmss "Selig sind, die da Lei tragen" from A German Requiem, Op. 45 begins}... I have had to face big things in my life. Can I cross the valley without bitterness? Life wasnt supposed to be like this. I never thought I would deal with this kind of stuff. The music is comforting - it draws me down into the valley. I am covered by protection - angels - they will be with me. I allow my angels to work. Angels are circling - some are over top. They have a glow; a light colored clothing... They are lighting the way . . . . [Q: What do you notice about the valley?] . . . There doesnt seem to be much there - it was darkness. There dont seem to be trees where dark things would hide behind. The path in the valley doesnt seem to be too bad. Were at the bottom. When I look up at the valley we will be climbing up - there is only light when they move with me. There are 10-12 angels with me...

{Brahmss "Irh habt nun Traurigkeit" from "A German Requiem, Op. 45 begins} . . . Im ready to start climbing now. I needed to have a break. The angels are climbing, too. It is hard work. I feel tired and it is slow going. They lift me up and grab hold of my elbows, helping me along. Theyre encouraging me, as I feel weak. Encouragement is felt by their presence - it pulls you on. I have bouts of extreme fatigue. Then I move through it and feel better or quite a bit better... Im just about at the top and my walk seems freer and my breath fuller. Ive reached the top - its so beautiful as I didnt realize how high up it is and how far I have climbed. Now I get to relax and breathe in the beauty, the air and the victory . . . .

{The music changes to Brahmss Symphony #4, "Andante moderato"}... As I lay stretched out in the grass there are lots of faces of people behind me. My friends, my family, church people, nurses, doctors, you, all the palliative people. I see faces, not bodies. Im lying in the grass on top of the hill and theyre in the sky . . . [Q: How is it to see these faces?] . . . Support - I couldnt have made it without the support, so I give thanks for the support . . . [Q: I ask if there is a response from the faces?] . . . No, I just know that theyre there and that theyve become good friends. Were not in this world alone. Now I stand up and walk into these faces, not really knowing what tomorrow will bring, but thats okay. Im just walking into the horizon, not sure where I am going - just walking. Its okay to not be sure - Ive dealt with the uncertainty a long time. I know where my strength and courage comes from. This only makes me trust in God and his faithfulness and wisdom. I can walk into the horizon with the sureness that all is well.

Immediately following this session while we completed an audio recording of one of her poems, Ellen spontaneously chose to add Psalm 23 to the same recording.

Psalm 23

The Lord is my shepherd, I shall lack nothing.
He makes me lie down in green pastures,
He leads me beside quiet waters, He restores my soul.
He guides me in paths of righteousness for his names sake.
Even though I walk through the valley of the shadow of death,
I will fear no evil, for you are with me;
Your rod and your staff, they comfort me.
You prepare a table before me in the presence of my enemies.
You anoint my head with oil; my cup overflows.
Surely goodness and love will follow me all the days of my life,
And I will dwell in the house of the Lord forever.

Ellen was reassured by this session, recognizing the need to ask for help and to allow people to help her. She recognized that the angels supporting her in the valley and her strong belief system were things that could only come from within. This reaffirmed for her that faith and belief could pull one through crisis. She also reflected on the need to keep putting one step in front of the other, believing and asking for wisdom, and living moment by moment. She titled this session "Through the Valley."

This session clearly reinforced the resources, allies and supports that already existed in Ellens unconscious and were waiting to assist her upon physical death. The poignant content of the session could be brought up again closer to end of life, as a means of reinforcing Ellens connection to her faith and her trust in God, and to the support that would be present during the dying process.

Session #11: "My Family at a Distance"

When we met 2 weeks later the dark man from session #9 was again discussed. Ellen felt that she had worked through this traumatic experience she had had as a youth, but realized that in trying to stand tall she had never allowed herself to cry. She found herself crying a lot since that session, and was able to allow herself to "be" with the tears. Ellen said that she didn't harbor anything against the "dirty old man" who had molested her, but that she felt anger at her mother for not being there and for not telling her the dangers of taking rides from strangers. She also felt anger at herself. Ellen said that as of late she had been dealing with the feelings of the lack of support she felt from her mother, both as a child and adult. Ellen had also recently seen a lot of her family, which had brought up feelings of isolation and of not being included.

As the Recollections Program (Bonny, cited in Grocke, 2002) began Ellen was asked to focus on being in a place in nature, with her family in the near distance. Ellen immediately found herself separated from her family by a river. During much of this session Ellen was reflective, again offering insight to the role she played in pushing her family away, even though she wanted to be with them. During "Brezairola" of Canteloube's Songs of the Auvergne she noted the positive changes that had occurred between her and her family stating,

There is hope and although things look the same, theyre not. I get a strong sense of forgiveness and to keep working on that I am loved, a created being. I was a child with trauma. I am taking the walls downthey were thick walls. Ive chipped at them everyday . . . . . The wall is coming down.

