Psychoanalytic Expressions:
A Journal of Art and Words.

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Early psychoanalytic authors and music educators in both Europe and the United States pointed to the contemporary use of music therapy as a powerful modality in an inpatient psychiatric unit. The inpatient community sing is discussed in its capacity to address both individual and group goals. A clinical vignette from such a group is presented and discussed.

INTRODUCTION: THE ROOTS OF MUSIC THERAPY IN BOTH PSYCHOANALYSIS AND IN MUSIC EDUCATION

"I thoroughly believe in music both as a prophylactic and as a therapeutic measure. My attention was first called to the value of music in the treatment of the sick, particularly the mentally infirm... In my work at the Battle Creek Sanitorium for more than fifty years, I have constantly made use of music as a means of creating an optimistic atmosphere.... I have been particularly impressed with the value of singing. It is not only a diverse and wholesome mental occupation, and on this account health promoting, but is also excellent lung gymnastics and promotes not alone breathing but the circulation as well... Music must certainly take high rank as a psychic remedy."

This letter was written in July 1931 to "The Etude", a magazine of music education by surgeon John Harvey Kellogg. Quoted in "Journal of Music Therapy", it represents one crucial strand of scholarly and medical confidence in the healing power of music in an inpatient setting. Another strand comes from the mainstream psychoanalytic movement and powerfully anticipates my own experience and that of other music therapists in utilizing music as both transference and countertransference:

"The tunes occurring to the analyst during sessions with patients are preconscious messages of thoughts that are not only meaningful, but also important for the understanding of the emotional situation of the patient. It would be an analytic mistake to brush them aside or to take them on face value, and to dismiss them as chance musical reminiscences. They not only convey contents unknown to the analysts's conscious thinking, but also communicate to him something of the hidden emotions that he has not yet been able to catch while he listens to his patients."

So says Theodore Reik in 1953 who was ahead of his time in paying attention to countertransference (and, by implication, transference as well,) via music. He set a model in the mainstream psychoanalytic community which has been taken up by music therapists who understand songs, song choices and song performances as potential symbols in the play space between analyst and patient. In music therapy, analyst and patient or analyst and group contract to use these powerful symbols as their primary medium

Yet a third strand, more contemporary is exemplified in the writings of Venezuelan psychologist Cora Diaz de Chumaceiro who has done studies on what she designates as "induced song recall". In a seminal article she contends that:

"1. Through the technique of induced song recall, patients (and therapists) unconsciously choose from their memory storage, in whatever language they many know, the best song available to indirectly express their present affective states and dynamic conflicts.
2. The songs each person likes or dislikes are dynamically related to important others within an original specific situation in time, as well as to the present interactional therapeutic content." (1992, p. 325)

Though referring to individual and not group therapy and though referring to a specific study and parameters unique to her work, this theory combines psychoanalytic concepts of free association and transference/countertransference with music therapy in an extremely cogent way.

GROUP MUSIC THERAPY AS A CORE INPATIENT INTERVENTION

For these reasons. music therapy is a standard and important component in the inpatient, adult psychiatric unit. In such a setting, the department of therapeutic activities often is at the forefront of group treatment. Music therapy groups of various kinds may be offered several times a week and each kind (such as therapeutic music listening, song writing, drawing to music, drumming, etc) has its own unique parameters and benefits. It is the therapeutic community sing however, which most trenchantly addresses the greatest number of goals, individual and group, verbal and non-verbal..

Irvin Yalom states that:
"From the research literature, we can draw these conclusions about inpatient psychotherapy" (and music therapy fits these criteria) ": 1. Group therapy is an effective modality on inpatient units. It demonstrably improves outcome; upon discharge, patients value it highly; patients treated in inpatient groups are more likely to pursue a post-hospital treatment program. .... 3. Inpatient group therapy techniques must be modulated to fit the type of patient population: different diagnostic groups require different group therapy approaches. There is strong evidence that psychotic and nonpsychotic patients require very different forms of group therapy." (1)

Parenthetically, the containing modality of music allows the therapist more freedom in leadership style, requiring LESS of the differing techniques which Yalom cautions about here.

