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De Backer 2008
De Backer 2008
De Backer 2008
To cite this article: Jos De Backer (2008): Music and Psychosis, Nordic Journal of Music Therapy,
17:2, 89-104
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RESEARCH ARTICLE
Nordic Journal of Music Therapy, 17(2) 2008, pp. 89-104.
Jos De Backer
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Abstract
This clinical research study examined the music therapeutic process from sensorial play to musical
form by psychotic patients. Based on the assumption that the psychic space has its origins in the
transition from sensorial play to musical form, and that the capacity to make representations is severely
affected by psychosis, there is a need to find out by which means this capacity can be re-established.
Because of their pathology, they do not make use of a psychic space to reach symbolisation, which
means in music-therapeutic terms that they are not able to create a musical form in which they could
exist as a subject. Therefore the therapeutic transition from sensorial impression to musical form (i.e.
proto-symbolisation) is a basic condition for the treatment ofpsychotic patients. In this contribution
the author examines and describes the process from sensorial play to musical form. The phenomena
sensorial play, moments oj synchronicity andmusicalform are definedandthe different characteristics
are summarised. The specificity of the phenomena ofsilence, timbre and inter-subjectivity, which were
essential to the therapeutic process, is discussed. The therapeutic interventions that are of central
importance for the clinical music therapist are examined. Finally, the usefulness of the study for the
clinical music therapist is made clear.
changes over time. Other questions related to how changes in behaviour) with specific events in
the change in the patient's musical production music - either in the patient's solo playing, or in
and interaction represented a corresponding their playing together with the therapist. There
change in their perception and insight, and how was no analysis of differences between playing
all these aspects determined the course of the where the patient was unaware or unrelated to the
music therapy treatment. therapist, and playing where developments in the
Working in music therapy with psychotic musical material indicated a shared or connected
patients, one sometimes encounters characteristic, experience. The need to explore this and offer
repetitive, and consistently similar musical some analysis and explanation of the processes
patterns. Psychotic patients tend to express that occur then became the motivation for this
their experiences and conflicts in musical study, and from this emerged the direction towards
improvisations, by 'fragmented'play, or constantly which this study was designed.
repeating rhythms or small melodic sequences This research concerning the relevance
(Bauer, 2000; Pedersen, 1999; De Backer and of music therapy for patients with psychotic
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Van Camp, 1996; Hengesch, 1974). From clinical disorders explored the means by which a certain
supervision and a general overview of relevant form and finite quality can be generated and
psychoanalytic and psychotherapeutic literature, established through musical improvisation and
looking specifically at Bion (1956), Duhrsen relationship in order to effect the disintegration
(1999), Ogden (1992, 1994), Tustin (1981,1990), and timelessness of the psychotic world. The
Van Bouwel (1998, 1999,2003) Van Camp (2000, intention of analysing these clinical processes was
2003) and Winnicott (1971), it became clear to me to show that music is active on the level at which
that this style of playing (with repetitive rhythms the central issues of psychosis can be situated. In
and melodic fragments) could be understood as view of this, aspects of the musical experience
an expression of a psychotic's sensoriality. As were essential to this research, in order to reveal
was discovered through a literature review, there how music therapy has a significant place within
were few publications, e.g., Pellizzari (1993) and treatments and interventions for people with
Bauer (2000), about music therapy and psychosis psychosis.
on this specific topic. What was written about
the effect and value of music therapy for people Method and Research Questions
with psychosis did not provide any relevant or For the research two subjects were chosen.
detailed analysis of musical material that could Both displayed a clearly identifiable musical
connect interpretation of the behaviour (and characteristic that was also typically presented in
other psychotic patients, specifically an endless
Dr. JOS DE BACKER, Professor at the College repetitive play of certain rhythms or melodic
of Science & Art, campus Lemmensinstituut sequences, or a fragmented musical play. Sessions
(K.U.Leuven) of music therapy and head for the with these patients formed the data that was later
Master training course Music Therapy. He is Head analysed.
of the Music Therapy Department at the Psychiatric A feature of this study is that the research
University Centre-K.U.Leuven, campus Kortenberg was always treated from a clinical perspective,
where he works as a music therapist treating young and the design was developed in response to
psychotic patients. He also has a private praxis. the subjects (patients), rather than the subjects
Prof. Jos De Backer completed his doctoral studies having to conform to a pre-determined design.
