Nordic Journal of Music Therapy

ISSN: 0809-8131 (Print) 1944-8260 (Online) Journal homepage: http://www.tandfonline.com/loi/rnjm20

About being meant: Music therapy with an inpatient suffering from psychosis
Susanne Metzner
To cite this article: Susanne Metzner (2010) About being meant: Music therapy with an
in-patient suffering from psychosis, Nordic Journal of Music Therapy, 19:2, 133-150, DOI:
10.1080/08098131.2010.489996
To link to this article: http://dx.doi.org/10.1080/08098131.2010.489996

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Published online: 06 Sep 2010.

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Date: 16 September 2015, At: 03:04

Nordic Journal of Music Therapy

Vol. 19, No. 2, September 2010, 133150

About being meant: Music therapy with an in-patient suering

from psychosis**
Susanne Metzner*

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University of Applied Sciences Magdeburg-Stendal (FH), Magdeburg, Germany

(Received 11 July 2009; nal version received 24 November 2009)
In psychotherapy with patients suering from psychosis, the necessity of
allowing acting and well-considered co-acting is acknowledged as a
means of communication. The use of musical improvisations seems to be
particularly appropriate for this, especially for the treatment of very
extreme human experiences, such as, for example, feelings of vast
emptiness, desertedness, persecution, fusion, dissociation, and unreachableness. These feelings are demanding in the therapeutic relationship,
yet unavoidable to deal with. By means of a single case study the author
analyses the challenges and the chances of musical interactions using
psychoanalytical as well as musicological approaches.
Keywords: analytical music therapy; psychosis; musical interaction

Introduction
His fellow patients called him Mike,1 a name which in retrospect appears
to me to be so tting that I will use it here, although during therapy I
addressed the 26-year-old man with his family name. That is to say if I spoke
to him directly at all, and usually I wrote the patient in my documentation
of the case. Both of these forms of address were common practice on the
psychiatric ward. Actually, there would not have been anything remarkable
about it at all if not the indirectness and the anonymousness were
expressions of exactly that disorder for which he was being treated, and
which is best described as the inability to feel that it is he, who is being
meant by someone else.
What does an individual experience, who is not able to feel that he or she
is meant? In what kind of world does he or she live so that anonymousness
and conformity take the place of mutual relatedness?

*Email: susanne.metzner@hs-magdeburg.de
**This article is accompanied by supplementary music les, available here: http://dx.
doi.org/10.1080/08098131.2010.489996.
1
Name has been changed.
ISSN 0809-8131 print/ISSN 1944-8260 online
2010 The Grieg Academy Music Therapy Research Centre
DOI: 10.1080/08098131.2010.489996
http://www.informaworld.com

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In individual music therapy I gained entrance to this world, which for me

was synonymous with senselessness and dreadfulness. In the midst of this a
movement came about, the beginning of which was not clearly discernible, but
which led to the circumstance that at the end of therapy there was a name:
Mike that is something like a signature, like a track that someone has left
behind; Mike that also stands for a specic kind of relatedness which
developed between us. Hidden behind companionship, care developed; a
special mixture of mutual concern, aection, and respect for each other.
My article on the use of music in the therapy of psychosis is based on a
case study in order to acquire some idea about how such a treatment
proceeds and what kind of challenges both patient and therapist face.
Furthermore, I give some insight into my psychoanalytical2 and musicological reections using italic graphs in order to separate descriptions from
interpretation as far as possible. As additional material some musical
examples are oered.3
The elaboration of the case covers some biographic and anamnestic data
of the patient as far as they were available. Also some information is
provided about how individual music therapy was integrated into the
inpatient treatment plan.
As a rule, the article of a case study does not stay without inner
resonance. Therefore I like to encourage the readers to follow their own
associations or reexions, as case studies can neither represent all
movements in a complex interactive eld, nor close up dierent perspectives
that arise from outstanding viewpoints.
Anamnesis
As agreed with the treatment team, I oered Mike music therapy a couple of
days after his admittance to the clinic, so that he would be given the
opportunity to communicate what he had experienced that had left him
completely silent (speechless). He was brought to the psychiatric ward as an
emergency case after someone had found him in the middle of a city square,
where he had been standing still for hours. Although on the psychiatric ward he
2

The psychoanalytical frame is strongly connected to the Self- and Object-Relation

Theory by D.H. Winnicott, the concepts of M. Balint, and to the Materialistic
Socialization Theory by A. Lorenzer, a psychoanalyst belonging to the so-called
Frankfurter Schule. He is not very well-known in other countries but his approach
had a great inuence on the developement of psychoanalytical informed music
therapy in Germany (Niedecken, 1988; Metzner, 1999a; Becker, 2002). Some further
explanations can be found in Metzner, 1999b. Lorenzer can be seen as antagonistic
to the French F. Lacan, to whom Jos De Baker (2005) refers to theoretically. But
interestingly De Baker and I come to similar results when describing the musical
processes in the therapeutic relationship with psychotic patients.
3
Publication has been authorized.