A frame that conceptualizes this work for an expressive therapist postulates that "the expressive form in therapy creates a third force as present as the patient and the therapist. Here, threatening affects and sensuous communications are witnessed and honored through nonverbal expression. Using an expressive modality as our means, we offer containers that hold, assimilate and provide the potential for transformation. In so doing, we create the third force, a space between patient and therapist-an expressive modality-that is neither inside nor outside but somewhere in between. I think of this as in between space... The expressive work, whether art or music, the symbolic form of the creator, and our own particular ability to receive the art form all come together like an alchemist creating a precious metal." Robbins p 88

THEORETICAL PARAMETERS FOR THE THERAPEUTIC COMMUNITY SING

The therapeutic community sing draws simultaneously on the best traditions of community singing, much beloved in the American past in both home and school, and the most current principles of psychodynamic group theory. Such groups can vary widely in content, format and feel, ranging from a group which might include almost all music and very little verbal content in between song selections, to one with fewer musical selections and much verbal processing, reminiscing, socializing and expression of emotions at the other extreme.

This kind of group is often held in the unit dayroom, a multipurpose space often filled with loud, alienating television sounds, ringing telephones and the voices of worried family members It is, as well, the gathering place for patients. Thus, the use of this space for a therapeutic purpose, particularly this one, can have a profound effect, transforming noise into sounds and music, and random comings and goings into greater spatial cohesiveness. Passively sharing space can be transformed into active interactions which can be quite meaningful.

I have prepared for a weekly community sing over the course of many years by assembling a fairly large group of songs, each of which will be known to at least some of the people in the group based on age range and taste. Although there is less and less a common body of American song, folk and popular, which everybody knows, yet there are "key songs" for each age range. It seems that these bellwether songs can stimulate memories and intense feelings for many people. Since these songs have powerful words as well, they utilize two triggers, tunes and lyrics which catalyze each other in a geometric fashion, melody potentiating the emotional content of words and words, of music.

GROUP PROTOCOL AND PARAMETERS:

The protocol of the group involves the therapist inviting each patient on the unit personally to attend, rearranging the dayroom, announcing the group in music by improvising an opening welcome song, proposing an initial group song which seems to mirror the mood of the group as I perceive it and one which everybody might know, and then turning the rest of the song selections and group protocol over to the patients. Although the therapist often intervenes during the body of the group to facilitate a holding environment in various ways, the choice of songs is the patients'. At the end, I might encourage the group to select a closing song which is the culmination of the musical "through-line" or subtext of the group, often suggesting the nomination of several songs and the discussion of which song would be "best". Sometimes, the last song is even voted on. The musical"through line" and the culminating song reflect in music what the deeper group theme is and does so with the music coming first and any discussion being secondary.

Indeed, at every point during the life of the group, the holding symbol of the song facilitates deeper, unconscious access albeit in a contained and safe environment. Group and individual treatment goals are processed in a symbolic way. Even improved physical well being and body awareness is promoted through standing, breathing more deeply and better posture. Endorphins are stimulated in a manner quite similar to when one is exercising, inducing calm, a natural "high".

The diverse individuals on the unit who enter the group typically represent ages sixteen to eighty and also the full range of psychiatric diagnoses and degree of disturbance, acute and chronic. Often the pathology expresses itself in body language, in posture and other physical mannerisms manifesting tension, disconnection and alienation from one's physical self. In ways which are relatively nonthreatening and which are also normalizing, singing encourages patients,( and indeed any singer) towards fuller physical as well as vocal and emotional self expression. The body can be oxygenated by increased breath and physical tensions lessened somewhat. The therapist can often encourage this in the context of various small, casual directives to the group so people are less likely to feel singled out and shamed.

At every moment in the life of the group, usually 45 minutes to an hour in length, individual and group goals are being worked on simultaneously. Perhaps the most important and obvious goal for both individual and group is the normalizing, playful nature of the activity. Although song content can range widely along the emotional continuum, the act of singing itself is usually associated with pleasure, fun, sociability and patients' outside lives and higher functioning. In addition, self esteem is fostered by engagement in such an activity associated with "normal" life, thus fostering the unconscious and conscious hope, even expectation that one might return to such a life and activities some day soon.

