View of Embracing Life with AIDS: Psychotherapy through Guided Imagery and Music

Embracing Life with AIDS: Psychotherapy through Guided Imagery and Music (GIM)

By Kenneth E. Bruscia

Editorial note: Reproduced by permission of Barcelona Publishers. Taken from: K. E. Bruscia (Ed.), Case Studies in Music Therapy. Gilsum, NH: Barcelona Publishers.


Background Information

At the time we met, Matt was 26-years-old, and had been diagnosed as HIV positive just a few months earlier. I remember our first meeting quite vividly. When he shook my hand, I could feel him trembling. He was tall and gaunt, and had dark circles around his eyes. He looked scared and worried, and smoked one cigarette after another. When he smiled, he had to visibly work the muscles in his face. Sometimes I caught him looking at me to see if I was looking at him.

Matt complained of dizziness, tremors, nausea and fever, for which he was taking several different medications—in addition to AZT (an anti-viral drug for AIDS) and Xanax (a drug to control anxiety). He talked about his symptoms and medication needs in a very serious way, almost as if he needed me to know how much he was suffering, or how sick he was. Perhaps he was trying to tell me how much help he needed. I felt uneasy because, in fact, I was wondering if he really needed to take so many things, especially since many of his symptoms can be side-effects of Xanax (Schatzberg & Cole, 1986). I was also worried that he might be relying on drugs to fix (or numb) everything in his body and thereby relinquishing responsibility for his health to doctors and medicine.

Matt had stopped working, and in the last few months, had also stopped going out altogether. He was "petrified" of passing out on the street from dizzy spells, or having a full-blown anxiety attack with other people around. Apparently, he spent most of his time at home watching television, trying to distract himself from his ruminations and fears.

Matt told me that he had contracted AIDS through his work as a hemodialysis technician in a nearby hospital. He said that on several occasions he had stuck himself with an infected needle. As he told me these things, the tone of his voice became quite emphatic, even clipped. It sounded like he did not want me to assume that he had been promiscuous or that he used drugs. It upset me that he might worry about such a thing, so I tried not to change my facial expression or body language. I wondered if he had already experienced blame from others. I thought of all the people I know who justify their detachment from AIDS or their negligence of those who have it by simply saying, "They deserve it!" On the other hand, he himself may have feelings of guilt and shame. Maybe he feels he deserves it.

As Matt continued, I had to change my body position to let go of some of the tension building. Matt has been in a love relationship with the same man for six years. They live together, and Matt feels their relationship is quite strong. John is ten years older, and has a Ph.D. His results were negative on the HIV test. Right now they are having serious financial problems because John has just lost a high-paying job as a hospital administrator. To make matters worse, Matt's current insurance company refuses to cover his medical expenses. Matt changed jobs (and insurance companies) before being diagnosed, and now neither company will take financial responsibility. Matt has also been refused Social Security benefits and welfare. Understandably, his face was filled with anger and frustration.

Matt then shifted the conversation to his family. He has already told them all about his situation: that he is gay and that he is infected with the virus. I was relieved, for this is not always the case: many men like Matt face AIDS alone, without the support they need from loved ones. Matt is very close with his two sisters, and talked at great length about them and their children. Then becoming rather terse, Matt described his mother as a "dominating bitch," and said he has an ongoing battle with her. He then described his father as passive and uninvolved, and said no more.

I then asked him what he would like to accomplish in our work together. Matt replied:

I get these terrible images . . . I can see myself dead . . . It feels like I am falling backward into a deep black hole . . . I live in constant anxiety, dreading the minute that they will come back . . . When they don't go way, I go into complete panic . . . Sometimes I imagine John sitting beside me, and that helps to calm me . . . After the images go away, I get very depressed . . . I can't live like this.

I was moved by what he said, realizing more each moment how desperate his cry for help was. I also realized that his trembling was more than a body symptom: his whole being was shaking.

I began to explain how Guided Imagery and Music (GIM) works: that after helping him to get relaxed and focused, I would put on a specially designed tape of Western classical music that would stimulate his imagination; that while listening, he might have body sensations, visions, feelings, memories, fantasies, or any variety of internal experiences; that while he was imaging, we would have an ongoing dialogue which I would transcribe for later reference; and that I would be with him throughout, helping him to explore his inner world in whatever way he wished. We talked about the possibility of his fearful image coming up, and that eventually he may need to confront it. Matt felt willing to take those risks, if someone was at his side.

Treatment Process

Moving into Imagery

After preparing the space and making both of us as comfortable as possible (Matt lying on a floor mat, and me sitting beside him), I asked Matt to close his eyes and to start breathing deeply. I then led him through a relaxation induction that I created based on our previous discussions. It involved having Matt imagine a ball of light moving through his body and making each part feel "strong" and "alive."

I took this approach for several reasons. First, I was worried that closing his eyes and experiencing the darkness would trigger his fearful image of falling back into a black hole. Thus, focusing him on a light would help him to illuminate or move away from the darkness. Second, Matt expressed such fear over "falling dead," that I felt that he needed to perceive himself as strong (in control) and alive in order to relax more fully. Third, I purposely used a "see-feel" sequence in the induction (i.e., see the light, feel strong and alive), because in our previous discussions he had described his experiences in this way (i.e., seeing himself dead then immediately feeling himself falling backward). Following how someone sequences their sensory channels to process their experience helps to build rapport while also facilitating inductions to an altered state of consciousness (Grinder & Bandler, 1981).