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did react when he was spoken to by making occasional eye contact or by

complying with simple requests, he did not speak a word. The whole time he
fumbled and ddled, and had a facial expression that alternated between angry,
happy, and sad he appeared to be reacting to voices that he was hearing.
From his medical record I knew that Mike had suered for about 10
years from a chronic paranoid-hallucinatory psychosis with secondary
addiction disorder (alcohol and drugs) and that he had repeatedly received
psychiatric treatment in dierent hospitals. Further, he had completed an
odyssey between a number of dierent places of residence, including several
therapeutic residential facilities for the mentally ill, remand prison, the home
of his grandmother, and a shelter for homeless men.
From this background information it was clear that Mikes acute state
was not a one-time occurrence, but an escalation of an illness which had
persisted over a longer period of time. Thus, music therapy was not situated
at the beginning, but rather at the end of a series of eorts and probably also
disappointments, both for the therapists as well as for the patient.
Besides the case history and the current situation, knowledge of the
patients biography is also important for psychological assessment, because the
experiencing and behaviour of an individual in the present must be seen in
connection with his or her previous life experiences. However, since there
hardly ever is a simple relationship between cause and eect, no premature
conclusions should be drawn from the sparse data that were available from the
life story of Mike. These facts are hard to evaluate as an outsider, although
one must admit that signs of horror and senselessness can be found in this
information. Much more enlightening, however, will be the ongoing assessment
during therapy resulting from the patients subjectively coloured expressions.
After all, as is commonly known, psychoanalytic therapy deals with the
manifold ways of experiencing and processing directly within the therapeutic
relationship. The goal of this approach is that the patient either re-discovers
subjective ways of experiencing and processing (as in the case of resources) or
changes them (as in the case of inappropriate defence structures). Indeed,
Mike related about them not only with the help of language or music but in
dierent ways, which of course was to be expected in view of his muteness and
the severity of his psychotic disturbance.
Biography
Mikes parents were both teenagers (16 and 17 years old) when he was born.
His mother left home when she became pregnant. According to her, she did
not have any motherly feelings for the baby and was overburdened with
caring for the child by herself. From time to time she left her child alone at
night. She had no contact with the father of the child. When Mike was two
years old, his maternal grandmother took him to her home against the will
of her husband, who had at rst ignored the child altogether. This, however,

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changed after a period of time. His grandmother worked at the weekly

market, while his unemployed step-grandfather spent a great deal of his time
at home lying on the sofa and watching movies, some of them horror lms.
In the course of time, as little Mike began keeping him more and more
company, a kind of mutuality developed between them. The rest of the data
is quickly told: Mike went to primary school, junior high school, and then
commercial high school, but he was forced to drop out because of increasing
drug consumption. In the end he was socially isolated and had no friends.
No information is available with reference to his sexual experiences. His
psychotic disorder appeared for the rst time after the death of his
step-grandfather, when Mike was about 15 years old. The only remaining
close relationship was the one with his grandmother.
Individual Music Therapy Part I (First Session)
Mike came with me to the music therapy room without saying a word. I
met him beforehand in the wards recreation room, and he came right
along with me to the therapy room that was located a distance away
without a comment. As he entered the bright room, with its broad array of
dierent types of instruments, without any hesitation he went straight to
the congas and started pounding out drum beats that went o like
reworks. It sounded relatively experienced, somewhat overhasty but full
of zest. A similar thing happened at the piano, the kettledrum, and the
temple blocks. I was surprised and at rst just remained standing where I
was. What to a bystander might have appeared to be a therapeutic stance
of watchful waiting, I had a completely dierent feeling: I experienced a
state in which there was nothing which I could have done or thought, and
it seemed senseless for me to be there at all.
For an outsider my reaction might, at rst, appear exaggerated.
However, if one assumes that the patient created a situation, which left
me feeling a little how he felt in the sense of projective identication and
which was a message of the patient that he was only able to deliver in this
way and not otherwise, then my reaction is not at all exaggerated
considering the severe mental disorder of the patient. I felt that although I
was still present, my existence was senseless, and for the moment I no longer
had command over my thoughts and actions.
Theoretical Excursus I: Psychodynamic understanding of psychosis and the
approach of music therapy
In order to facilitate the understanding of the further course of therapy for this
kind of disorder of self-experiencing from which I assumed the patient was
suering, it is necessary to give a few brief explanations concerning the
psychodynamic understanding of psychosis.

