Music Therapy and Eating Disorders

A Single Case Study about the Sound of Human Needs [1]

By Susanne Bauer

Introduction

This article considers reflecting and integrating new theoretical perspectives into a music therapy intervention. In this case, the treatment of a young woman who was diagnosed with Bulimia Nervosa, was originally based on the psychoanalytical theory. Now, it will be presented and analyzed from an alternative theoretical perspective, the concept of resource- orientated psychotherapy and the Bernese concept of need adapted -and motivational attunement (Grawe, 1998; Grawe & Grawe-Gerber, 1999; Grawe, 2002; Stucki & Grawe, 2007). The presentation of "Mrs. H." follows some of the ideas developed by these authors and concludes by naming the intervention Need Adapted Music Therapy. The four basic needs, as they are defined by Grawe et al., are used to conceptualize the case. I describe how they "appear" symbolically during shared improvisational moments with the music therapist.

Mrs. H. was referred to music therapy with the classical diagnosis of Bulimia Nervosa, with episodes of binge eating two times per week. She presented herself as a person who suffered from a chronic eating disorder, which started about ten years prior to the music therapy treatment and which sometimes was accompanied by a depressive mood. She felt tired and her greatest wish was to regain normal eating behavior and physical strength.

Need Adapted Therapeutic Attitude and Treatment

The Bernese concept of need adapted and motivational attunement in psychotherapy is described in an article written by Christoph Stucki and Klaus Grawe in 2007. In an earlier paper, Grawe (1998) pointed out the basis of this concept-- the existence of four human basic needs which determine human motivational behavior. These needs are a) the need for attachment, b) the need for control and orientation, c) the need for increasing self-esteem and d) the need of augmenting pleasure and avoiding displeasure. Following the author's ideas, when building up the therapeutic relationship the therapist should know, recognize, and consider the patient's basic needs and expectations towards therapy, and show that she is open to them. In their training programs young therapists must learn to recognize and to distinguish their own basic needs from those of their patients; otherwise they will get confused and project their own motivational aspects and expectations onto their patients (Grawe & Grawe-Gerber, 1999). Only then, can the therapist have faith in the integrity of her own counter-transference perceptions and her resonator function (Stucki & Grawe, 2007), with the help of which she can "get" her patient's unconscious motivational structure [2]. In their reflections about activation of resources in psychotherapy, Grawe and Grawe-Gerber (1999) affirmed that the degree of satisfaction of basic needs in a person depends on his or her potential resources and on the way the concrete environment reacts to the needs. People with intra - or interpersonal conflicts often didn't get their needs met consistently in early infancy and learned compensative behavior patterns. The consistent attitude of the therapist towards the needs of the patient might reactivate her resource potential. Resources are considered to be the most important components of problem solving skills. A consistent responsiveness to someone's needs is the first step towards a good therapeutic relationship. In this sense, the therapeutic relationship itself is also considered a resource (ibid.).

Grawe and Grawe-Gerber (1999) support the hypothesis that in almost all patients attending counseling, loss has been experienced in the areas of at least two or three basic needs. Most of them suffer from the loss of self-esteem and loss of control and orientation and cannot feel pleasure or avoid displeasure. The need for attachment might have been satisfied in a distorted way. The fact that the therapist listens to them attentively, takes their words and emotions seriously and expresses her sympathy, has a positive effect on patients from the onset. In the beginning of a therapeutic process and in the initial diagnostic interviews, motivational attunement as an attitude means not questioning the patient's emotional state, her point of view and her perception of the world. At the same time, the therapist must structure the setting and the session to give the patient a safe surrounding for the expression of her needs. The proposal of an organized therapy plan, the certainty of regular sessions and dates permits the patient to reorganize her ideas and also her life rhythm. What is important is the active participation in this kind of restructuring. The patient must express what she expects and the time she is willing to invest in therapy, so that she also feels responsible for the maintenance of the therapeutic process. Grawe and Grawe-Gerber (1999) remark that many patients feel much better after a number of sessions. They feel and act differently; some of them even leave therapy, not because they disagree but because they feel relief and feel capable to go on alone. It seems that when basic needs are contained and responded to consistently and expectations are fulfilled to some extent, resources are activated. The better a patient feels, the more she is ready for cooperation and so is the therapist. The quality of the relationship improves and the therapeutic alliance will be solid (Grawe and Grawe-Gerber 1999).

