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Section 21
Music Therapy in Grief Resolution

Question 21 | Test | Table of Contents

The session
The music therapy or grief therapy session takes place in a room with armchairs, a box of tissues, a whiteboard on the wall, and an electric keyboard. (It is important for the patient to realize that he or she will not have to perform, otherwise the atmosphere may be marred by misunderstanding and apprehension.) I use a touch-sensitive keyboard as a convenient substitute for a piano. It has the advantage of producing many other authentic sounds, such as waves on the seashore, as well as the full range of orchestral and other instruments.

Assessment is not simply a preliminary to therapy but continues as ongoing appraisal throughout the session. Nevertheless, a self-assessment scale used early in the session is helpful, and it often forms the basis for further work, in words and in improvised music. Although it has long since proved its worth with patients of varying diagnoses, this scale was originally developed by the author for those who had alcohol-related brain damage with consequent difficulties in abstract thinking (Butters & Cermak, 1988; Walsh, 1978) and who therefore needed a concrete method. Perhaps the scale has succeeded with other patients because, during major difficulties of experience and emotion, their capacity for abstract thought may be similarly impaired, so that a visual presentation facilitates insight for all those in crisis.

The scale is drawn afresh for each patient on the whiteboard in the therapist's consulting room. A computer printout was tried but proved less effective than a large drawing done by the therapist while the patient watches. (It is helpful that the author is not gifted artistically, so that the sketch is quite simple, giving some patients a pleasing sense of superiority over the therapist. For most patients, this is probably a unique experience while in the hospital!)

The sketch is then explained: "The bottom step represents feeling pretty hopeless. The top step shows someone sitting down because it has been a huge effort to reach the top, but the person will not stay there. The arrow pointing ahead shows that soon the person will move on." The therapist then asks the patient: "So can you draw yourself in, where you are today?" The answer may reflect the patient's situation. For example, an answer, "There are not enough steps downwards at the bottom," may indicate suicidal ideation. Someone who draws the figure between two steps but on the way down also indicates difficulties, whereas the person who places the stick figure on one step but walking upward to the next suggests hope.

Placing the figure with both feet on a single step can represent various feelings: "I'm stuck"; "I'm consolidating what I've done so far"; or "I'm planning how far I can go next!' and so needs elucidation. For this reason, the stick figure now has a flag (not part of the original scale) to hold, and the patient is asked to write a key word on it. Commonly used expressions include "Hope! .... Thinking, .... Stuck," "???," "HELP!" and "Getting there!"

Sometimes obscenities are used, even when the person otherwise uses polite language. The possibility of using obscenities informs the therapist and also helps the patient, because it allows the expression of anger that is otherwise socially hidden. (I reassure the patient: "Having worked for over 30 years with people from jail or off the streets, I know all the forbidden words and nothing will shock me!") From this sketched assessment scale, it is easy to move on into the life story.

Understanding the life story
I avoid questions wherever possible, preferring to make statements in a fairly gentle tone of voice and leaving silence for a few moments afterward. For example, when working with a patient coping with the death of a spouse, I may say: "As we look back over a marriage, we remember lots of things, don't we, some of them good, some of them not so good." On rare occasions, the patient's response is, "Oh, really?" (i.e., "I'm not ready to talk about problems yet"). Sometimes the patient replies, "I was one of the lucky ones. Most of my memories are happy ones." Because my work is with people who have difficulty resolving a bereavement, more often the response is, "Huh!! You can say that again!" or a similar remark.

The next statement after such a reply would be, "I often find that when a relationship has been really difficult, the survivor is left with a guilty sense of relief after the death." This statement gives patients permission to be open in a way that would be impossible if they were responding to a question. "Did you have a feeling of relief when he died?" will almost certainly be met by denial. Moreover, because the statement begins "I often find," it helps people to know that they are not alone in their feelings of relief and so it takes away undue guilt or shame at acknowledging the reaction. (All comments are worded so as to be appropriate to the circumstances of the loss.) We should note that tears after the death of a difficult spouse or child often result from disappointment that the relationship was unhappy, when the opposite had been expected.
I do not always avoid asking a question. For example, "Can you tell me what happened, or is it too painful?" allows freedom to maintain silence but also gives permission to speak because it has acknowledged the painfulness of the process. Usually the patient then tells his or her story, although often only in a factual outline.

Using music in the session
At this point, I introduce music into the session. In many instances, it is only through music that the affective content of the patient's story emerges. Familiar music associated with a lost relationship often helps to bring suppressed thoughts and feelings to the surface.
1. Songs of courtship may reveal the bitterness over a relationship that failed.
2. A childhood song may help a patient ventilate grief over the child who "went wrong" and share a yearning to return to a simple childhood when parents could nurture and protect from harm.
3. After a stillbirth or an abortion, the woman who was not allowed to cry because grief was "bad for her" finds relief in hearing, perhaps singing, the songs she wished she could have sung to her lost child, and in being allowed to cry as she does so.

It is helpful to have a good repertoire of music of all genres, not only from the 20th century but also earlier.
Playing (if one can) this familiar music, or talking about the music if it is unknown to the therapist, leads to significant disclosures about relationships. The therapist can respond with some fairly general comment, such as "It sounds as if life has been really rough for you" or "You've really been able to show me something of what life has been like for you (over the past few years, all your life, most of your life, since your father died, or whatever is appropriate)." If the patient requests an unknown song, the therapist might say, "Tell me about why this song means so much to you." On one occasion, my patient found reassurance and comfort by teaching me the melody.