I selected a GIM tape program that is commonly used for a first session, originally called “Group Experience.” It consists of six musical selections (which are cited in italics below), lasting a total of 42 minutes. As each piece is quite different in instrumentation, mood, and style, the program has the potential to evoke many different imagery processes (visions, memories, fantasies, feelings); and since each piece is relatively short, the program also allows the imager to move in and out of each image or process as desired. By encouraging the imager to explore different areas and layers of the imagination, the program is useful for clinical assessment.

The Imagery Preview

Often GIM sessions present different chapters in the person's life, with the first session giving a preview of the entire story about to unfold. This was particularly true with Matt. Images from his first session set the stage, painted the scenery, and introduced the main characters of his life story. In the ten weekly sessions that followed, these same images returned, transformed, generated new stories, and clarified themselves continuously—as if they were speaking to Matt's psyche with insight and loving persistence.

Matt's began his story alone—stranded on an island. The opening sections of Ravel's ballet, "Daphnis and Chloe" set the scene. {Note to the reader: The italicized sections below are taken from session transcripts. Brackets have been used to enclose my interventions or observations, and titles of the music being heard. Ellipses have been used to indicate silence, passage of time, or irrelevant segments of the transcript.}

I am walking along a deserted beach . . . alone and stranded . . . I can see a huge rock ahead, blocking the shoreline . . . [Allegretto from Brahms' First Symphony begins] . . . I want to walk around it and get to the other side . . . but I don't know how . . . [Take a good look around] . . . [The "Gianicolo" from Respighi's "Pines of Rome" begins] . . . Gulls are hovering over the edge of the rock, way out in the water . . . I can't get around it in the water . . . I have to walk inland . . . I'm climbing around the rock . . . I see a cave that looks like a big black hole in the ground . . . [How do you feel?] . . . I am scared . . . But I'm OK—there are iron gates blocking the entrance . . . I am walking past the cave entrance . . . I see an old dead tree that has fallen to the ground . . . Its roots are all sticking up . . . Its trunk has been burned and there is a hole in it . . . [The "Sirenes" from Debussy's "Nocturnes" is playing] . . . It's getting dark and starting to rain . . . I don't think I can get around this rock . . . It seems senseless to go on in the dark . . . I better go back to the beach . . . I'm walking back . . . [How are you feeling?] . . . Really frustrated . . . and anxious. I want to get off this island, but for some reason, I can't . . . [Tschesnekoff's "Salvation is Created" begins almost inaudibly] I'm back on the beach . . . [How does it look now?] Over the water, where the gulls were, I can see people dressed in black, floating and hovering in the air . . . [Notice anything else?] . . . I'm looking all around . . . Oh, my God . . . Two men are coming to rescue me in a boat . . . I can't see their faces, but one is dressed in red and the other in blue . . . They're taking me to their boat . . . They don't have faces . . . [Pachelbel's "Canon in D" begins] . . . I'm getting in . . . we're leaving . . . I'm looking back at the beach . . . I see a small child that we've left behind . . . and a huge black bird is perched on the hill behind him, looking down . . . We are reaching the mainland . . . The blackbird has followed us here, and is hovering over us . . . I'm going home now, where I can be safe.

As the tape ended, I helped Matt to return to waking consciousness. In our discussion of the imaging experience afterwards, I encouraged him to react to whatever affected him most, while also focusing him on aspects of the experience that I felt were significant to his therapeutic process.

This session gave an incredibly accurate preview of Matt's process. In the next seven sessions, he weaved in and out of the main images in this session, and each time, the images transformed or moved his life story along. What follows is a description of how Matt worked through these central images (i.e., the black bird, the rain and the house, the island cave, and the abandoned child), and as a result was resurrected to a life with AIDS.

The Black Bird

The black bird was a key image in the first session—one that had already begun some kind of active transformation process—from a gull, to hovering people dressed in black, to a huge blackbird with a foreboding and ominous presence. Matt felt threatened by the bird, yet he did not voice his fears, neither during nor after the imaging—as if it was too much for him at the time. Matt was also unable to identify what kind of bird it was. I allowed my own feelings to enter my awareness: I did not trust it with the child. I did not like it hovering and following—like a vulture insidiously waiting to devour a carcas. I was afraid of it.

Before the second session, I went through the transcript I had taken of Matt's imagery, and discovered that the bird appeared when Matt was confronted with an obstacle, when he felt powerless to escape, and when he left the child behind. My inquiry made me feel like I had begun to hover over the bird hovering over Matt, and I wondered why I felt it was important to do this. Does Matt need to be protected, or do I need to reassure myself that (like any good therapist) I could protect or rescue him? Will my rational understanding of the image somehow make it go away? Did I need protection from it?

The bird did not re-appear in Matt's imagery for several sessions, however it did arise quite prominently in his mandala drawings. In the first, he drew the bird quite representationally, flying beneath the sun. In subsequent portrayals, it changed positions and shapes. In the next drawing, it was so big that it created an eclipse of the sun; in another it was a large ground mass (like a black hole); and in the next, it turned into shadowy human figures on the edges of the mandala, with their backs towards the viewer.