When an individual makes choices offered during the group, volition, the exact antidote to the passivity and helplessness of depression, the disorganization of psychosis is activated. Choice is activated at various moments in the group: when the therapist invites individuals to choose songs they would like, when people verbalize associations to a song just sung or about to be sung (their choice or others'), when they volunteer in the middle of the group to sing or play a solo, and when they cast their individual vote or discuss their choice for a final song. At these times, they individuate, separate for a minute, or even differentiate themselves from their fellow group members and, symbolically. from their historically based objects. This stance is anti apathy, fear and isolation and is pro involvement, interest and even courage. It can serve as a small jolt to their recessed capacities to make choices in their everyday lives. For psychotic patients, it is a brief moment in which to experience a self unmerged with others.

For elderly or even younger demented patients, accessing song memories can temporarily increase memory on a direct physiological and neurological level. Memories for word and for music are stored in different lobes of the brain, In remembering a song melody, the brain effects a temporary right-left brain cross over and accesses more language than the patient might be capable of under other circumstances through "hooking" the language onto the words. Indeed, music therapy is one of the therapies of choice with dementia and increasing research documents this.

The sense of autonomy and control which is stimulated via choosing songs has many implications. As noted above, psychoanalysts as diverse as Theodore Reik and Cora Diaz de Chumaceiro have talked about the unconscious symbolism attached to the songs we replay in our minds during our daily lives, the music we choose to listen to at any given time and the music which comes into a therapist's mind in regard to a patient or a group. In a profound sense, we are always practicing a kind of music therapy with ourselves and in regard to others. When this is made more formal as it is in a community sing, an individual has the opportunity to process a feeling, change a mood or retrieve a memory in a contained and symbolically safe manner. Whether one wants to "stay with" a thought or feeling or move to its opposite, we all know how to do this intuitively with music, and do so regularly in our daily lives.

A CLINICAL VIGNETTE:

A vignette from a recent group illustrates individual and group themes of autonomy and control. A short while before gathering patients for the afternoon community sing, I noted a marked increase of noise, energy and disturbance on the unit. This was soon traced to the arrival of Helen, a new admission who was pacing the hall agitatedly. Her speech was rapid, pressured and disorganized, her voice elevated. In passing, I casually invited her to the upcoming group. Momentarily stopped in her tracks, my invitation piqued her interest and we established a human connection, bantering back and forth as to whether she could (or should) sing or not. When I arrived in the dayroom, having gone all around the unit to invite everybody, she was already there. Acutely manic, she was impatient to begin the group. Other patients looked dubious and a supportive nurse/colleague was coaxing her out of the room. Out loud, I mentioned certain group parameters (safety of everybody, equal opportunities for song selection) and I mused with her as to whether this group would be the best choice for her today or would even be possible. We mutually agreed to give it a chance with both of us having the opportunity to decide that she should leave with minimal shame involved.

Helen immediately announced: "I can't sing but I can dance." I informed her that dancing might be acceptable but not if it distracted the group unduly or took her too far away from singing. Again, we agreed to check in with each other. All of these negotiations were done in an above board manner in front of the entire group, modeling an interpersonal style which was equal and subject to change depending on circumstances. Other patients chuckled fondly, sadistically or uneasily. Helen had become the designated new "crazy person" in the group and the object of individual and group projections. I made a protective comment which acknowledged this. As Yalom states:

"Even with rapid turnover, still an "in-group" cadre of patients does develop. The therapist must not allow that core to exclude new members."

He offers an example with an interpretation:

"Much anger was present and directed at the new members, not because of who or what they were, but simply because they were there, because the group was not the same....". (2) page 79-80

As always, I chose the first song based on my observations about the climate in the group. I usually choose a song which everyone knows, in this case "Hey Jude" by the Beatles, a song known by Americans of all ages. Helen remained curious, irritable and speedy. However, she remained solidly in the group and in the room. After this initial song, she chose the second song, "Leaving on a Jet Plane" asking at the end whether her voice was "terrible". Choosing this particular song seemed to represent her desire to leave, to fly and to levitate at a jet plane speed. Michael Eigen and Arthur Robbins discuss how "The creation and transformation of expressive objects leads not only to fresh sense of what an object can be but radicalizes our awareness of what it is to be a subject." p 83.