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Even though the psychotic disorganization of perception, thinking, and

feeling may appear to be a malfunction, it is actually a protective mechanism.
This means that this is the only reaction (in psychoanalytic terms: defence) to
the experience of an existential psycho-physical threat that is available to the
individual. The type of defence naturally reects the type of threat, which in
most cases is rooted in the individuals biography.
If Mike as an infant was exposed to an existential psycho-physical threat
such as being left alone for a longer period of time and if crying did not lead
to somebody coming to alleviate the situation, perhaps instead even leading to
the opposite, namely being left alone even more, then the only remaining
alternative was to cease his communication of life-expressions and mentally
withdraw from the situation in order to lessen the horror. If this happened
repeatedly, and if further aggravating circumstances arose and there were not
enough opportunities to make positive experiences, then the basis for
psychological development is a very shaky one. In such an early disorder,
this aects the dierentiation between an inner and an outer world, the
formation of self- and object representations, and the development of more
mature defence structures (see Mentzos, 1995).4 In such a case, the
possibilities to react to the demands of life are extremely limited (see Brent,
2009). Profound psycho-physical changes during puberty or the loss of a loved
one, which constitute crises for any person, are much more existential for
individuals, who are instable or have only limited coping abilities. Instead of
being able to fall back upon good experiences, memories of earlier (traumatic)
experiences of being alone and helpless were triggered, which Mike had to
defend against at rst with social withdrawal, later with drug consumption, and
nally with psychotic symptoms (see Dumpelmann, 2003).
These are some short explanations on the psychodynamic view of psychosis
followed now by some comments about my understanding of music therapy.
As with every psychoanalytic therapy, psychoanalytic music therapy is
based upon the resolution of psychic conicts through interaction. The central
hypothesis is that a latent meaning stemming from the individual life story
evokes and shapes manifest phenomena. In music therapy the patient gains
insight not only through communication that is primarily organized by
language, but insight can also be gained through analysis of the element of
music and the musical interaction, and its particular structural characteristics.
In other words: here I describe music therapy as a treatment approach in
which aesthetic feeling and thinking are considered to be prerequisites for the
initiation and success of therapeutic processes (see Metzner, 2005). The
central hypothesis is that the human being needs a medium, which allows him/
4

Mentzos, the outriding author in Germany on the psychodynamics of psychosis,

with strong inuence on Lempa (1995) and Dumpelmann (2003) can also be seen in a
wide panorama ranging from Bion (1962) to the modern conceptualization of
mentalization (Fonagy, Gergely, Elliot, & Target, 2002; Brent, 2009).

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her to cope with his/her inner states. Of course, this can be language, but it
must not be language alone. Although there is no doubt that aesthetic processes
are involved in the speech act, it is easier to recognize them in materials such as
sound, rhythm, or movement. Stimulated by the perception of a concrete
external object, for example a tone, sensorial qualities can be triggered such as
presence of mind and peace of mind, fascination and resentment, boredom and
involvement, in other words internal states that are highly intertwined with
consciousness, emotionality, and capacity to act. Surely music is also closely
linked to the eects, but for good reasons I would like to call your attention
here to these sensorial qualities, which in some ways are related to what Daniel
Stern calls forms of vitality.5
What is so special about sound material is that although it does represent a
concrete external object it does this only in part. It is just as possible to nd
qualities therein of the primary substances as Balint (1997) called them for
example, indestructibility, inseparability, and innity. In stages of early
development, the human being lives in a harmonious intermingling with the
primary substances, which are used in the sense of Balint. From this point there
is a developmental link to Winnicotts (1985) transitional object and object
use, and this is where the therapeutic process will eventually lead to. However,
what rst becomes apparent in the world of sounds with Mike is failure, failure in
the harmonious intermingling with a substance-like environment, failure to
establish a transitional object, and failure to make use of me as an object.
In the treatment of psychotically ill persons, occurrences such as the ones I
experienced are nothing unusual (see Lempa, 1995); still, in the specic
situation they are always upsetting. However, as a healthy person I am in the
position to identify this inner state, and in doing this I am able to constrain it.
My task as a psychoanalytic therapist is to accept the message of the patient
contained therein, to hold it in safekeeping, and to rescue this particular
situation by putting an end to it.
After a couple of minutes, which seemed like an eternity to me, the
patient paused in his playing, and so I used the opportunity to tell him that
we could gladly do music therapy at another time, but today I had only
wanted to show him the therapy room. In response to that, the patient said
(!) that he knows music therapy from his stay in the city of N, and that we
could do that here too. I wrote down two appointments per week for 30
minutes each, gave him the slip, and walked him back to the ward. What
was not explicitly stated but nevertheless clear was that we would work with
free improvisations. This had nothing to do with the music therapy in the
other city. Rather, it must have been either the specic need of the patient or

In his earlier publications Stern (1986) used the termvitality aects but changed it
into forms of vitality as pointed out orally at the Nordic Conference of Music
Therapy held in Aalborg 2009.