As the music ended Ellen and her family continued to be separated by the river. Her subsequent response to this was that theirs was "still a work in progress" and that "the forgiveness is coming." Ellen went on to say that she was hooked or bonded to her family before, but in a bad way, and that maybe, sometime they would be together. She titled the session "My Family at a Distance."

Session # 12: "Cleaning My House"

When we met again 2 weeks later Ellen had just returned from a family reunion. She had initially been very distressed about attending it, but described this time with her family as "blessed and wonderful." In the 2 weeks following the reunion she had spent time with five of her seven siblings, and in particular had shared a lot about herself with one sister. Ellen had begun the process of disclosing her private world with at least one of her family members. She had chosen to spend the up-coming weekend with her mother and had a sense that the distance between them had decreased saying "I feel there may be a breakthrough with Mom this weekend." She was continuing to work on disclosure and on how much to open up and invite her family into her life. Ellen felt that her anger towards her family had been decreasing since we started our sessions. Ellen was reflective in this session, wanting to focus on the cancer and find some meaning in the length of time she had been ill. When asked for an image of the cancer she described it as a "blob."

As the Mostly Bach music program (Bonny, 2002) began, Ellen was asked to focus on her aforementioned image of the cancer. During the Bach "Passacaglia & Fugue in c minor" Ellen found herself in a room with a being who was black, and whose head and limbs were like that of a man, but his body was a "blob". Ellen was scared of this being, revealing that his name was Fear. Ellen stated that she was tired of feeling fear, trying to find a sense of meaning and insight in the experiences she had undergone. She asked herself if it was because she had more endurance than others. Ellen subsequently noticed that she had ropes around her ankles that were attached to an anchor in the floor. Her family was outside the door but she was hesitant to ask for help, as it would mean she was obligated to return the favor. One of her brothers subsequently passed an ax through the door to her and she realized it was to cut her own ropes. During the Bach Concerto for two Violins Ellen voiced that she did not have the energy to cut the ropes, but was supported by angels who gave her a sense of strength. She took time to question what cutting the ropes would mean. A new way of life? Ellen commented that when she did cut the ropes and leave the room, the angels would be her support system, and ensure that she was all right. She also commented that "maybe my years of being alone are finally coming to an end."

In the post session Ellen talked about how she had bound herself with what had happened to her as a youth, noting the lack of guidance she had had to deal with the many emotions. As with her recognition of the impact of the shackles in session #5, Ellen again reflected on the events that have influenced her life. She said, "Those experiences put strong ropes on me and they stayed with me." Ellen clarified that it was okay to accept the ax from her brother saying, "I needed an ax to start working on those ropes. Now that Ive started to work on them hopefully theyll come down quickly and I can soar like an eagle." Of significance Ellen titled this session "Cleaning My House."

Although Ellen did not voice awareness that she was nearing end of life, her imagery, session title and post session comments indicated an inner awareness. In our next and last session, time was spent reviewing Ellens ten BMGIM sessions. Although she expressed a desire to continue with the work, our subsequent session scheduled in 2 weeks was canceled due to Ellens declining health. She was subsequently admitted to hospital and died peacefully four days later. In response to a request by Ellen, her mother became her primary caregiver during the last 2 weeks of her life and was with her when she died.

Discussion and Conclusion

In summary, Ellen used BMGIM to access a body of guidance, support, and insight from within herself to address issues related to her illness and end of life. She utilized the imaginal realm as an arena to seek reconciliation as she voiced feelings of resentment and anger towards her family and mother, and offered forgiveness to her mother. Twycross (2002) has spoken to the need of dying persons to complete their business, defining completion as being able to say "I love you; forgive me; I forgive you; thank you; and good-bye" (p. 277).

As a youth of 10 years old Ellen was able to both thank her mother and forgive her. The significance of this imagery is that the act of forgiveness spanned both the traumatic incident experienced by Ellen at 9 years of age and the related feelings of lack of support, as well as the subsequent pain of isolation and misunderstanding later experienced with the cancer. Lastly, the work undertaken by Ellen within the BMGIM sessions was replicated in her outer reality by improved relationships with her family and an ability to own her part in the conflict, as well as by the sacred request made to her mother at end of life, asking that she be Ellens primary caregiver.