Need-orientated Perspective

Based on the principal ideas of the Bernese concept, we can describe the basic needs as follows:

Need for attachment: the need for a stable and trusting relationship; the need for security and protection. The need for feeling accepted and respected by an open-minded person who thinks positively.
Need for orientation and control: The need for self-determination, active participation and making one's own decisions. The need for developing an identity: Who am I? What do I want? What do I need? Where do I go? Where are the limits? Where am I standing?
Need for increasing one's self-esteem: the need for being recognized. Knowing one's qualities and capacities and getting a sense that other people are interested in one's self. Trusting in one's own qualities and sensing that others do likewise. Need for appreciation and positive reinforcement. Feeling content with oneself without the necessity of over-adaptation and fulfillment of external demands.
Need for extending pleasure and avoiding displeasure: the need for enjoying life without feeling guilty, feeling comfortable with oneself and with others, not hurting oneself for the sake of unreachable goals or extreme achievements. Need for relaxation and expression of positive feelings; enjoying the sensation of satisfaction.

The Patient

Ms. H. came to the Outpatient Psychotherapy Service at the age of 28. She presented as a person with a chronic eating disorder and "moments of depression", as she called it. She was tired physically, partly due to her ongoing symptoms over a period of more than ten years. Since the onset of her symptoms she had twice been in psychotherapeutic treatment; the first time she went to therapy as an inpatient, the second time as an outpatient. She considered herself a sick person in relation to her eating behavior and she also recognized that her symptoms had a negative influence on the relationship with her boyfriend. They had only few social contacts and spent most of the time in Mrs. H.'s apartment instead of going out. Her best friends lived far away. She did not really feel sexual desire and quite often she had negative feelings towards her boyfriend.

Ms. H. was referred to music therapy because her earlier therapies were both verbal psychotherapies with which the patient had not been very satisfied. Ms. H. agreed and appeared motivated to try out a new treatment method although music had never played a very important role in her life.

Ms. H. was a committed bilingual secretary with a stable job. She was not married and had no children, but at the time of treatment she had been in a relationship with a man for about one year. She was working a lot with many extra hours during the week. She lived in a flat on her own, had no economic problems and organized her weekends with different activities. She did a lot of sports, sometimes some kind of extreme sport, other times, when she was not motivated, she would not do anything. Doing nothing made her feel very bad, as she was not able to enjoy moments of leisure time. She then felt guilty as if owing herself or someone something.

Before the bulimic symptoms started she had suffered from unspecific eating disorders since she was a child. At the time music therapy started she was having two episodes of binge eating per week.

Family Context, Needs and the Early Onset of "Symptoms"

Ms. H. was an only child. Her father was a businessman, her mother a teacher. As far as she remembered, her parents had always worked a lot. Her mother joined her father's company after a few years of working as a teacher; both were very ambitious and successful. They were considered a respectable family and esteemed by their neighbors. She was expected to be like her parents: this meant to be a brilliant student and to bring home good grades from school. Her parents' main interest in her consisted of the "final results" and as far as she remembered, the only questions they asked her while sitting at the table were about her marks. Affection was a sort of recompense for successful achievements, but did not exist in other contexts. She felt that her real wishes and needs were never heard or taken into account. Her childhood was therefore difficult; her parents lived their lives, held their own "adult" conversations and did not include her very much. Whenever she tried to focus the attention on herself, for example, by rejecting food and making a scene while sitting at the table, her behavior did not get the desired reaction. Another attempt to get into contact with her parents consisted of mediating between them when they had an argument. She did not gain anything but reproaches although her intention was to do her best and to make them feel happy again. Another strategy she developed to gain attention was to eat more and more and get fatter. But even this would not have a big impact on her parents. Instead, she began to feel ugly and suffered a lot when people saw her as the fat little daughter of this young-looking, slim and sportive mother. Some people even thought that she and her mother were sisters. She thought that her facial expression must have become sadder during this time, as one day her mother demanded of her to always be "her happy little girl". She decided to never show a sad face again and to do everything to fulfill her mother's desire. She hoped to come closer to her this way. Instead, she became more and more desperate, but learned to smile and to not disappoint her mother. She remembered one of the most remarkable days of her life: that day she was alone in her room when she suddenly had a crying fit and was not able to stop her tears. She could not calm down until she found a bar of chocolate and ate it. She stopped crying and felt a great physical and emotional relief; from this moment on she "cured" her sadness with eating lots of sweets. She discovered that by vomiting she could even control her weight. So she achieved two aims at the same time: calming down and not getting fat. Everything was perfectly regulated and indeed, she now fit into the scheme of the "perfect daughter" within a "perfect family".