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perhaps, even more so, his ability to sense my preferred method of work and
to adjust himself to it.
In the following session Mike immediately sat down on the chair on which
I usually sit. Since there was nothing which actually indicated that it was my
chair, it may have been a coincidence. However, a certain parallelism to the
already mentioned aggressive response to my being there is obvious. Yet, in
view of the severity of the patients disorder and the fact that we were just
starting therapy, it would have been counterproductive to mention this. For
this reason I simply sat down on the other chair. From where he was sitting
Mike reached for the guitar and began playing a short sequence of notes. On
the one side it seemed like a mechanical nger exercise; on the other side it was
quite evident that he had something specic in mind that he wanted to nd
again. A sequence of movements or a melody, that was not for me to say:

Figure 1.

Sequence of notes 1 (Online musical appendix Mike 1) .

The playing of this sequence of notes became the pivotal point of

therapy, and, although quite a lot happened both inside and outside of
music therapy, I would like to concentrate on it, its function, and its
development.
It was quite evident that Mikes goal was to be able to play the sequence
smoothly. He repeated it many times and practiced the nger movements so
that his ngers were better able to change from one string to another. He
was so deeply engrossed in what he was doing that he was completely
oblivious to the outside world.
Commenting on the situation and process, I would like to point out that
Mikes concentration is indeed something quite unusual for patients
suering from acute psychotic symptoms. Much more frequently observed
in patients suering from psychosis are forms of playing that are much more
arbitrary, blurred, uneventful, and endless. What can be seen therein is the
search for and the failure of the harmonious intermingling with the at
best substance-like environment. Jos De Baker (2005, 2007), refers to such
mechanical play as sensorial play.6 It is a musical play that has no
intention, that means nothing, that simultaneously marks existence and
destroys it. The task in music therapy is rst to hold ready this substancelike environment in a manner so that while refraining from own
expressions it becomes possible bit by bit to restore the harmonious
6

See also Kunkels (2009) investigation on improvisations of schizophrenic patients

in rst music therapy sessions.

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intermingling. However, if one is not accustomed to playing in such an inane

and seless manner, then.

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Individual Music Therapy Part II (Sessions 224)

In therapy with Mike, sensorial play took up the lions share of the
sessions; after several repetitions of the sequence of notes at the beginning of
the session, Mike put the guitar aside and then turned to the other
instruments, usually in a specic order conga drums, gong, temple blocks,
piano, etc. before returning once more to the guitar and his own note
sequence at the end of the session. Mike used it to mark the beginning and
the end of the hour, and it appeared to me that he used it to reassure himself
of his autonomy, which had been called into question by the fact that it was
I who had specied the time and place for the music therapy sessions.
Whereas with other instruments it was possible for the two of us to
improvise, sometimes in the same rhythm, more frequently, independently
of but never against each other, he always played this note sequence
alone. Initially I had tried to join in. But my play was accompanied by
very unpleasant feelings, which I estimated as projective identication but
possibly also as counter-transference feelings belonging to a protorelationship with an early self-object. They continued to stay, no matter
which musical position I took or what I played; for example, little
intermediate tones, a counterpoint, or tonal background music. What was
especially dominating and alarming was the feeling that I was being
intrusive and pursuing, which is what I wanted to avoid. Thus, over
many sessions, I restricted myself to listening and just let myself take
in this sequence of tones. Apparently, this did not disturb the patient at
all.
While listening to Mike, the peculiar pattern of this sequence of
notes preoccupied me. Here I broaden the frame of reference of analytical
understanding by referring to the musical material and examining it
more closely. I regard it as my privilege as a music therapist, that I can
concentrate on something else besides the therapeutic relationship,
emotional experiencing, and the meaning of words. There is
material available to me that can be regarded as objective, at the same
time it is highly individual and embedded in a cultural context. I follow the
tracks of the other and occupy myself with his tracks, imprints which he is in
the position to distance himself from, as if they do not belong to him,
although it was he himself who left them. This seems to be particularly
important in the therapy of psychosis because the direct threat which is
always present in a dyadic relationship is put in perspective through the
introduction of a neutral third. For most of my professional colleagues, this
is very, very unusual. Instead of seeing an aect-laden space in music, in
psychosis therapy it is almost completely aect-neutral.

