I have a long-standing and considerable respect for the clinical practitioners in our profession, especially those who are prepared to document their experiences and knowledge for publication. By stating this, I am declaring a bias from the outset, because it tends to suggest that I perceive a collection of clinical case stories, such as these, as having a primary and significant value in informing the music therapy profession - as well as those in related disciplines. I should also declare the consideration I feel for writers whose motivation is almost always altruistic and selfless - as there is certainly no evident financial reward to be gained from the arduous and sometimes exhausting task of writing. So having declared my positive bias from the beginning, I will nevertheless strive to offer as fair and critical review of this collection of case studies as I can.
.....As a collection of case studies, the text offers a rather specific focus on certain populations, with 14 of the 21 cases perhaps unsurprisingly drawn from the field of psychiatry - eight from child and adolescent psychiatry and six from adult psychiatry. Of the remaining seven cases, four are about clients with learning difficulties (two with autism), one from child oncology and two from the field of physical illness (although one of these emerges with early abuse and stress. Dr. Sue Hadley has structured the book well, following the style of Bruscia's 1991 text Case Studies in Music Therapy. Authors have followed a pre-defined structure for presenting their cases, described by Hadley in her preface as "a uniform format which begins with an introduction that provides information about the approach, client, or condition, followed by background information on the client, a detailed description of the treatment process, and finally, the authors discuss the case study in terms of various psychodynamic constructs." For me this was a balanced and structured means of ensuring some consistency in the way information was organised, while at the same time allowing the narrative style inherent in case reporting. The book is consequently very accessible, and the consistency of style ensures the presence of necessary elements in each case.
.....Hadley begins the text with a succinct and useful overview of theory underpinning psychodynamic music therapy, briefly explaining Freud's foundational work in Drive Psychology, following with Ego psychology, Object Relations Theory, Self Psychology, and Jungian Theory. This is helpful in framing the theoretical constructs that emerge throughout the book in each chapter. Hadley presents short definitions of three main psychodynamic constructs used by authors in the book including - Defences, Transference, and Countertransference. Traditionally, reviews of edited volumes such as this work through the various chapters offering individual comment to authors and commending the chapters for their value. I would like to try a slightly different format by considering the relevance of the material in how it can inform in two quite specific areas—to those in the clinical field, to music therapy students and those concerned with their education.
.....I will also focus my commentary by grouping the chapters together into the three main clinical groups, Child and Adolescent psychiatry, developmental disability and adult psychiatry, concluding with a miscellaneous group of three cases that don't easily fit into these categories.