Then, in the fourth session, the bird presented itself again in Matt's imagery. Bach's "Passacaglia and Fugue in C Minor" set the stage. Matt was walking along a path with the blueman and redman, when the bird appears and starts to follow them. As the melody in the bass repeats over and over, the bird circles and hovers around them, getting closer and closer with each increment in volume. The fugue begins, and relentlessly piles layers of fear and frustration on top of one another as the three men watch the bird hovering over them, arguing among themselves. A terrifying climax is inevitable, and as the chords crescendo to a crashing close, the blueman overcome by anger, shoots the bird to the ground.

A long silence ensues before Bach's "Come Sweet Death" begins—the music is now slow and desolate, and Matt sighs deeply, showing great consternation in his face, despite the relief evident in the rest of his body. When asked, he explains that he feels confused about why the blueman, who is his model of goodness, has killed the bird—rather than the redman (who Matt believes has an evil side). In the next piece (Bach's "Sarabande" from the "Partita in B Minor"), Matt questions the blueman, who refuses to explain himself other than to say: "One day you will understand." Matt's frustration with this evasiveness builds during Bach's "Little Fugue in G Minor" until all three men decide to leave. As they do, Matt has to pass by the dying bird. As he does, the bird tries to communicate to him, but is barely audible. Matt refuses to listen, and supported by the strong bass notes in the fugue, steps over it quickly, in contempt and disgust. In the final fortissimo chord of the fugue, a black snake sneaks away in the grass.

The slow movement of Brahms' "Violin Concerto" begins, and as the violin plays long, tender melodies over a soft orchestral accompaniment, Matt shares how he feels about the redman and blueman. Despite their differences, he loves and accepts them both. Then a wonderful transformation takes place during Bach's "Double Violin Concerto." Matt takes the blueman and redman by the hands and pulls them into himself, as if to unite them and to re-incorporate them into his own being. As he does this, the three merge to form a large green swirl. This integration takes place as the two violins (blueman and redman) play with orchestra (Matt) in perfect, harmonic counterpoint, each part barely distinguishable in timbre but clearly different in contribution.

Afterwards, Matt and I talked about what a relief it was to be rid of the bird. Matt felt like he had been successful in overcoming a menace that had tortured him for a long time. We talked about what menaces in Matt's life this bird might have represented, and how good it felt to triumph over them. We talked about the need to be strong to conquer the menaces of life, including AIDS. We also discussed how uniting the redman and blueman felt like he was literally "pulling himself together."

I was silently skeptical because of the black snake that appeared—I suspected that it was yet another transformation of the bird. The next week, Matt drew a mandala that had a huge black phallus penetrating the lower left part of the circle. In my thinking, the bird had transformed yet again, but I said nothing to Matt. He believed that the bird had really gone away, and in fact, it did not appear in his images for several sessions. Then, another mandala appeared with many black spots evenly scattered throughout the space. I could not help relate it to the previous drawing. It looked like the black phallus had exploded, and germinated enough spots to completely occupy the territory. The spots looked like sperm—the black sperm of the bird (or snake). Since AIDS can be transmitted through sperm, I further imagined that, in Matt's psyche, the bird was the carrier of AIDS, the 20th century black plague, and the black messenger of death.

In the fourth session, the bird re-appeared. Matt was sitting under a tree, as the Adagio from Marcello's Oboe Concerto edged him into feelings. The tree was alive, and its roots were in the ground, but it was very sad and lonely. Its branches were drooping downward, and there was a large hole in the trunk. It sounded like the tree he saw in the first session—before it had been uprooted from the ground. I wondered if Matt had gone back to an earlier time in childhood. He had.

I am wearing blue pants and a red shirt . . . an outfit I had when I was 8-years-old . . . The blackbird is back . . . It's perched on top of the tree . . . [The Adagio of Rodrigo's Concerto de Aranjuez begins]. The tree is trying to shake it off . . . but it can't. It's starting to rain . . . My throat is tickling . . . [Matt's body begins to writhe, and his voice gets constricted]. I am stuck on the ground . . . I feel caught . . . paralyzed . . . My arms and legs are so heavy I can't move . . . I am trying desperately to move . . . but I can't . . . .[long silence during orchestral version of Bach's Prelude in E-flat Minor] . . . [What's happening now?] . . . I am down at the stream . . . washing myself . . . The bird has gone away.

Matt's images came to a close peacefully, with the Romanze from Dvorak's Czech Suite—as if nothing had happened. I was shocked. What had transpired in those few moments of silence? Since it was not possible to pursue the matter within the imagery, I waited until Matt had regained consciousness, and then asked how he freed himself from the ground. Staring straight into my eyes with a stone face, Matt answered: "Sheer rage!" I noticed that that he was trembling again. No more was said.

Strangely enough, the bird never reappeared in Matt's imagery. I took this as a sign that the full story, without symbolic or fictional characters, was ready to unfold. Often, images and symbols provide us with safe ways of dealing with very disturbing material, things that we repress and do not allow into consciousness. The bird had been very important to Matt because, as we shall see, it allowed him to work through very painful material in a gradual and ambiguous way, just as dreams do. The elusive nature of the image and its lack of reality as a "figment of his imagination" allowed Matt to deny or distort its true meaning at the earlier stages; however, every time it recurred, the bird further redefined itself, and in so doing began to gradually debunk each denial and distortion, until Matt was willing and able to admit and integrate into his consciousness what really transpired in that image and what the bird really signified.