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Theoretical excursus II: musicological approach

1. Melody and use of instrument
Alone because of its large register over more than two octaves and its
descending pattern, the tone sequence was not so much a melody that could be
sung. For me it was more like the descant of a chord progression from the
major-minor-system of our Western world, as suggested by the tuned strings of
the guitar and the typical use of this instrument in our society.
2. Harmonization and tension
The tones allow dierent harmonizations, some of them quite interesting. But
no matter how hard one may try, they do not divulge the key note. This means
that the listener is unable to nd the harmonic orientation, although the tone
sequence itself is clear. Without actually realizing it, the listener is in no mans
land as far as harmony is concerned. Not even at the end is there a tonic: the
chord progression remains suspended in air.
This eect of being suspended in air is intensied by the inuence of the
upbeat semitone steps. Understood as suspension, they express a certain
striving from tension to relief and give the tone sequence an orientation toward
a goal, which is, however, not achieved, neither in reference to harmony nor
period.
3. Form and coherence
If one takes four-four-time as a basis, the last chord is left hanging on a
relatively unstressed beat. The player could begin anew here with an upbeat,
but that would lead to a perpetual mobile of three beats if one could not
manoeuvre around this situation by adding a fourth beat, the best alternative
being the tonic from the rst beat. The problem with the unstressed beat cannot
be solved with the help of two-four-time. In correspondence with how we
experience Western music, it would be necessary to complete the chord series
to an eight-bar period. Further, two-four-time is the poorer alternative from
another point of view. It chops up into fragments the still fairly coherent
suspense curve and the phrasings of the musical line, which in spite of
everything else still contains at least the idea of a dialogue: Here me, there
you//come here, go away//from where/to where?
Attempts to initiate a dialogue with Mike, either verbally or musically,
were doomed to failure right from the start. Alone, the way in which he
produced the tone sequence, namely nger exercises on always the same frets
and on the inherently limited number of strings of the guitar, protected him
from my questions concerning the meaning of the music and his feelings.
Likewise, he made use of the same immunity protection when the head
psychiatrist on weekly rounds asked how he feeling by responding Same as
always.
The guitar piece, however, did not remain the same as always, because
Mike started working on it. This development was drawn out over many
months and happened so gradually, casually, and apparently

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unintentionally that it would not have seemed appropriate to mention this at

all. The majority of the time was still spent playing the conga drums, the
gong, and the temple blocks. One could say that they shielded o the
development that was taking place underneath like a thick foam cushion
that was not sounding incompetent at all. (online musical appendix Mike 2)
The seemingly trivial occurrences De Baker (2005, 2007) calls them
moments of synchronicity are moments in which one is not yet
completely sure if there is something happening that involves aesthetic
sensation: the term synchronicity can refer to a playing together; in this case,
however, where the patient played solo, synchronicity refers more to
conveying the aesthetic idea and the arrangement of the specic material.
When I now describe the further course of development, it will appear
rather terse and almost seems to progress in leaps and bounds.
Individual Music Therapy Part III (Sessions 2540)
At rst, Mike lengthened the tone sequence. Having reached the bottom
note, he then played the sequence backwards in one go and then once again
in descending order. These loopings were very lively, but this variation could
not establish itself as something really new. However, another extension had
more permanence. Through the repetition of semitones, the suspensions
became changing notes. The upbeats were omitted, and the small oscillation
which occurred between each of the two tones brought an element of repose
into the music. This made the tone sequence altogether smoother and in a
way more vocal. From this basis, Mike worked more and more on the
ending. He slowed down the movement, put a vibrato on the nal note, and
later added a nal note that was somewhat louder, so that the piece now
sounded like the music as shown in Figure 2.

Figure 2.

Sequence of notes (Online musical appendix Mike 3).

Interpretation
In the Western musical culture the vibrato here I do not mean the habitual
constant vibrato that some string and wind players have is considered one
of the most personal forms of expression. Applying it to the nal note led to
a heightening of intensity and with this a greater purposefulness of the
melody. The attention of the listener was drawn to the dying away of the
tone, indicating the niteness of the music. The repetition and rhythmic shift
of the nal progression to stressed time supported the feeling that this was

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the end of the piece. Alone the not reached tonic, was reminiscent of being
suspended in air, since, as far as harmony was concerned, the end remained
open. But it had become a calling, not helpless and not questioning, rather
demanding, but without meaning anything in particular. The way I
understood this half-close was that an answer would not have made any
sense but at least the calling was no longer senseless.
Theoretical Excursus III: Scenic understanding
As is quite evident from the preceding passages, musicological and psychoanalytical approaches are closely intertwined in these interpretations of the
material. As theoretical foundation, I borrow on the concept of so-called scenic
understanding by Alfred Lorenzer (1983). It develops from the scenic
sympathy conveyed by the material, which encompasses something more than
the previously mentioned emotional involvement of the analyst. Assuming that
traces of past interaction experiences were formulated in the patients
productions, which one must picture as unconscious scenarios even though
they are experienced as complex situative scenarios in the concrete situation, I
encountered the musical material with my own interaction experiences on the
one side and with the knowledge of the articulation of human experience as
handed down and condensed in the musical idiom on the other. My
presumptions about the experience of the other person were examined in
reference to their coherence, and reected upon from the perspective of
psychoanalytic theory until all discrepancies between my ideas and the
communications of the patient were resolved. The ultimate goal of this
successive spelling it out (Lorenzer, 1983) is to convey what has been
understood in such a way that the patient is able to recognize him- or herself,
allowing the previously unconscious repetition of agonizing experiences to turn
into active action in the present situation.
In other words: without an awareness for ones own presence, no processes
can get underway that have as their goal the promotion or maintenance of
health, the alleviation of illness-related suering, or the stimulation of healing
processes.
Individual music therapy interpretation of the process so far
Applying the previous remarks to the specic case study, this means the
following: by understanding that I can only set the general framework and
otherwise do nothing more than just sit down at the assigned place and at
the most be allowed to listen, I respected Mikes need for separation and
autonomy, while at the same time giving him the opportunity to formulate
in a sequence of tones the hopeless concurrence of being left in a helpless
state, and the annulment of everything personal. This opened up
new possibilities. The question of whether it was more the physical