(PhD) in Music Therapy at the University of This was necessary in order to stay true to the
Aalborg, Denmark. unique characteristics of the clinical situation
Prof. Jos De Backer is President of the European and, as a consequence, to come to an adequate
Music Therapy Confederation (EMTC). formulation of the theory. Because of its practical
Email: jos.debacker@scarlet.be orientation, the study made use of a "single case
design." The case studies were audio as well as
complementary in their reflections. The analysis as a significant way of making music for the
and interpretation was from a psychoanalytical psychotic patient. Psychotic patients demonstrate
music therapy perspective. This frame of thinking through their pathology an inability to create a
was made use of to the extent that it was already psychic space through which they can appropriate
developed within the research of psychosis, and the musical object and give it a symbolic status
as a consequence was of central importance in the (Bion, 1967; Freud, 1911; Lacan, 1981; Ogden,
research intervision and for the interpretations of 1986; Van Bouwel, 1998; and Van Camp, 2001).
the therapist. The specific changes in the musical This inability expresses itself through an endless
parameters were also examined and selected, and repetitive and monotonous play, or a fragmented
insight was gained into musical processes as well play that the psychotic patient does not experience
as psychic processes. This made it necessary that as something that belongs to or comes from him.
not only a music therapist participated in this This means that when playing music a psychotic
study, but also a psychoanalyst and a composer. patient is not able to recognize his own playing.
This research was primarily inspired by clinical This research shows that music therapy offers
material, without reference to or departure from psychotic patients an opportunity for the creation
a fixed theoretical assumption, and therefore of a certain psychic space which can create
the analysis of the data did not refer to existing the possibility for a certain degree of potential
therapeutic phenomena such as projective symbolisation. In order to demonstrate this more
identification, containment, holding, splitting, specifically, five sub-questions addressed this in
etc., but emerged from the music material and the detail, the findings of which are given below.
therapy practice itself. In this research process I The sub-questions are as follows:
was not only focussed on the outcome, but rather
I always put the musical and therapeutic process 1. How can we describe and define sensorial
at the centre and acted as a neutral observer in play?
trying to determine what was essential, and what 2. How can we describe and define musical
could be observed, experienced, and used in the form?
research. In this sense the research could be called 3. How can we describe the elements
clinically applied research (Wigram, 2001). and identify which ones are needed
In order to present the findings, the main to understand and have insight in the
research question and sub-questions of this process?
research will provide the structure for a systematic 4. How does the process of sensorial play
summary of the results. evolve to musical form and how can one
describe and compare the important music
therapy moments (i.e., changes) in this process?
other
5. Which interventions of the music therapist process and which develops from the foundations
contribute to the development of musical laid during moments of synchronicity. Clear
form? rhythmic and melodic themes may appear
that can be further explored or varied. Musical
How Can We Describe and Define Sensorial figures can be characterized by phrasing and
Play? pauses. Features of the musical improvisation
Sensorial play is a term describing the typically include a clear beginning and ending
characteristic playing of a patient where, while and these are prepared for mentally by patient
producing sounds, the patient is not able to and therapist. This is always an inter-subjective
connect with or experience these sounds as phenomenon between patient(s) and therapist,
coming from himself. The patient's music who experience being equal to each other and
is characterised by repetitiveness and/or feel free and autonomous to play, think, exist, and
fragmentation. The improvisation cannot really develop their own images and thoughts. There is
be begun nor ended, and there is no clear melodic, an intertwining of the timbres of both players.
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I
Aspects of inter-personal / intra-personal
experiences from the music therapist's point
of view:
1. Aspects of inter-personal /intra-personal
experiences from the music therapist's point
of view:
2. The patient is involved in the play and
allows the therapist into his play
3. Initiatives come from the patient
4. There is interactivity between the patient
and the therapist
5. The patient and the therapist are also
autonomous
6. The patient is in resonance with himself and
with the therapist
7. The therapist is able to take the Bass-line
position
8. The therapist is present as a subject
9. Inter-subjectivity is present
from this concrete musical data musical material the paradoxical experience of each individual's
could be analysed in a systematic way (for detailed freedom and autonomy. The mutual dependency
description see De Backer, 2005; De Backer & in the creation of a shared musical object leads to
Wigram, 2007). From this musical elements a liberating feeling of being able to make music
and structures became visible and the musical in a completely independent way. The patient
processes were discovered in both cases. Finally, and therapist are free in relation to one another
in order to be able to examine the therapeutic and can play, think, exist and develop their
processes the impressions of the therapist and own musical thoughts. This paradox involves
the research intervision were the main source of emerging autonomy in the patient and therapist,
information and were of crucial importance. while at the same time, there is acceptance and
recognition of mutual dependency. During this,
How Does the Process of Sensorial Play brief moments occur where the timbre of both
Evolve to Musical Form and How Can One players intertwines.