Despite the fact that during the singing, Helen was so pressured that she was singing faster than anyone else (a diagnostic indicator of mania), the beginning of each new verse or chorus did temporarily help her rejoin with the group singing.

I reassured her, and everyone else that we were singing for pleasure and self expression and that she was doing fine. As the group progressed, it seemed hard for her to tolerate anyone else choosing songs or any discussion between songs. She continued to speak and sing at a faster tempo than the others. By the end of group, however, her ability to stay, participate and even initiate helped her to exercise her inner controls to some extent and to integrate herself into the patient community, somewhat reducing the scorn of others. The next day, Helen greeted me raucously but playfully with increased trust. "You mean I don't have a terrible voice", she said. We bantered about this, and she was accepted by her peers into the groups of the day with less contempt.

SUMMARY AND CONCLUSIONS:

Indeed, powerful benefits of the community sing, as demonstrated above, can include an increased sense of connection with peers via a pleasurable activity and shared knowledge of songs, decreased impulsivity and increased attention span via tolerating each others' song choices. Therapist and patients also meet as equals in creativity and in the transitional play space of the songs. Group esprit is often created symbolized both by singing and by the choices of songs.
Winnicott states:

"I have tried to draw attention to the importance both in theory and in practice of a third area, that of play, which expands into creative living and into the whole cultural life of man. This third area has been contrasted with the inner world of personal psychic reality and with the actual world in which the individual lives, which can be objectively perceived. I have located this important area of experience in the potential space between the individual and the environment, that which initially both joins and separates the baby and the mother when the mothers's love, displayed or made manifest as human reliability, does in fact give the baby a sense of trust or of confidence in the environmental factor." (pages 101-103)

In a fascinating article on "Lullabies as Transferential Transitional Songs", Diaz de Chumaceiro refers to patient's songs as "transferential transitional music" referring both to Winnicott's third area and to the transferential meaning of songs. In the community sing, though the songs used are not music COMPOSED by the patients, the playful use of music allows affect laden choices to be made "On Wings of Song". These choices expand into the lives both of the individuals in the group, and the life of the group itself.

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BIBLIOGRAPHY
•Chumaceiro, Coral L. Diaz . "Lullabies are Transferential Transitional Songs": Further Considerations on Resistance in Music Therapy, The Arts in Psychotherapy, Vol 22 No. 4, pp.353-357, 1995, Elsevier Science Ltd.
•Chumaceiro, Cora L. Diaz, "What Song Comes to Mind? Induced Song Recall : Transference/Countertransference in Dyadic Music Associations in Treatment and Supervision"; The Arts in Psychotherapy, Vol. 19, pp. 325-339, 1992, Elsevier Science Ltd.
• Eigen, Michael and Robbins, Arthur; "Object Relations and Expressive Symbolism" ,in Robbins Expressive Therapy: A Creative Arts Approach to Depth-Oriented Treatment, Human Sciences Press, Inc, NY, NY , 1986. page 83
•Hunter, Bryan C. "Singing as a Therapeutic Agent, in The Etude, 1891-1949, Journal of Music Therapy, Summer 11999, Vol XXXVI No. 2, p. 133
•Reik, Theodore, The Haunting Melody, Farrar, Straus and Young, New York, 1953, pp. 19-20
•Robbins, Arthur; " A Field Energy Approach to Expressive Therapy through a Symbolic Dialogue in "The Arts in Psychotherapy, vol. 27, Elsever Science, Ltd, pages 87-88
•Winnicott, D. W., "The Location of Cultural Experience" in Playing and Reality, Routledge Press, London and NY, 1989, pp 102-103
•1. Yalom, Irvin D., Inpatient Group Psychotherapy, Basic Books Inc., New York, 1983, pp. 32-33
•2. Op cit, pp 79-80.

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