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self-experiencing, that is holding the guitar in his arms and the increasing
dexterity of his ngers, or the ability to relate to the tones, which he of course
heard as well and which he imitated and varied (similar to the way infants do
with their voices), or if it was that he was getting used to my unobtrusive
presence which allowed something new to develop is impossible to answer.
However, what was clear was that Mike began utilizing resources. Using his
own devices he was able to regain tranquillity and self-reassurance by
movements of the pendulum as well as he was able to regain intentionality by
his calling. Where he was not able to make any progress was in being able to
direct his calling to an other. In his imagination, there was nobody who would
have felt meant by his calling and would have answered his calling, since the
ideas of meaning somebody or feeling meant were made impossible by the
experience of being threatened or even annihilated.
The fact that somebody was not there had the eect that it was not
possible to determine who was threatening whom. Was it I with my oer to
build a relationship with him just by my being there that kindled his fears,
and stirred his unfullled desires from early childhood? Or was it he, who
was threatening me in his unconscious fantasies, who was harming me alone
through his mere presence, such as had been the case with his too young
mother during her pregnancy? Or the other way around, did he, so to speak,
suck in her lack of motherly feelings with the milk? Was this conrmed even
more by the hostile ignorance of his step-grandfather who didnt want to
have him around, and was only able to tolerate his presence after the little
boy was willing to cuddle up and look at pictures with him, the meaning of
which he could not understand at the time, but which were far from being
suited for children?
The requirement of interdisciplinary treatment approach
When a developmental phase is concerned, in which self- and object
representations are not yet suciently developed, when neither inner world
and outer world nor I and you can be clearly distinguished from each other,
then the threat is without direction and omnipresent. The patient showed
manifold signs of this kind of experiencing, although it was not able to be
understood everywhere. For example, on the ward he used to pour quarts of
milk down the drain, because he believed it was spoiled. But there, where the
reality of normal life reigns, milk was not mothers milk which had gone
sour and which he wanted to protect himself and perhaps others too from
drinking, but something to add to ones coee. His fellow patients were
angry with Mike because he was causing them harm with this behavior. For
a while there was no other solution to this than to store the milk containers
in the nurses refrigerator.
At this point it is important for me to add that inpatient psychoanalytic
music therapy must be guided by an understanding of illness that rests upon

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a psychodynamic approach and that is mutually accepted by the entire sta,

so that one does not work against each other instead of with each other,
which would only aggravate the patients state of confusion. Therefore, the
self-perceived professional roles of the nursing sta that is how they
perceive their mission are also crucial for the successful outcome of
treatment. Although the sta have the task to establish order on the ward so
that it becomes possible for patients some of them seriously disturbed to
live together, for analytic (music) psychotherapy it is not irrelevant how and
with what kind of therapeutic attitude this occurs. Therapy can only be
optimized to the individual needs of each patient if there is a very intensive
exchange of information among the sta.
The knowledge that pouring out the milk had a specic function for
Mike made it important to make sure that keeping the milk locked up did
not appear as a punishment to him but instead as an act of safekeeping. On
the one hand, the intention was to protect the patient from repeated
traumatic experiences of being insulted and rejected by fellow patients. On
the other hand, one had to consider the fact that at the same time it
demanded of him to do without the for him necessary behavior dictated
by his inner self. For this reason the nursing sta took great care to protect
the patient from excessive demands with respect to interpersonal relationships on the ward.
Individual Music Therapy Part IV (Sessions 4560)
This background, together with what I had understood up to that point, was
decisive for the further course of music therapy. By way of indirectness more
and more was brought into a state of ux, and Mike was increasingly able to
relate to his environment. One visible step in this development was the fact
that he himself gave the name rain forest to one of our improvisations
(online music appendix Mike 4).
Having mustered some courage, I voiced a spontaneous idea one day
and asked Mike if it would be okay for me to try to play the guitar melody.
The question was sincere in so far as I really had not yet attempted it and
besides this I hardly know how to play the instrument, although by that time
I had long memorized how to produce the sequence of notes. Mike gave a
seemingly indierent answer: Yes, if you like, and so I took the other
guitar and started playing. I was able to play it right from the start as if
listening to it and seeing it played so many times before as well as my
repeated reections about it had put me in the position to do so. But I
refrained from playing the vibrato because that would have looked as if I
were miming him.
After the last note had faded, I anxiously awaited what would happen
next. As if nothing at all had occurred, Mike started playing the sequence of
notes himself. But he too did not end at the usual nish, but continued