Describe and Compare the Important Music These moments of synchronicity can be brief,
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Therapy Moments (i.e. Changes) in this unexpected and infrequent, acting as possible
Process? precursors for the development of the musical
The development of sensorial play towards form. Moments of synchronicity usually appear at
musical form happened in both case studies via a specific or right-moment in a shared experience.
the appearance of moments of synchronicity. The list of features of moments of synchronicity
From the results of the two case studies I came to (Table 3), itemised within defined categories, is
the following categories and detailed definition inclusive, and some, but not all, items are present
of moments of synchronicity. in an analysis of improvised music.
In the moments of synchronicity we can find
Moments ofSynchronicity in a Music Therapeutic the same musical elements present in the musical
Context material of both patients, as follows: a first
Moments of synchronicity is a term describing initiative to develop phrasing in their music by
points in time in which there is a shared inner permitting pause and silence to happen; variations
experience of the patient and the therapist, through some rhythmic and melodic development
in which they both feel free and autonomous as well as some variability in dynamics; and a first
in their play during a musical improvisation. apparent level of control or intention to "round
This shared experience appears unexpectedly off' an improvisation, or to bring it to a clear
and unintentionally, and is characterised conclusion. However, it is important to emphasize
phenomenologically2 by attunement between that these moment of synchronicity only last for
the musical parameters of the patient and the a moment each time they occur, and they are not
therapist. continuous. Holding or containing these musical
elements occurs when they become consistent
Further Explanations and stable enough to develop into musical form.
Both patient and therapist have the feeling that When there are moments of synchronicity, the
they are able to come into a genuine shared play first musical interactions are present, and on a
for the first time with an intertwining of two psychic level a first inter-subjectivity originates.
musical lines into one entity, or one whole, for The body is then, for the first time, able to co-
example, where both share the same pulse with resonate with the music. It is also the first time
shared accents in the meter. Underpinning this is that the timbre of both players intertwines.
The specific interventions of the therapist
2 Phenomenological is a term that can be defined as
something that exists and can be seen or heard. It is part (which will be discussed in the following sub-
of the concept of synchronicity, but is not a description question) were necessary to give the patient the
of the concept, because synchronicity is experienced opportunity to make the therapeutic process of
on a more inter-subjective level. sensorial play towards the musical form.
Which Interventions of the Music Therapist harmonic foundation the therapist offers. The
Contribute to the Development of Musical therapist, who is seen as a longing and supposed-
Form? to-know subject, will in no single way be willing
In the analysis of the two case studies, there to fill in the question or desire of his patient. The
were some significant examples of interventions Bass-line-position therefore is closely connected
that facilitated, influenced or supported the to the abstinence rule in psychoanalysis and
process of the patient's playing from sensorial because of this, the filling in of the Descant-line
play to musical form. Outside the fundamental position lies entirely open and is unknown for
therapeutic phenomena such as transference, the patient, as well as for the therapist. It is the
counter-transference, holding, containment and patient who will move from the transference into
projective identification the following therapeutic a psychic space and will be able to give form to
interventions were noted: their traumatic experiences and memories. The
Bass-line-position only supports and makes free
a) Taking the Bass-line position and Descant- improvisation in the Descant-line possible.
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the patient and needs to have enough insight in with sound or noise.
his own desires (i.e., his counter transference). In both cases in this study, the patients had a
As noted by Van Camp (2001) it remains a tendency to fill up each space and every silence
difficulty that in work with ego-weak patients when they were engaged in sensorial play. They
such as psychotic patients and there is always failed to allow the possibility of, or prevented the
the imminent danger that the pressure on the creation of, a psychic space in which imagination
therapist becomes so great that he gives in to the could originate, and within which one could
desire of the patient and takes the Descant-line- fantasize or could think. The inability to allow
position upon himself. Through this the therapist an inner sound was not only observable in the
will coincide with the patient. This, however, will sensorial play of the improvisation, but often
obstruct or even destroy the therapeutic process stretched out over the entire music therapy
and make the patient entirely dependent on the session. The musical production remained
therapist. entirely external, strange, and undirected, and
the appropriation of the musical material became
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certainly a feature when the patient was still dynamics of the therapist. Therapeutic provoking
caught up in sensorial play. Pedersen (1998) is not a technique, but an intuitive event in the
wrote about the therapist listening through their desirable play of the therapist, who senses when
body to the body of the patient. This physical he could allow this intervention to occur. In this
listening stance mainly becomes visible in the way there it is not a conscious intervention, but
video analyses, where the physical attitude of the rather an intervention which is directed from a
therapist is identical to that of the patient. One can given transference. When this happens too soon,
state that the therapist listens to the body of the the patient cannot allow this opening and thus
patient through his own body, where one listens increases their resistance towards it.