At the age of eighteen, her eating behavior spiraled out of control and episodes of binge eating overwhelmed her and apparently occurred independently from her emotional states. She felt the need to eat whatever she found, but secretly. Later she prepared her binges by buying all kinds of high calorie food. Once the "ritualistic mission" started in her mind, she could not interrupt or stop it anymore, but just kept fulfilling the cycle: buying-planning and preparing the right moment-eating-vomiting-feeling guilty and depressed. The episodes of binge eating were independent from the family surroundings and did not stop when she moved to a flat of her own. She felt very alone when she was referred to inpatient treatment and her mother went to see her only once in two or three months. Her father never went to see her. She again felt not only that nobody had any interest in her, but also ashamed and guilty for her deplorable state.

The only family member who seemed to like Ms. H., as far as she remembered, was her mother's sister. She lived in America and was a very successful businesswoman. Besides that, she was a friendly and very caring person who showed interest in her and - since Ms. H's childhood - brought a lot of gifts every time she visited the family. Ms. H. found her aunt to be very congenial, warm and genuine and always wanted to be like her.

The Music Therapy Process

Ms. H. was interested in her new therapy and accepted the proposal of one session per week for the following ten months. The time frame seemed adequate for the patient from a therapeutic point of view. The patient, too, preferred a short-term to a long-term therapy. Each session was about 60 minutes long. Ms. H. signed a consent form and agreed to be videotaped. The Psychotherapy Service was part of the Department of Psychotherapy at a German university, so this was the usual way of working for all therapists and patients. The sessions took place in the music therapy room of the Department of Psychotherapy. The treatment included 28 sessions and the patient had no other psychological or pharmacological treatment while receiving music therapy.

The patient came regularly, never missed a session, was always very well dressed and in an almost "perfect outfit". Her weight was within the normal range; she looked neither overweight nor thin. Her physical bearing seemed somehow slack. Her facial expression was serious and she looked sad. Nevertheless, she often tried to smile.

The Patient's Expectations towards Music Therapy

During the first sessions the patient described some of her goals. She wanted to learn to eat normally, to regain physical strength and feel better emotionally, especially around her boyfriend.

These goals were very symptom orientated and limited and did not represent a real indication for music therapy.

After a few sessions she reformulated her goals: she wished to get more relaxed and to become a less success-orientated person. She wanted to learn not to fulfill everybody else's needs and to renounce her self-imposed-role of the well-adapted person. She wanted to learn how to express her "negative" feelings, how to say "no" without being afraid of rejection. On the other hand, she wanted to learn to show her gentle, soft and more feminine side, to listen to her inner voice and to learn to enjoy life, to enjoy free time and to not worry about leisure time.

When asked about her self- image, it became apparent that it was very disturbed and that she had the worst opinion about herself. She thought she was ungraceful and felt that nobody really liked her and that other people - also the therapist - might get bored with her easily. On the other hand, she felt that in spite of her bad self-esteem she often found herself in exposed situations, because of her impulse to "make noise" and to seek other people's attention; this exposure could happen as a consequence of special achievement or through loud-voiced behavior. She was aware of her ambivalence of needing to be noticed on the one hand, and being afraid of other people's expectations and her inability to fulfill them on the other hand. Besides that, she felt guilty when she showed who she was, what she felt and what she really needed.

The patient's motivation, the rephrased aims and the aspects of her self-image largely fit with the possibilities of music therapy (Smeijsters, 1999) and spoke for an indication of the treatment.

Observations on Meeting Basic Needs, Based on the History and Declared Goals for Music Therapy

For the sake of meeting her basic needs, the patient learned that self esteem, recognition and attachment could be attained through the negation of her real self and her own desires, through over-adapting to reality and fulfilling the expectations of others. Her need for pleasure was distorted and perverted into "I never feel satisfied, I always find things to do better; discontent stimulates me to reach more and more; otherwise I would feel boredom and standstill" (2nd. session). The self-regulation process "conspired" with her external control mechanism so that she would not feel what was right or wrong by herself, but by the reaction of others - adapting to their measure of right and wrong. She was over-sensitive to others' signals, words and gestures and able to adapt and harmonize immediately. The cost was high since she had to control herself all the time resulting in her fatigue during the last twenty years. She compensated and regulated her own need for control and orientation through eating ceremonies, which really formed a vicious circle: the eating ritual (Bulimia Nervosa) represented a closed system, following cybernetic epistemology and systems theory (Haley 1983), with all consequences, leading to implosion instead of bringing about new information and personal development, growth and learning.