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S. Metzner

playing as sometimes in the past loopings up and down the scale. I

interpreted this as an invitation for me to follow him and overcame the
feeling that I was chasing him, which had strongly hindered me in the past,
as I already mentioned before. What resulted was a piece like a fugue, which
could have gone on forever. But somehow or other it ended. By this the
seeds of what De Baker (2005, 2007) calls musical form were sown. Then,
however, the patient put aside as always the guitar and went (the same as
always) to the congas, and I (the same as always) to some other instrument.
Mike returned to the guitar toward the end of the session and played the
note sequence once more, and since I was somewhat concerned I told him
that it would always stay his note sequence even if I did try it out today.
Mike was visibly startled by this remark. I realized that I had gone one step
too far. He would have been able to bear the fact that I made myself equal
with him and followed him, but not that I dened the melody as his personal
signature tune. Although I resolved to be more careful in the future, I was
sure that I was on the right track, since his fearful reaction also showed me
that Mike, who otherwise let everything else fall into the seemingly
indierent but for him vitally necessary phrase same as always, was able
to feel that he was personally meant, and was also able to show this to me:
his counterpart.
In the following sessions when we as so often before played on two
instruments at the same time, sometimes also playing together, I now and
then worked in small parts, that is to say changing notes of his melody, into
my play. From Mikes sensorial play it was not clear if he noticed this at
all, but our mutual playing became increasingly smoother (online musical
appendix Mike 5).
Individual Music Therapy Part V (Sessions 6072)
One day he suddenly and unexpectedly interrupted his and my playing and
asked me if I knew: dididididi. He made an amateurish eort to sing the tune,
but it was quite obvious what he meant: For Elise by Beethoven. I struck up
the melody on the piano, and Mike asked me almost enthusiastically to
continue playing. He was disappointed that I was only able to play the rst
part and not the entire piece. The version I improvised did not satisfy him. He
wished that I would bring the notes with me to the next session.
The same as always he came to the next session, took a short glance at
the notes lying on top of the piano, sat down, took the guitar, and played his
piece. In my counter-transference I began feeling uncertain if the
occurrences of the last session had actually happened or not. Then, instead
of changing to the congas, as he normally did, Mike asked me if I had the
notes. I told him yes and oered to play the piece. If you want to was his
response. Actually it was he who wanted it, but I did not insist upon
discussing this, and so I sat down at the piano without a further word.

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Playing For Elise once was not enough. Again and again he asked me
to play the piece. Mike soaked up the music like a dry sponge or like a
thirsty baby gulping down his mothers milk. Eventually it was enough, and
we improvised for the rest of the session on the other instruments. For the
time being, Mike did not return to the note sequence. It had apparently been
replaced.
Reection on Methodological Challenges
This was repeated in the following sessions. I had the feeling that my piano
playing was like breast-feeding. At the same time I was worried that the
repetitions might develop into stereotypes. What appeared important was to
avoid becoming entangled in the compulsive habits of the patient which
would then be irresolvable. Likewise, it seemed crucial to not entice the
patient into therapy with an oer to obtain substitute satisfaction for the
privations suered in early developmental stages, while taking care not to
confront him with this in a way that would be hard for him to bear.
At rst my concerns were connected with the treatment technique. At the
same time, however, I noticed that there was more to it than that and looked
for signs that a counter-transference might be responsible for my
anxiousness. In contemplating this possibility I came upon Mikes mother,
who had felt dominated by the infant and neglected him for this reason.
However, by describing herself as not good enough, she demonstrated her
concern and this in itself was something positive that she felt for Mike.
Even if it appeared to me that in accordance with the available
biographical data it was rst the good grandmother who was able to
translate her concern into action, it must be pointed out that the greatest
part by far of the story remained in the dark. For example, there is no
answer to the question why Mikes mother left home when she became
pregnant, and if and how her parents expressed their concern for the young
mother.
The analysis of my counter-transference allowed me to make a new
connection to the past, and to adopt a conciliatory attitude towards Mikes
mother. As minute as this step of understanding may seem, especially in
retrospect, it is not possible to shortcut the long road there, because here we
are not dealing with rational understanding but with working through
emotional processes.
Because of the intimacy in the therapeutic relationship and the
associated processes of direct interpersonal exchange, the change in my
attitude also elicited a crucial step in treatment on the side of Mike. He
began to participate in our relationship in a completely dierent way than
before, and through this he was able to revise the unconscious fantasy that
he was bad. Mike wanted repetitions of the piece, but it was obvious that
after the seventh or eighth time he noticed I had had enough and he then