on the level of the affect. Here the therapist tries
to come into resonance through their body with g) Mentalisation after the Session
the affect of the patient. Holding and working through the sensorial play
of the patient was sometimes unbearable for the
e) The Therapeutic Reaction therapist. However, unlike the patient, the therapist
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This is a reaction of the therapist to the projected has the possibility to make all of this tolerable and
powerlessness and lack of freedom of the patient, digestible by improvising in a reverie style after
which the therapist experiences in a fundamental the session. Through this play (mentalisation) the
way in sensorial play. In his therapeutic desire therapist could create everything that affected him
the therapist will continuously try to come into during the session in a musical form. Mentalising
resonance in his musical play with the sensorial through these musical improvisations made it
play of the patient. The therapist hopes that possible for the therapist to back himself out of
the musical forms that he is playing will graft the mire of sensorial play. He could then integrate
themselves onto the sensorial play of the patient, this emptiness or the compactness of the affect
so that a first contact originates in which the within an inner imagination (impression) and let
patient can co-resonate for a moment, or comes the hope and desire exist in order to continue the
briefly to an inner movement. The therapeutic therapeutic process.
reaction is the steadfast attitude of the therapist An illustration of this is found in the first
that is necessary to create enduring conditions in session of the first case, who left an intense,
order to come to an inner imagination. It is being full emptiness behind. The therapist had the
alert for the play of the patient and intuitively possibility to make the vibrating affect in his
seeking the emergence of phrasing, structure, body bearable and digestible through a musical
pulses, while letting silences and possible improvisation. By improvising he could allow
variations emerge. an inner therapeutic silence, which was essential
for the mentalisation of the full emptiness full of
f) Therapeutic Provocation of the Therapist repetitiveness. Via the play he gave form to the
This is connected to the therapeutic reaction, sensoriality that remained external.
although this intervention is more direct. With
the two cases, the therapist provoked sensorial h) Absence of the Patient (reverie)
play by opposing it carefully and undertaking The empty space that originates when the patient
this mainly with counter rhythms. One can state is very late for therapy, or does not show up at all,
that, because of this provoking intervention, the has a therapeutic value. Ogden described, "that
therapist tried to create an opening in the compact, the patient's physical absence creates a specific
closed and lack-of-contact playing or the rigid, form of psychological effect in the analyst (and
controlling and fearful playing of the two cases. in the analysis) and that the analytic process
Even though both patients were not yet prepared continues despite the patient's physical absence.
to allow that something might come into process, In this way, the specific meanings of the patient's
they could abandon their sensorial play for a presence in his absence are transformed into
moment by, for example, taking over the tempo or analytic objects to be fully experienced, lived
with, symbolized, understood, and made part of something unknown. This cannot be viewed as
the analytic discourse"(Ogden, 1997, p. 43). The a confirmation that the patient expresses himself
music therapist, however, has the potential to in the music.
form an image of the patient by improvising and We can see the same phenomena in literature.
by reflecting about the patient and because of this The writer allows himself to be surprised (the
the therapeutic process can be continued. This happy accident) or overwhelmed by a series of
therapeutic level of thinking was a remarkable untraceable and thus never interpretable, syncretic
and necessary experience for the therapist in associations. This process (the fertile motif) is
the second case. For example in the first three organized by an autonomous I (Ehrenzweig,
sessions the therapist waited for the patient who 1977). It is a process of surrendering that repeats
came too late. The patient continuously wanted itself endlessly while the work evolves; the reader
to exercise control over the music therapeutic only sees the final result. The writer is also not
treatment because of his narcissistic problems only influenced by his own associations, but by
and, by arriving late, created a situation where what he (partly through a happy surprise) finds
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it was he who controlled the framework. For there on his page (i.e., discovering the piece of art
the therapist, it was therapeutically valuable as an autonomous object). This can be correlated
to improvise in order to be able to think about with what the two cases experienced when they
the patient. The musical improvisation was a reached musical form as an autonomous play.
purely intuitive play, where the therapist let The writer is a spectator of his own work. In the
himself be guided by the music. As a result of same way Stokes (1965) described, "The artist is
this, the therapist could come into resonance with in the fullest sense the spectator of his own work;
himself and the imaginary image of the patient not just of the finished work, but of the work in
and the therapeutic process could be continued all stages" (Stokes, 1965, p. xxvii). Beethoven
and held. This process of giving form musically did not really "invent" the famous first notes of
and mentally had its reflection on the therapist's his fifth symphony. They occurred spontaneously
therapeutic attitude and listening during the in his mind. This is also the case with musical
proceeding meeting with the patient. findings in the musical form of the two cases.