Musical Characteristics and Possible Expression of Basic Needs

In the beginning stages of the therapy, some of the patient's typical patterns in the music improvised by patient and therapist were as follows:

Loud, hard and harsh sounds, sudden aggressive sounds, combined with a slack body posture - therapist playing loud at times, aggressive and overwhelming. Audio example no 1, session 15:
Soft "adhesive" sounds - therapist playing low, melodic structures or regular rhythms.
No melodies or other recognizable rhythmic structures or forms - therapist playing "on her own"; isolated sounds.

In the loud and harsh sounds, preferentially played on the big tube xylophone or on the piano, the therapist sensed a search for attention mixed with rage and desperation, as if saying or crying: It's me! It was as if she was waiting for recognition based on the need for appreciation and positive reinforcement, but in an unfavorable manner. Instead of showing herself with her "qualities", she presented the unwanted, unhappy and helpless child. At times the loud playing transformed into a quality of rivalry and aggression between peers and created a competitive atmosphere. It sounded and felt like the need for controlling the situation, standing up for some idea and not giving up. It had power and energy but did not last and was not a real dialogue. The improvisation between therapist and patient was also characterized by a sudden, brief promising contact, which then was quickly interrupted by a surprising change into another way of playing. Direct contact did not last. Instead it seemed to be like a temptation which was immediately followed by retreat.

The soft sounds produced the sensation of timidity, fear and loneliness. The patient rarely used small instruments, like kalimba or glockenspiel. So even these timid sounds always came from rather big instruments. When combined with an "adhesive" way of playing, through imitating the therapist for some moment, it felt very much like the need for attachment, the need of the protective other; the sensation of helplessness arose and in the therapist the wish to reassure the other came up. The low sounds also provoked tension and curiosity, as well as the impression of the presence of a secret within a mystic atmosphere. The therapist then felt a kind of "mixed and morbid pleasure". Maybe this was the sort of "pleasure" she had learned to feel and which was related to her helplessness and her distorted self-regulation. Being alone and unhappy, she learned to build up secrets with herself, which made her feel unique and independent, of course it was not a real independence but a pseudo-independence.

The chaotic and the almost arbitrary way of improvising produced an atmosphere of getting lost. It made transparent the need for identity, orientation and control. At the same time, thinking in psychoanalytical terms, it invited the patient to have fantasies like "incestuous entanglement" as there were no limits and no boundaries.

In general, the improvisations were long rather than short and rather using a lot of sounds than silent moments and periods. The patient preferred rules before engaging in free improvisation. The fear of not being noticed every time that no music sounded was very big, as well as the fear of getting lost when no rules were given. The self-regulation worked while she had some control over the situation. In contrast to this, it brought her into a conflict when she was invited to try out "The New".

Topics Relevant to the Patient in the Course of the Treatment

During the ten months of treatment different topics arose through instrumental improvisation and verbal reflection. Sometimes the patient brought concrete ideas to the session in terms of what she wanted to talk about and play this day. Sometimes the therapist made a proposition. Both patient and therapist chose their instruments deliberately. Sometimes an improvisation was referrential, at other times there was no specific frame. Therapist and patient almost always played together and the observations that followed the improvised music were connected to the relation between the instruments, the feelings of the patient while playing or consisted of an associative metaphor, which was related to the patient's symptoms and needs. Some of the topics during the music therapy process were:

Looking for recognition and appreciation for what I (really) am.
Taking centre stage with all my fears.
Creating boundaries, saying "No".
Longing for shared experiences while being afraid of too much closeness.
Enjoying the music without feeling guilty.
Looking for the sensation of safety.
Building up The Own - The New - The Chaos.
Feeling the silence without boredom.
Being heard by the therapist in spite of the whispering sounds of my instrument.
Letting things go and detaching, even if they are not perfect.