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suggested something else. Or he began to play the piece together with me,
trying out dierent instruments: the congas, the kettledrum, the temple
blocks, even the guitar (online musical appendix Mike 6).
For Elise was also a neutral place between us, a cultural possession
which did not belong to either of us and to which both of us could relate.
What was important in playing together was the mutual rhythmic and
dynamic atunement, the joint beginning and ending, the small rhythmic
variations, and the compensation of accidental slips, but we did not have to
do this without the support of an objective third.
Individual Music Therapy Part VI (Ending: Sessions 7378)
After one of our mutual playing sessions, Mike said that we could perform
as a band one day, burrowing behind this chumminess the special quality
of relatedness that characterized our playing and which, in consideration of
the early developmental disorder which was the root of the psychotic illness,
was the more important one. Still, partial denial was for the moment an
appropriate compromise, because it was apparent that the end of inpatient
treatment was not far o. There was no room for further development, so
that in the act of concealing, it was at least possible to preserve what had
developed up until then.
In the meantime, almost a year passed. The health insurance medical
service was no longer willing to pay the hospital bills. The social worker had
been successful in talking Mike out of moving into his own apartment.
Together with him she had looked for and found a therapeutic residential
facility that was suitable for him. The occupational therapist had worked with
Mike to get some system into his practical work, and to enable him to relate to
his products. The responsible physician modied the pharmacological
treatment so that there were no more side eects, and Mike was willing,
although reluctant, to continue taking his medication ( if you want me to).
The nursing sta had seen to it that he no longer neglected his personal
hygiene, got accustomed to a regular daily schedule, and was no longer forced
to avoid the company of others. His fellow patients liked him, and some of
them wanted to keep in contact with him. Although these were very positive
developments, too much optimism would have been out of place. Up to this
point Mike had not yet acquired any insight into his illness, which could have
functioned as a basis for assuming responsibility for the future course of
treatment. Further, in the foreseeable future he would not be in the position to
lead an independent life, to build mature relationships, or nd a job. On the
other side, visible results of the treatment were the improvement of the acute
psychotic symptoms, an increase in vitality and hope, and progress in social
integration due to newly acquired or regained intrapsychic structures.
The last session of music therapy ended the same as all the previous
ones, simply when the time was up. Perhaps the missing parting

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formalities would have made me become somewhat skeptical about the

outcome of therapy, if I hadnt known that Mike, without admitting it,
took something with him that he would never lose again. He would be
able to nd For Elise, one of the most popular pieces of classical
music, everywhere. For Mike the piece had the character of a so-called
transitory object (Winnicott, 1985), meaning that it represents interaction
experiences that can be described as follow.
From a call that remains hanging in air (suspended in air) something
emerges that is like being nursed; one can make use of someone without
destroying him/her, one can be in tune with each other without loosing
oneself, one can share experiences with an other without disintegrating, one
can feel meant without being threatened in ones existence.
The advantage of For Elise is that this music is so to say common
property, and one can keep the personal meaning and story incorporated in
it to oneself. It was in this sense that I understand the missing parting ritual:
each of us kept something to themselves. At the end Mike simply remarked,
we also could have talked, if I had wanted to.
Epilog
Mikes nal comment could be interpreted in many ways. The touch of
hidden humour makes me smile even years after the end of this
therapeutic process but I also can feel the underlying danger of
questioning the whole process and our relationship. I leave it open to
the reader to nd his/her favourite interpretation. My renunciation to
analyze it any further is owed rst to the autonomy of the patient at the
end of a long therapy, second to his artistic ingenuity to put so many
meanings into one single sentence, and last but not least to the necessity
of concealing which is equally important to revealing in analytical
music therapy but often enough forgotten.
What does an individual experience, who is not able to feel that he/
she is meant? In what kind of a world does he/she live so that
anonymousness and conformity take the place of mutual relatedness?
These were the questions I raised in the beginning. I hope I could show
in this single case study, and through my continuous theoretical
reections, that oering an unobtrusive presence is in general the
prerequisite for a person, who is living in an instable state concerning
the dierentiation between an inner and an outer world, and the
formation of self- and object representations, to nd his/her own
structures for encountering self and the world. This therapeutic approach
includes methodological and also personal (emotional) challenges for the
therapist, but as in music therapy they can be regarded as musical
challenges, they can also be handled musically. At least as long as this is
the preferred of all possibilities by both the patient and the therapist.

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Notes on contributor
Prof. Dr. Sc. Mus. Susanne Metzner, music therapist, musician, psychotherapist for
children and adolescents (PTG). She has clinical experiences in working with children
and adults in oncology and psychiatry, specialization in psychoanalytic theory,
aesthetic theory and in pain treatment and improvisation. Metzner has numerous
publications.

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