One of Ellens primary goals in doing this work was to open up her heart, and find her authenticity and core being. Ellen was able to move towards this goal of re-claiming her own sense of identity and self, as her illness dictated that she surrender her commitment to the farm identity and its related family expectations. Of significance, it was upon achieving this awareness that Ellens illness shifted and began to move towards end of life.

Ellens other primary goal was to explore the deeper issues and emotions related to her illness. As the sessions progressed the content provided insight for her to reflect upon what she saw as the relationship between her cancer, the assault she had experienced as a child, and the long standing feelings of grief, sadness, and anger that had never been expressed. She was eventually able to grieve and express these feelings, both in relation to her experiences as a youth, and in relation to the changes that the advancing cancer had on her life. Lastly, she was able to be at peace with the resulting cathartic release.

Ellen used poetry writing to further express and understand her feelings. Her poems gave insight to her inner struggles, torment and anguish. They inspired the direction of several sessions, allowing Ellen to explore issues related to her mother and family and intense feelings of grieve and sadness. The significance of her first two poems, "Words, Words, Words" and "Untitled," became more apparent as the sessions progressed. In addition, her disclosure of the sexual assault gave additional insight to their content, and to the deep anger felt towards her mother whom she perceived had not protected her as a child. Through her final 8 months of life Ellen actively addressed the elements that were so prevalent in her initial poetry. Her additional two poems, "Moment by Moment" and "Yesterday," helped her to maintain hope and courage.

Ellen identified and acknowledged the feelings of shame that were related to having cancer, recognizing the role this had had in distancing her from both family and friends. She was eventually able to ask for help in her imagery, and from her family and the Palliative Care Team. Further, she was successful in directing and having a sense of control over her treatment process.

Ellens search to find meaning and purpose in her experience led to imagery of an archetypal nature whose related myth addressed themes of life, death, and life after death. Not only was she able to address fears of the cancer metastasizing, but also she was able to receive guidance of how to find meaning in her illness, a way to co-exist with it, and an existential sense of safety, no matter what happened. Ellen was continually supported by religious figures in the form of angels and Jesus Christ. Not only did these images reinforce her existing religious beliefs, but also they played integral roles in encouraging her to find resolution and forgiveness, in feeling a sense of worthiness, and in supporting her through her struggles. Lastly, she used the imaginal realm to prepare herself on a symbolic level for her death.

The touchstone of dying well - the sense of growing in the midst of dying - is for the experience to be important, valuable and meaningful for the person and his or her family. (Byock, 1996, p. 251)

References

Adelbratt, S., & Strang, P. (2000). Death anxiety in brain tumor patients and their spouses. Palliative Medicine, 14, 499-507.

Bonny, H. (1978a). Facilitating guided imagery and music sessions: Monograph #1. Salina, KS: Bonny Foundation.

Bonny, H. (1978b). The role of taped music programs in the GIM process: Monograph #2. Salina, KS: Bonny Foundation.

Bonny, H. (1980). G.I.M. therapy: Past, present and future implications: Monograph #3. Salina, KS: Bonny Foundation.

Bonny, H. L. (1975). Music and consciousness. Journal of Music Therapy, 12, 121-135.

Bonny, H. L. (2002). Music consciousness: The evolution of guided imagery and music (L. Summer, Ed.). Gilsum, NH: Barcelona Publishers.

Breitbart, W., Gibson, C., Poppito, S. R., & Berg, A. (2004). Psychotherapeutic interventions at the end of life: A focus on meaning and spirituality. The Canadian Journal of Psychiatry, 49, 366-372.

Bruscia, K. (1992). Visits from the other side: Healing persons with AIDS through Guided Imagery and Music. In D. Campbell (Ed.), Music and Miracles (pp. 195-207). Wheaton, Ill: Quest Books.

Bruscia, K. (1995). Images of AIDS. In C. Lee (Ed.), Lonely Waters, (pp. 119-124). Oxford, UK: Sobell Publications.

Budge, W. E. A. (1967). The Egyptian book of the dead: (The papyrus of Ani) Egyptian text transliteration and translation. New York: Dover Publications.

Byock, I. R. (1996). The nature of suffering and the nature of opportunity at the end of life. Clinical Geriatric Medicine, 12, 237-252.

Campbell, J. (1968). The hero with a thousand faces. Princeton, NJ: Princeton University Press.

Cassell, E. J. (1982). The nature of suffering and the goals of medicine. The New England Journal of Medicine, 306, 639-645.

Chochinov, H. M., Wilson, K. G., Enns, M., Mowchun. N., Lander, S., Levitt, M., & Clinch, J. J. (1995). Desire for death in the terminally ill. American Journal of Psychiatry, 152, 1185-1191.