This did not happen until a few sessions later. Several other recurring images had to develop sufficiently until Matt would be ready to recount the life events that he was trying so desperately to forget and confront at the same time.

The Rain and the House

Images of rain storms appeared in several of the early sessions. Rain is so ambiguous! It cleanses, muddies, and fertilizes. It can bring relief from a drought, or it can flood the landscape. It can pour down from black clouds or fall gently from grey skies, and when the sun follows, it can bring rainbows and pots of gold. It comes from above, as if the good and bad of it are sent to us from the heavens by God (Cirlot, 1971).

When Matt encountered rain, it was "stormy weather," and he frequently sought refuge in a house. On the first occasion, Matt was walking along a country road, and passed by a white house that belonged to an elderly couple. Some time later Matt saw black swirls in the sky, and fearing that a storm was coming, ran back to the house for protection. Upon his return, he found that the windows and doors had been boarded up. Unable to go inside, Matt stood on the porch and waited until the dark clouds and rain had passed.

I remember this image so vividly. In my mind's eye, the house looked like the faces of his parents: with their eyes, ears and mouths completely covered. It was as if Matt were seeking the safety of his home, wanting to take refuge in the laps of his parents (the porch), but they had gone off somewhere and left him behind, at least in spirit. Their eyes had blinders on and they were unable to see the storm; their ears had been plugged, and they could not hear Matt's call for help; and most disturbing, their doors were closed, as if they were no longer willing or able to give him refuge from the storm. The image of Matt standing on the porch reminded me of the child who had been left behind on the island, unprotected from the bird. Each time Matt saw a house in subsequent sessions, there was danger lurking. In the third session, he escaped another storm by running onto the same porch with his lover; in the fifth session, he passed a house before entering the island cave which had frightened him earlier. Again it was raining.

The Island Cave

Matt went to the same island in three of the initial five sessions. Islands are often isolated places where people go to withdraw (very much like Matt's apartment). They are also places of refuge from the ocean—or the deep, threatening waters of the unconscious (Jung, 1954). I felt that this was particularly relevant to Matt. He seemed to be struggling with whether he should allow certain material to emerge or to suppress it. Every time he went to the island he encountered some kind of threat, but then would leave before confronting it. His images on the island were full of fantasy and symbolism, with very few real-life people or events, suggesting that he could only deal with these images if their true meaning was disguised in some way. His repeated returns gave me the sense that he had some unfinished business to clear up there before he could leave it once and for all.

After the bird had been slain, Matt gained greater confidence in confronting images that frightened him. In the seventh session, he returned to the island and proceeded directly to the cave. This time Matt was accompanied by a man dressed in green (the swirl that merged the redman and blueman into Matt).

It's too dark to go in . . . I'm lighting a torch . . . We're inside . . . We're walking on a bridge over a huge cavern. At the bottom are deep craters . . . filled with bubbling black tar. I'm real uncomfortable in here . . . (What do you want to do?) I'm going to solve this once and for all . . . We're going back outside, to climb the hill over the roof of the cave. [With determination and a bit of anger in his voice, Matt says to the greenman]: "Let's dig a hole in the ground, and let sunlight into this f--king cave once and for all." We are digging . . . We've reached through the roof of the cave. I can see down into the cave. I want to go back inside now, and see what's inside. We're back where the hole in the roof is . . . I can see rays of sunlight coming down . . . There are tons of green powder everywhere . . . We are putting it in buckets and throwing it over the bridge . . . It's cooling down the tar . . . kind of deactivating it . . . We've won a battle.

Afterwards, Matt was quite proud of himself. I told him how much I admired his courage and determination. He saw this session as a triumph over the big black hole that frightened him so, and therein his fear of death. I cautioned him that this image could still return, but that the important thing was that he had created his own "antidote" for it. We also explored what the greenman and the green powder might represent in terms of resources within himself. Matt concluded: "I have to care enough to do something about my problems."

For me, this was one of those split-level discussions therapists sometimes have. Outwardly, I was focused on helping Matt relate his experience and images to his life. Inwardly, I was focused on what implications these images had within the therapeutic process. I was struck with Matt's boldness in letting the sunlight flood the cave, and illuminate its contents. Was Matt readying himself to let the painful material into the light of day? What would emerge from the cave?

I agreed with Matt that the greenman was a part of himself—that part that wanted to help him—not only to pull himself together, but also to help bring something from his unconscious into the light. But I also realized that the greenman was an image of me as therapist. In Matt's positive transference towards me, he was beginning to see that I cared, and that through me, perhaps he could care and do something about himself. If there was a negative transference, Matt's concluding statement could have been a warning to me: "You have to care enough before I can do something about my problems."

Paradoxically, it is always scary for a therapist to gain this kind of trust or hope, even though it is a primary goal. I could not help think of all the greenmen in my life. I hoped that, for Matt's sake, I could be like the best of them—not the many that had let me down. I realized that this was a countertransference reaction that needed to be examined closely at another time; meanwhile, I had to refocus myself on Matt's needs in the here-and-now.