Musical Patterns of Change

The loud and sudden, unstructured and harsh way of playing transformed into a more intensive and intentional way of playing with a more direct contact to the therapist's music: short dialogues in a-b-a-b �format, which she did not do before and shared elements like ups (crescendo) and downs (decrescendo) in volume.
The low volume playing became also more intentional, more intensive, like "a soft touch", possibly expressing what she called her "feminine side". She could combine loud and low volume music better without separating them as much as before and establish a better connection between them.
She started to create her own melodies, contours and limits. Likewise, the increase in intentionality in her playing gave the music a different strength and made it sound more authentic. There was clearly a presence of a self and identity.
Audio example no 2, session 21

Other Changes and Learning Process

During the music therapy process, the patient had the experience that the therapist was interested in listening to her and that the therapist did not get bored when she was playing quietly or in silence. She could feel that the therapist would not get lost or lose her when sounds diminished. She felt accompanied, but still could not always share her feeling of inter-subjectivity musically (Stern, 1985).

She experimented and learned that she could set her own limits in terms of time, space or intensity without that the therapist became annoyed or left her and without feeling guilty herself. Whereas at the beginning of the therapy, she interpreted her own loud and long improvisations as putting a limit without understanding against what, she then understood it as the trial of the escape from a real and authentic contact with the therapist.

She became aware of the fact that it was not the therapist who expected her to play in a certain manner or to achieve musical aims, but her over-adapted Self. She became less ambitious and could accept her "imperfect" way of playing. Starting her music therapy treatment, the patient perceived the therapist still as a rival or as a superior playing against or for her, at the end she partially enjoyed playing and creating with the therapist. Instead of waiting for the therapist's opinion or judgment, she learned that it was possible and even better to be self-aware and to trust one's own music. This was necessary to develop a sense of Self.

Conclusion and Discussion: Conflict Orientated or Need Adapted Intervention?

As a conclusion we can say that analyzing the improvisations focusing our attention and our music therapeutic ear on the basic needs, as described above, we can find them expressed in the patient's way of playing, in her way of using the instruments and in her embodied attitude while playing.

Nevertheless, during the therapy, the therapist was thinking in terms of conflict and not in terms of basic needs. The idea about the unconscious conflict, for example, between the longing for closeness and at the same time, the fear of coming too close and being refuted again, as well as the therapist's counter transference feeling of deception or anger, guided part of her musical and verbal intervention.

But we also realize that the therapist, more than provoking or confronting the patient with her unconscious conflict, for example, of rivalry, tended to accompany and play with the patient in a holding way. The therapist always carefully chose her instrument after the patient did so, sitting down on the floor or standing behind her instrument following the patient's position. The therapist was "just there" most of the time, without challenging the patient. The patient reacted to this emotional-musical responsiveness opening herself and getting into an authentic contact with two very important "systems", the person of the therapist and the music itself. This highly dynamic process led to intentional interaction and to what Bowen calls a "feeling of togetherness" (Kerr & Bowen, 1988). Altogether, this situation of interaction between the different systems helped to increase knowledge, which is the base of all learning processes and personal development.

The author of this article is convinced that it makes a difference if thinking and feeling in terms of "need" or thinking and feeling in terms of "conflict", and that this difference must be expressed in the music therapist's verbal and nonverbal attitude. Although the conflict is the result, again, of the unsatisfied need followed by the unconscious distorted or neurotic reaction of the person to it. Maybe this is the reason why we found both conflict and need- adapted interventions and attitudes in this particular case.

The patient started a couples' therapy with her boyfriend shortly after the music therapy treatment ended. Her episodes of binge eating became rare and she wanted to work on her sexual conflicts, the lack of sexual desire and pleasure and the fear of sharing erotic experiences.

Notes

[1] The author will use the feminine form when referring to therapist and patient, as in this special case, both were women. This will include all male therapists and patients, too.

[2] This term was introduced into music therapy by Langenberg (1988). See also: Kenny, C., Jahn-Langenberg, M., Loewy J., 2005. For the psychotherapeutic context Fuchs (2005) speaks about complementary, mimetic and body resonance from a phenomenological point of view.

References

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Kenny, C., Jahn-Langenberg, M., Loewy J. (2005). Hermeneutic Inquiry. In: Wheeler, B. (ed.) Music Therapy Research. Second Edition (pp. 335-351). Gilsum, NH: Barcelona Publishers.

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