can describe musical form as the origin of the subjectivity are important phenomena in the
musical conditions that enable the sounds which therapeutic process. They manifest themselves
are generated during a musical improvisation not only at a non-visible and non-audible level,
to be no longer experienced by the subject as but can also be experienced by the patient or the
external, as something that is foreign to him, therapist. It is also possible to examine the specific
but instead can come into resonance with an and differentiated therapeutic interventions of the
inner self (Schumacher, 1998; Gindl, 2001, music therapist, because these are important to
2002; Metzner, 2001) During the point at which facilitate and support the possibility of developing
moments of synchronicity emerge one can see as musical form. The therapeutic methods of
a moment that is the most decisive, but because interventions seemed from this research not to be
of this, the most precarious in the creation of applied by the therapist as concrete techniques,
an appropriate musical form. In the two cases because they are not used consciously, but rather
reported in this study, this precarious moment are directed from the transference. Through self-
always takes place during an inter-subjective experience and supervision these interventions
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event. The moments of synchronicity have been can become insightful and appropriated, and will
described as the shared experience of patient and contribute to a reliable and authentic therapeutic
therapist, where they feel free and autonomous attitude in therapeutic interventions with
in their play. In relationship to each other, both psychotic patients. From this research, I hope to
patient and therapist are free to play, to think, to have developed a theoretical frame of thought
exist and to develop their own musical thoughts. that is applicable in clinical practice, in order
This moment of polyphonic resonance is the to provide psychotic patients with possibilities
condition that allows a musically dynamic build- for developing a psychic space within which
up to originate within the improvisation, wherein symbolic thought and experiences can exist, and
rhythmic and melodic themes appear, which can as such, make an ending to his "unimaginable
further be explored or varied in the musical form. storms" (Jackson and Williams, 1994).
The musical figures are characterized by phrasing These musical analyses offered me the
and pauses and another specific feature is that, for possibility for exploring the musical material
the first time, a clear, mentally prepared beginning and for finding hidden structures and musical
and ending mark the musical improvisation. developments. A very interesting aspect was
One can describe sensorial play in all aspects the research inter-vision in which my own
as the opposite of musical form. It is a play of countertransference became clear and several
the patient during an improvisation with the interpretations could be made conscious. This
therapist, where the patient produces sounds, but was significant not only for this research, but
does not come to music, let alone appropriate also as a useful process for the supervision of
these sounds. The improvisation does not daily clinical practice. The conclusion of this
generate an experience within the patient and he study also makes me aware that at one level the
is not inspired by the music. The patient does not research is still continuing, as many new and
experience his musical play as something that interesting questions have come to my attention.
comes from himself, but rather as sounds in which This study created a fertile basis from where
he does not participate. The sounds are outside of new music therapeutic insights and theories
him, and they do not belong to him. On the basis can be developed or examined in the work with
of his pathology the psychotic patient does not psychotic patients, and also with other patients
have a psychic space which allows symbolising where the symbolising function is affected.
and which would make it possible for the musical Therefore, this study is not an end, but is rather
objects to be appropriated. Sensorial play is like a phrase that connects the past with the future.
endless, without beginning or ending. It can be likened to the silence that can only be
It became clear from the research that specific felt if there is a connection with what previously
phenomena such as silence, timbre, and inter- happened, and where what previously has
Nordic J o u m a l of
102 Music Therapy 17(2) 20(
MUSIC AND PSYCHOSIS
sounded continues to sound. Within the bridging De Backer, J., & Van Camp, J. (1996).
tension of the phrasing there exists a time bridge Muziektherapie in de behandeling van
that connects the past to the continuing music, psychotische patienten. In M.De Hert, E. Thys,
which makes it possible for a new beginning. J. Peuskens, D. Petty, & B. van Raay (Eds.),
Something from this study has now to emerge Zin in Waanzin, de Wereld van Schizofrenie
into the future, where other music therapists can (pp. 179-193). Berchem: EPO.
take what was learned to inform their own work. De Backer, J. (2005). Music and Psychosis.
Future music therapy research should also be Unpublished doctoral dissertation. University
undertaken to explore further the inner world of of Aalborg. http://www.musikterapi.aau.dk/
psychiatric patients, and in this way to continue forskerskolen_2006/phd-backer.htm
the development of music therapy theory and De Backer, J. & Wigram, T. (2007). Analysis
clinical applications. of Notated Music Examples Selected from
Improvisations of Psychotic Patients. In Th.
Wosch & T Wigram (Eds.), Microanalysis
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