I often find that significant sessions such as this mark off stages within the therapeutic process, and that a review of what has been accomplished to date is very helpful in consolidating and integrating material that has been brought into consciousness. After we had finished discussing the specific details of the imagery in this session, I asked Matt if we could spend some time going over earlier sessions. To guide our discussion, we put all of his session transcripts and mandala drawings in chronological order, and then proceeded week by week. I asked him to summarize what each session and drawing meant in a few words, as I took notes. Upon finishing, we turned the individual statements into a brief narrative:

All of my troubles appear when I am alone—marooned on an island. I let the bird do his thing, as evil as it is, and I will face obstacle after obstacle until the nicest part of me reaches the breaking point. Before I do, I am consumed by fear, and I feel paralyzed to do anything about things, but then I become enraged and this gives me the power I need. There are different parts of me that take over at different times. The most frightening thing is when I stop caring and give up. If I really care—if I really want to live—then I can find the courage to work out my problems. Maybe the courage comes from rage over what life has brought me.

As a result of this review, Matt and I both felt good about his progress. After the session, I realized that there was still one recurring image that Matt had not explored—the house.

The Abandoned Child

In the eighth session, the tar bubbled up and the full story of Matt's life was brought to light. It was a horrible tale of childhood—one that had made it necessary for him to create his images of the bird, the rain, the house, the island, and the cave.

Matt and I had decided to begin the session with a house as a focus or starting image. To prepare him, I asked him to concentrate on taking in-breaths that brought him inner strength, and releasing out-breaths that brought calmness. I then asked him to return to his favorite house from childhood. Matt began:

I am playing in the back yard . . . where I lived when I was six . . . I have on red pants and a blue shirt . . . Mom is calling me to go inside . . . Everyone has been packing . . . We're moving . . . Mom and Dad are leaving to take the last truckload . . . They have left me behind with Bruce, a friend of theirs . . . He's picking me up . . . I'm getting real nervous . . . He's holding me too tight.. [Matt's body tightens up so much that his trembling stops; his face reddens as if he cannot breathe] I wish he'd stop . . . Stop! . . . He's getting on top of me . . . crushing me . . . I can't move . . . I can't breathe . . . I can't even scream.

He had been raped. I remember crying—realizing that he could not do so—not then, and for some reason, not now either. I also remember holding back the tears. Matt needed more than tears, he also needed someone strong who could support his rage, and help him survive this ordeal.

As soon as the rape scene ended, Matt's images were flooded with memories of violence and blood, all episodes that actually took place later in his life. He recalled: breaking the neighbor boy's arm with his bare hands (age 8); cleaning up the blood after his grandfather had a lung hemorrhage (age 12); being beaten by his pimp (age 15); killing a squirrel who had been hit by a car (age 18); and being struck by a car himself (age 21).

Afterwards, we talked very little. I said I was sorry for what Bruce had done to him. He said he still felt ashamed, because Bruce continued to rape him for several years. Apparently, his parents were completely oblivious. He admitted that most of the time, he controlled his anger over what had happened to him, but that occasionally it surfaced. When the session ended, I remember hating to say good-bye. I did not want our parting to feel like another abandonment. All I could think of was how he had been left alone that day in the empty house, and that later, he would be alone again in his apartment. He assured me he would be "fine."

As I drove home that night, Matt's images flooded my consciousness, coming together in streams: The hovering bird had descended upon an unsuspecting child who had been left behind, a child who was wearing red and blue. Then, while being held down and unable to move, the phallus was inserted. The rains came in storms of dirty sperm, and the house stood empty with no one to protect him. The family tree had been uprooted, and if it was to turn green again, someone would have to care. Matt was the island, alone then and now, for his secret would always set him apart. Yet he was surrounded by oceans of feelings that could flood him at any time. As with the cave, a part of him had fallen into a black hole and died, and the remains had been locked there with iron gates. In the aftermath came blood—blood that would be shed as sacrifice, blood that caused shame, and ultimately, blood that would become infected as a final punishment.

Resurrected: To Live or Die?

After this, Matt's images were quite different. None of the previous images recurred. The bird, the rain, the house, the island, and the cave had all given full voice to the horrors of his past life. The grief and rage of the child he had left behind were now in his awareness. Matt's life story had been told; it was up to date.

The irony of releasing the past is that, despite the relief that comes, the person is plummeted into the realities of the present—which for Matt, were as ugly as those in the past. The fact that he had AIDS came to the forefront of his consciousness, bringing increased anxiety. His symptoms seemed to worsen, and he became even more of a recluse. He took no consolation in the news from the doctor that his blood count was better than ever, and he ruminated over the progression of the disease. He seemed more frightened than ever, and his trembling was more pronounced. Even his imaging, which had been so easy and productive, was beginning to falter.

Though this seemed like Matt's bleakest hour, his imagery said otherwise. In the next (and final) three sessions, he had tremendously healing images—all related to the death and resurrection of Christ: Matt forgave his father for abandoning him and healed their relationship through a cross; his side was pierced with a harpoon, and he tried to wash it clean with water; and as he walked through the cemetery, Easter lilies bloomed over each grave.