Chochinov, H. M., Tataryn, D., Clinch, J. J., & Dudgeon, D. (1999). Will to live in the terminally ill. The Lancet, 354, 816-819.

Chochinov, H. M. (2000). Psychiatry and terminal illness. The Canadian Journal of Psychiatry, 45,143-150.

Chochinov, H. M., Hassard, T., Kristjanson, L. J., McClement, S., & Harlos, M. (2004). Dignity and psychotherapeutic considerations in end-of-life care. Journal of Palliative Care 20(3), 134-142.

Clark, M. F. (1995). The therapeutic implications of the heros myth in GIM therapy. Journal of the Association for Music & Imagery, 4, 49-65.

Cohen, S. R., Mount, B. M., Thomas, J. J. N., & Mount, L. (1996). Existential well-being is an important determinant of quality of life: Evidence from the McGill quality of life questionnaire. Cancer, 77, 576-586.

Conrad, N. L. (1985). Spiritual support for the dying. Nursing Clinics of North America, 20, 415-426.

Erdonmez, D. (1995). A journey of transition with Guided Imagery and Music. In C. Lee (Ed.), Lonely Waters (pp. 125-134). Oxford, England, United Kingdom: Sobell Publications.

Frankl, V. F. (1992). Mans search for meaning. (4th ed.). Boston, MA: Beacon Press.

Grocke, D. E. (2002) The Bonny music programs. In K. E. Bruscia & D. E. Grocke (Eds.), Guided imagery and music: The Bonny Method and beyond (pp. 99-133). Gilsum, NH: Barcelona Publishers.

Harstade, C. W., & Andershed, B. (2004). Good palliative care: How and where? Journal of Hospice and Palliative Nursing, 6(1), 27-35. Kellehear, A. (2000). Spirituality and palliative care: A model of needs. Palliative Medicine, 14, 149-155.

Kissane, D. W., & Clarke, D. M. (2001). Demoralization syndrome - a relevant psychiatric diagnosis for palliative care. Journal of Palliative Care 17(1), 12-21.

Kubler-Ross, E. (1997). On death and dying: What the dying have to teach doctors, nurses, clergy, and their families. (1st ed.). New York: Simon and Schuster.

Kuhl, D. (2002). What dying people want: Practical wisdom for end of life. Scarborough, Ontario, Canada: Doubleday Canada.

Marr, J. (1998/1999). GIM at the end of life: Case studies in palliative care. Journal of the Association for Music & Imagery, 6, 37-54.

Martin, J. A. (1993). An exploration of the contraindications in the Bonny Method of Guided Imagery and Music with the terminally ill. Unpublished manuscript, Temple University, Archives for Guided Imagery and Music.

Penson, R. T., Partridge, R. A., Muhammad, A. S., Giansiracusa, D., Chabner, B. A., & Lynch, T. J. (2005). Fear of death. The Oncologist, 10, 160-169.

Periyakoil V. S., & Hallenbeck, J. (2002). Identifying and managing preparatory grief and depression at the end of life. American Family Physician, 65, 883-890, 897-898. Retrieved November 15th, 2005 from http://www.aafp.org/afp/20020301/883.html

Puchalski, C. M., Dorff, R. E., & Hendi, I. Y. (2004). Spirituality, religion, and healing in palliative care. Clinical Geriatric Medicine, 20, 689-714.

Rando, T. A. (Ed.). (2000). Clinical dimensions of anticipatory mourning: Theory and practice in working with the dying, their loves ones, and their caregivers. Champaign, IL: Research Press. Rousseau, P. (2000). Spirituality and the dying patient. Journal of Clinical Oncology, 18, 2000-2002.

Saunders, C. (1988). Spiritual pain. Journal of Palliative Care, 4(3), 29- 32.

Singer, P. A., Martin, D. K., & Kelner, M. (1999). Quality end-of-life care: Patients perspectives. JAMA, 281, 163-168.

Skaggs, R. (1997). The Bonny method of guided imagery and music in the treatment of terminal illness: A private practice setting. Music Therapy Perspectives, 15, 39-44.

Twycross, R. G. (2002). The challenge of palliative care. The Japan Society of Clinical Oncology, 7, 271-278.

Ventre, M. (1994). Guided imagery and music in process: The interweaving of the archetype of the mother, mandala, and music. Music Therapy, 12(2), 19-38.

Wylie, M. & Blum, R. (1986). Guided imagery and music with hospice patients. Music Therapy Perspectives, 3, 25-28.

Yalom, I. D. (1980). Existential psychotherapy. New York: Basic Books. World Health Organization. (1990). Cancer pain relief and palliative care. Technical Report. Series 804. Geneva, Switzerland.