After using familiar music, I introduce musical improvisation. I may say, "I'd like to try to improvise some music for you, which may describe some of your feelings as you look back over the past and deal with the present." It is important not to define dearly the feelings the therapist has perceived at this stage but to leave this verbal reflection in general terms. Music is then improvised to reflect the content of the session so far.

The range of volume may vary from very soft to very loud, and the discords used can be powerful. Some improvisations focus mainly on one emotion (such as sadness or anger) if this is concordant with the life story that has been told, but there is music suggesting other emotions as well, even if these were not mentioned by the patient.

It is important that the music leave the way open for the patient to interpret it according to personal need and experience. Projection often causes the patient to "hear" in the music emotions that differ from the general direction of the improvisation. As noted earlier, delineating the affective content before the improvisation is restrictive. If the therapist says, "I'll play music to illustrate something of your sadness (anger, confusion, fear, or whatever)," then the patient may hear only the named emotion and other feelings are less likely to be perceived. By avoiding any clear identification of the emotions portrayed, the therapist clears the way for hidden feelings to be recognized and acknowledged, and for projection to reveal previously undisclosed affects.

The improvisation leads to further verbal interchange of thoughts and feelings, with informal whiteboard sketches to illustrate key issues. The sketches are done by the therapist, the patient, or together as a shared task (see Figure 2). Sometimes this is followed by further improvisation whether by the therapist or shared improvisation at the keyboard by therapist and patient; perhaps with percussion instruments, too. (Drumming can externalize anger to a frightening extent and decompensation can occur, so one must make a therapeutic decision as to whether drums are used and, if so, when.)

Songwriting is a helpful tool, but it is generally used only when a series of sessions is possible, to avoid overloading the initial sessions. The responsibility for words, melody, and accompaniment is shared according to the skills of the patient. Some patients feel competent to write only words, whereas others--despite ignorance of musical performance--are willing to try the keyboard and find some kind of melody that fits their needs, which the therapist writes down on manuscript paper. (For reasons of confidentiality, sessions cannot be recorded.)

Occasionally, the therapist writes both words and music. For example, the following song was written with a simple melody for a depressed elderly man with extremely low self-esteem. It was "prescribed" for him to sing 16 times a day!

"I'm an OK person,
I'm not the best,
But I'm not the worst,
I'm OK!"

The consultant's opinion was that singing this song of self-acceptance quietly to himself several times each day was a key part of this patient's recovery.

Ending the session
At the end of each session, what has transpired is discussed and summarized, ideas are discussed for dealing with difficulties, and tasks are suggested to prepare for the next session (e.g., a road map of one's life, a poem, ideas for change). The patient receives a paper copy of the sketches done on the whiteboard to take away as a reminder. Although the patient knows that the content of the session will be discussed with colleagues, he or she is invited, as a symbol of confidentiality, to clean the whiteboard so that nobody else will see the sketches and self-assessment scale. Finally, a familiar theme song is suggested that the person can recall. Such songs include "Climb Every Mountain," the theme from the movie Chariots of Fire (the waves in the opening scene of the film symbolize a powerful force that can either overwhelm or strengthen one, as it did for the athletes in the film), and "The Impossible Dream" (because dreams are not always impossible, we must keep hoping). One young woman wrote words to the Finlandia theme by Sibelius: "I won't give in, I'm going to keep on trying!"

When suggesting a theme song to take from the session, the therapist should choose familiar music after discussing this with the person. Improvised music is useless because it will not be remembered (probably not even by the therapist in any detail!) and the person must be able to recall the theme as a reminder of the session content in times of difficulty.
When the session is known to be the last before discharge, appropriate separation techniques are included in the final summary. Finally, the work is described in the file of progress notes and, whenever possible, discussed with colleagues.
- Bright, Ruth; Music Therapy in Grief Resolution; Bulletin of the Menninger Clinic; Fall 1999, Vol. 63, Issue 4.

Personal Reflection Exercise #7
The preceding section contained information about music therapy in grief resolution.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Katz, A. C., Norr, A. M., Buck, B., Fantelli, E., Edwards-Stewart, A., Koenen-Woods, P., Zetocha, K., Smolenski, D. J., Holloway, K., Rothbaum, B. O., Difede, J., Rizzo, A., Skopp, N., Mishkind, M., Gahm, G., Reger, G. M., & Andrasik, F. (2020). Changes in physiological reactivity in response to the trauma memory during prolonged exposure and virtual reality exposure therapy for posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Presseau, C., Contractor, A. A., Reddy, M. K., & Shea, M. T. (2018). Childhood maltreatment and post-deployment psychological distress: The indirect role of emotional numbing. Psychological Trauma: Theory, Research, Practice, and Policy, 10(4), 411–418.

Smith, K. V., & Ehlers, A. (2020). Cognitive predictors of grief trajectories in the first months of loss: A latent growth mixture model. Journal of Consulting and Clinical Psychology, 88(2), 93–105.

What should the therapist do if the patient requests an unknown song? To select and enter your answer go to Test.

Section 22
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