Then came the turning point:
I am standing over my own grave . . . It's open, and I'm looking down at my body . . . I feel a man's presence behind me. I can only see his face. He's beautiful. His hands are on my shoulders now, and he is telling me to be strong . . . in a very fatherly and loving way . . . I feel love towards him, but I am afraid . . . He is telling me to go back into my body . . . to get into my body and live . . . But I'm afraid . . . how strange . . . I wonder if I am afraid of living or dying . . . He is repeating it again: "Go back into your body, and live!" . . . I feel unsteady . . . like I'm falling back . . . I can't stand it anymore . . . I have to come out!

Suddenly (midway into the tape), Matt's eyes opened and he rose up, like he had just awakened from a terrible dream. Then, with seemingly no rhyme or reason, he blurted:

It's all so clear to me now:
Dizziness is not being held up . . .
Nausea is what I get instead of crying . . .
The knot in my stomach is when I lose myself . . .
Trembling is not having anything to hold onto . . .

This was the first time I saw Matt lose control of his emotions. And unlike anything that he had ever done before, he asked if I would hold him. I sat next to him, and as I put my arm around him, he rested his head on my chest and cried—very much like a child who needed to cry in the safety of his parent's embrace. I rocked him until his crying and trembling subsided, and then he said something I will never forget: "Living is more like falling into a black hole than dying is."

I was reminded of what Laing (1967) said about the human dread of nothingness: "We are afraid to approach the fathomless and bottomless groundlessness of everything. 'There's nothing to be afraid of' [is both] the ultimate reassurance and the ultimate terror" (p. 20). The relevance of an existentialist such as Laing made me realize that Matt had moved from an early life (or psychosexual) crisis to a full-blown existential (cognitive) one.

The Truth Sets Him Free

A few days later, Matt called me at home, and said that he needed to talk. After hemming around for several minutes, he told me that he had not been completely honest with me. For a long time, he had been abusing alcohol and his medications, and could not bring himself to tell me. I could hear in his voice how difficult this admission was for him, and despite my own feelings of shock, I tried to reassure him that his telling me was a significant turning point. I then asked him: "Why are you telling me now? What makes this secret so difficult for you to keep any longer?" In his reply, Matt's progress and the value of our work together were revealed: "Before it didn't make any difference. In the last session, I realized that I have been more dead than alive for a long time. If I'm going to try to live, I better do something about this now, before it's too late."

Matt checked into an in-patient unit of a local hospital for detoxification and treatment, where he stayed for nearly two months. After being discharged, he began regular follow-up treatment with his psychiatrist, and joined a weekly support group for alcoholics who are HIV infected.

Several months later, I called Matt. From what he said, it sounded as though he was back on the road of the living, taking full responsibility for himself. Before we ended our conversation, Matt thanked me and said: "You really helped me to take a look at myself, and to begin embracing the life I still have to live."

Discussion and Conclusions

Psychotherapy with Matt involved five dynamic elements: the imagery, the music, the mandalas, my personal perspectives, and our relationship as client and therapist. The roles of each are described below.

Role of Imagery

As implied throughout the case, imagery probably played the most significant role in Matt's treatment. Because they carry symbolic meanings and are by nature ambiguous, images provided Matt with the distance he needed to eventually integrate very threatening material into his awareness. As containers of feelings and the energy attached to them, images also helped Matt to acknowledge his despair, powerlessness, and rage which had been buried deep inside since his childhood trauma.

Early in his work, Matt himself realized that his imagery provided symbolic vehicles for working through inner struggles. As we made progress, he also realized that transformations in his imagery provided symbolic representations of real interior changes taking place in his psyche.

Matt once commented that when new images appeared, it gave him an opportunity to discuss things about himself that he had never shared with anyone. Somehow his imaginary world brought forth reality, and presented it in terms that he could talk about with as much distance as he needed.

Images also bring time and timelessness into perspective. Because they are not limited to one time zone, they often reveal the links between different time periods. Thus, the stories that unfolded with each image allowed Matt to see the continuity of his own past, present, and future. Time made sense; sequels from the past became cycles of the present. The evil that the bird perpetrated on him in the past had planted the seeds of shame and guilt, which formed the basis of his present reaction to his AIDS diagnosis, which in turn spread the bird's blackness into an eclipse of his future. Matt realized he had given up on life a long time ago, and that rage was one of the few things left—even if it was suppressed.

Finally, images also instruct and inform the psyche by bringing forth the wisdom that already lies within the person. Matt's images helped him to find meaning in himself and to create meaning for his life. Perhaps, this newly discovered possibility—to find and make meaning out of the meaningless—had more significance for Matt than anything. His past was filled with pain and sorrow—which he suffered for no good reason; his present was filled with anxiety and fear, because of a disease that struck him—for no good reason; and now his life would prematurely come to an end—again for no good reason. What does it all mean? What is life really all about? Is it worth it? These are questions that haunted Matt.

In terms of process, imagery first served as an uncovering technique—one well-suited for exploring secrets of the unconscious and past. But as Matt progressed in therapy, the past was uncovered, the experiences of the wounded child were revisited, and his unconscious scars were revealed. This allowed the images to move forward in time, and to focus Matt on current issues, and how these issues were residues from the past. At this point, Matt was ready to face the existential conflict that he was experiencing as a person living with AIDS: to live dead or die living.

Throughout this case, and in my discussion of the role of imagery, I have given a great deal of attention to the symbolic meaning and significance of Matt's imagery. I have done this, not because I believe that images always need to be interpreted, nor because this is common practice in GIM, for neither generalization is true. I have emphasized interpretation for several reasons peculiar to Matt's case. First, imagery was the main arena for action and change within Matt's therapeutic process. His progress was inextricably linked to and expressed within his images and transformations therein; it did not depend upon verbal interactions or our relationship, though these elements played important supporting roles. Second, Matt's images were primarily of the symbolic or metaphoric type: he did not often have purely sensory or affective types of images, or images that contained real-life people and places. Third, according to Wilber (1986), different pathologies characterize different developmental stages in the life span, and consequently call for different psychotherapeutic techniques and orientations. I believe that Matt was in the stage of personal development which is characterized by problems originating from the repression of unconscious conflicts from childhood. Unconscious material does not present itself to the psyche in a logical or direct way: rather it relies upon symbolism and ambiguity to make its entry into consciousness more acceptable. Thus, much of our work was geared toward gradually translating the symbolic language of Matt's unconscious into acceptable and decipherable terms, thereby moving him from pathologies steeped in the past to realities of the present.

Role of Music

The significance of music in Matt's case is quite basic: without it, his imagery (which was so central to his process) would not have been as rich, productive, or transformative. Matt was very susceptible to the various elements of music and to changes therein, and his images always related directly to what was happening in the music. In fact, Matt's images were so closely related to the music that I sometimes wondered whether they were dependent upon it. I find that when a person's imagery is "music-dependent," there are two potential problems in guiding, both of which I considered at various times in working with Matt. First, it gave me too much control over his images. I did not want to manipulate his process by selecting and changing the music in ways that would push his imaging in a particular direction. Second, it gave him an opportunity to resist the process. Sometimes, as he would approach an important experience within the imagery and the music changed, Matt would move away from the image to accommodate the music, thus avoiding something difficult or unpleasant that he may have been ready to confront. Other imagers are more "music-independent" and forge ahead with the imagery process they are undergoing, regardless of shifts or even drastic changes in the music.

Ironically, Matt did not respond to music very emotionally. When Matt had intense feelings, they arose from the images, which in turn were supported or amplified by the music—not vice-versa. I might even say that Matt resisted the emotional force of the music, and did not allow it to trigger any cathartic releases.

In contrast, the music helped me to stay emotionally involved and attuned to Matt's images. As suggested earlier, I often felt that I had to model the feeling responses that Matt denied himself.

Last but not least, the music helped to take Matt into deeper levels of consciousness, while also providing him with the supportive matrix he needed to do so.

The Mandalas

Matt thoroughly enjoyed drawing mandalas. From a therapeutic point of view, I found that they helped Matt in several ways. First, they helped him to contain threatening feelings aroused by the music and the imagery. Putting the images, shapes or colors into the confines of the circle provided boundaries for all the material that was escaping from his psyche; it also gave him the means by which he could exercise some control over the emotions attached to the material. Being a recognizable, archetypal form, the circle also afforded him some intellectual control over its contents, for after he was finished, he could take a good look at how everything fit together, and in doing so, he could see the "whole" of it.

From my point of view, the mandalas provided a framework or context for understanding Matt's imagery. And related to this, they helped me to recognize symbolic equivalents in his unconscious material. For example, he used black for several things in the mandalas which related directly to the black bird and its equivalents in the imagery (e.g., eclipse, dark clouds, phallus, seeds, black hole, snake, cave, grave, Bruce, etc.). These equivalences in the mandalas and images bring together seemingly unrelated unconscious material, and reveal symbolic themes or underlying processes operating in the psyche. For example, all of the black images or symbols used by Matt were either evil forces that penetrate (phallus, seeds, snake, Bruce) or empty spaces that are penetrated (black hole, cave, grave). Going one step further, the theme of penetration can be further understood by examining equivalences in the qualities and activities associated to it in the mandalas and imagery. Matt associated penetration to sexual exploitation, fertilization, infection, and burial.

Personal Perspectives

Throughout this case, I have kept the reader informed of my own personal thoughts and reactions to Matt and his imagery processes. I have even shared my projections, interpretations, and countertransference issues. I have done so because these personal perspectives are central to the way I work. For me, psychotherapy, regardless of mode and technique, is a process of traveling between three experiential spaces: the client's world, my own personal world, and my world as therapist.

I see the process as "lending" myself to the client—but not only myself as therapist, but also my personal self. Without going into every one of these spaces, psychotherapy is impossible: I cannot be fully present or empathic to the client without entering his/her world—however to do so, I must leave my own world as person or therapist to do so; I cannot react to the client authentically if I do not leave his/her world and return to my own personal world; and I cannot intervene therapeutically if I do not monitor my travels to both other worlds by seeking the expertise and skill found in my world as therapist. Of course, central to the ability to move between these worlds is the ability to have both fluid and firm boundaries, depending on what is required. A therapist must be able to leave him/herself, but also return at will.

These world travels are required regardless of method, technique, or theoretical orientation: for who I am as person and therapist, and how I feel as person and therapist ultimately determine how I will use music, imagery, mandalas, verbal discussions, etc. Without me being fully human as both person and therapist, these are mere artefacts of therapy.

From an existential point of view, I can experience these worlds on three levels: (1) directly (i.e., through spontaneous and unmediated apprehension through the senses); (2) perceptively (i.e., through perceptual or affective classification of the experience, such as hot/cold, sad/happy, etc.); and (3) reflectively (i.e., through thoughtful analysis of relationships between experiences and worlds).

Thus, depending on which world and level of experience is relevant to the moment, I may experience any of the following:

The Client’s World: Directly, perceptively or reflectively;
My World as Person: Directly, perceptively or reflectively;
My World as Therapist: Directly, perceptively or reflectively.

Of course, it is important to also acknowledge that the client has similar options as to which world and level of experience s/he will enter at any point in time.

Client-Therapist Relationship

Matt and I had what I considered a very positive relationship. At the most basic level, I liked him and he liked me. We enjoyed being with one another, and we were rarely at a loss of words. We also laughed a lot.

From a psychodynamic point of view, Matt had an essentially positive transference towards me through most of our work together. This was extremely important, and not always easy, given Matt's past experiences with men in my same age bracket. He resented his father for being weak, blind, and not protecting him from Bruce; and he hated Bruce for the unforgivable crime of raping him. With this in mind, I had to be strong, reliable, present, kind, and nonsexual. I also took note of what he resented in his mother: she tried to dominate Matt in every way; yet because of her own oblivion, had no control over what Bruce was doing to him. I was careful therefore not to be directive, oblivious, or useless! I felt that it was important to avoid inviting or working through these negative transference issues with Matt because time was limited, and I felt that he desperately needed a positive male or father image. I was also certain that he could not meet the emotional challenges he had to face in our work together without unequivocal trust in me and the support that I would provide.

As for negative aspects of the transference, certainly Matt's concealments could be seen in this light. He had concealed his childhood "shames" from his own father until he was an adult, and similarly, he had hidden his adult "shames" from me until he was ready to terminate therapy. Ultimately, I suspect that the abruptness of our termination also had its origins in negative issues that were out of my awareness and therefore left unresolved. I have often wondered whether he "abandoned" me to punish his own father for abandoning him.

Unfinished Business

Matt's termination was timely yet premature. I missed the opportunity for us to achieve some kind of closure in our work. Given his decision to enter a residential treatment program, it was impossible for us to continue working together until after his discharge; and by that time, we were both in very different circumstances.

Had we continued, I feel that our work would have focused on two areas: dependency and the expression of feelings. My approach to his dependency issues would have been existential, emphasizing the importance of personal freedom, will, choice, and responsibility—this in contrast to a psychoanalytic approach focusing on dependency relationships and deficiencies in holding environments of the past. If a negative transference was present, I would stress the need to be "authentic" in our own here-and-now relationship rather than stuck in someone's else's from the past. Improvisational therapy would have been the method of choice, as it can explore these kinds of issues so directly, and especially within the context of authentic interpersonal relationships (Bruscia, 1987).

Matt did not express his feelings very freely. Even in the most intense GIM sessions, it was difficult for him to cry, lose his composure, or even raise his voice; yet it was quite obvious that he had very intense feelings that were suppressed. Here again, my approach would have been improvisational. I believe that Matt first needs to "sound" his feelings out with full use of his body, before he would be ready to release them fully in nonmusical ways. Once Matt became freer with musical self-expression, we could have resumed receptive methods of cathartic release, such as GIM.


Matt's case has truly been a source of wonderment to me: How indomitable must the human spirit be—that Matt has survived the ravages of so many rainstorms! How powerful must images be—that they healed Matt's deepest wounds and resurrected his life! What a gift of life music is—that it goes in and out of our deepest and most intimate spaces with such ease—resonating, soothing, and understanding the very fiber of our being. And how human a therapist has to be—to realize that it is not in our knowing or doing that we can help someone like Matt to move along his life path—but in our accepting and loving wherever he is.


HIV Positive: Presence of the Human Immunodeficiency Virus (or retrovirus) in the blood, causing an excessive increase in immune suppressor cells and a corresponding decrease in immune helper cells.

AIDS: Acquired Immune Deficiency Syndrome.

Guided Imagery and Music (GIM): Originated by Helen Bonny (1978), GIM is a method of psychotherapy, healing and self-actualization which involves spontaneous imaging to music in a relaxed state, while dialoguing with a guide. The practice of GIM requires special training.

Mandala: A drawing enclosed in large part within a circle.

Transference: Reactions client have towards therapists wherein the client relates the therapist as if the therapist were a significant person in the client's life, usually his/her parents. In a positive transference, the client projects positive feelings about the associated significant person onto the therapist/associated significant person; in a negative transference, the client projects negative feelings.

Countertransference: Traditionally, the therapist's reaction to the client's transference. The author's definition is: any conscious or unconscious reactions of therapists to clients which have their origins in the therapist's own personality or life experience. A positive countertransference takes place when the therapist uses these personal reactions to the therapeutic advantage of the client; a negative one takes place when the therapist is unaware of personal reactions towards the client, and because of this, puts the client at risk and endangers the therapeutic process.


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