The Cases from a Clinical Viewpoint

Child and Adolescent Psychiatry

The studies in the sections on child and adolescent psychiatry are all, with the exception (perhaps) of case 11, concerned with abuse. Mahns (Case 3) describes a case of selective mutism (at school), set against the background of a Middle Eastern culture where attitudes to bringing up children are affected by cultural history. The therapy is over a long period (50 sessions), and Mahns uses a variety of therapeutic media, including improvisation, art, and play activities. He addresses the abusive attitude of the client's mother, the need to give the client a safe space, and use play techniques to allow him to symbolically externalise his huge anxieties and fears. Music and play are seen as effective containers for the emotional needs of the client, and we can add this case to those examples where music therapy provided an effective avenue for treating a condition inaccessible to more conventional verbal approaches. Kowska (Case 5) gives an excellent example of group work with emotionally disturbed children of substance abusers. In this group case, Kowska describes two specific methods in two chosen sessions to exemplify the needs of these 8-12 year old children (particularly differentiating the four boys from the three girls). Rather than document events in more than 25 sessions of therapy, Kowska selects an example of free improvisation in an early session and song writing in a later session to illustrate resistance and transference phenomena, and to reflect on her countertransference. The free improvisation was well documented, with detail about the musical contributions of the seven children and the therapist, and how the musical and therapeutic process developed. I felt the song-writing example from session 25 was less detailed, but nevertheless drew out important issues about terminating therapy.
.....Wesley (Case 6) describes individual work with an abused 10 year old boy. This case shows an interesting process in therapy which is linked to some of the treatment methods in the hospital unit, and also initially addresses the influences of a noisy ambient auditory environment. Careful documentation of 12 x 45 minute sessions show a transition from active music making to a receptive mode of therapy (modified BMGIM), following which Wesley described phase two of therapy that involved song singing, and drawing of pictures. This case is interesting because Wesley showed how the very severe, on-going behaviours of Bruce were addressed by physical restraint and medication, and in music therapy by coping strategies, imagery and relaxation. The conclusion at the end gives good documentation and argument of the effect of music therapy, and the story ends with the post-script of how the approach was sustained after discharge. Rogers (case 7) has already published several papers on music therapy with both children and adults who are victims of sexual abuse, and has also written about her work with abusers. This paper gives another insightful overview of a lengthy (55 sessions) process of therapy. The therapeutic frame for sessions was well defined, and Rogers relates the themes that emerged through the therapy process, drawing in from her previous experience the recurrent issues of control and power. There is limited but, on one occasion, rather interesting reference to musical material and musical events in the sessions, while the main focus stayed at an interpretational level, and the importance of the therapeutic relationship. Rogers knowledge of related research surrounding sexual abuse is demonstrated with relevant references to authors such as Furniss and Sgroi. Again, the value of Arts therapies, here in the form of music therapy is well demonstrated as an ideal media of treatment for traumatised children. In Case 8, another disturbing story of early childhood sexual abuse unfolds in the case of Lena, where Robarts has described her theoretical influences in a musical, developmental, and psychodynamic frame incorporating Nordoff-Robbins Music Therapy, infant developmental psychology and object relations theory. Robarts defines what she describes as poietic processes in music therapy, a multi dimensional and bi-directional process. The case is illustrated by the predominant use of improvised songs, and through an account of events in three phases of therapy over 63 sessions. As in other cases of music therapy with sexual abuse, the value of the therapy lies in the therapists` capacity to hold and contain the very disturbed and challenging material presented by the client.
.....Schonfeld (Case 10) presents an adolescent girl, Ira, with whom she had undertaken long term therapy over six years. Schonfeld's narrative tells a story of a therapy process where the psychological state is strongly affected by the surgical treatment and physical bodily problems resulting from early abuse. The main media of therapy appears (by choice of the client) to have been puppet play, with only a small reference to days when the client wanted to sing songs. The story is both traumatic and fascinating, and the comment by Schonfeld on her client's musical talent and expressivity leaves one feeling rather aware that music held a great potential for this client. Fruchard and Lecourt (Case 12) describe a receptive approach in working with an adolescent boy in a home for teenagers with social difficulties. The authors described work with this client during 45 sessions over two years. The case focuses on interpreting his physical and mainly verbal responses and reactions to the voices/singers in the recorded music. These interpretations about the impact of choruses, male voices, female voices form the basis for understanding the client's 'story' - his adolescent process. While the actual music used in the therapy was listed at the end, there was a lack of connection between the chosen pieces and the interpretations. The final case in this clinical group is Eli, a 15 year old maladjusted teenager with whom Nirensztein used a Winnicottian approach involving mirroring and holding (case 11). Her therapeutic orientation also reflects Stern, seeking a therapeutic relationship founded on attunement. I liked the structure of Nirensztein's study, following her client's gradual process of meeting, communicating, 'showing himself', being angry and after 16 months of therapy, separating. The narrative provides many examples of musical expression from the client, incorporating the concept of the 'leitmotif' in his themes.

Children and Adults with Developmental Disability

There are four chapters devoted to developmental (learning) disability. Case 3, reported by Helen Tyler, describes a child with moderate learning difficulties, and evident emotional disturbance. Tyler refers to Winnicott and Klein in her theoretical frame, encouraging and nurturing play in the sessions. This is well reported in this study with a lot of her client's verbal text written up as she acts out various characters in the sessions, including a preacher, and a quite dominant male personality. Compared to others, Tyler primarily focuses on the story, without overtly providing a strong theoretical frame. Di Franco (Case 4) offers a very different style of presentation - giving us bullet points under headings to document the case of an eight-year-old boy with autism. This case is another good example of Di Franco's quite systematic assessment procedure which he has defined previously, and on which he bases therapeutic decisions. He goes on to describe ways in which he approached and worked with his client, referring back to the assessment to support choices made about therapeutic technique. He gives plenty of perspectives on the interpersonal aspects of the relationship, but rather less about the musical activities that went on.
.....Dvorkin and Erlund also report long-term therapy with an eleven year old child with autism within an object relations approach. This gave more examples (evident in other cases with children) of the use of puppets and symbolic play in the sessions. The authors reflect well on the child's anxiety about separation from her mother in some sessions, and the mother's role in others. There are detailed transcriptions of improvised songs, and the child's desire for familiar songs. Going to the severe end of the autistic spectrum where profound developmental disability is also very present, Rafieyan (Case 17) describes her work with a 37 year old man. This is a classically 'difficult' case where interpretation of behaviour and an intuited sense of intention is the way the therapist develops the therapeutic relationship. Rafieyan described the manipulation of instruments that appeared characteristic of autism (lining up and spacing), while referring to the more engaged and allowing state of the client when listening to the therapist.

Cases from Oncology, Physical Illness and Personal Development

Before reviewing the six studies in this book drawn from the field of adult psychiatry, there are a three cases that don't fall into a specific group. The first case in the book by Sweeney addresses terminal illness in children and the place of music therapy in a hospice. This report reflects the peculiar nature of hospice work - irregular sessions, sudden endings. The therapy involved only two sessions, but with quite different experiences occurring some weeks apart. Sweeney offers interpretation of events in the second session of a symbolic play representing anticipated death in the young boy. The use of certain songs and the description of the dismantling of a metallophone may support this, although there could be other possible interpretations. The capacity for the therapist to adapt to her client was well evident in this study.
.....Also addressing significant physical illness in the form of rheumatoid arthritis, Grocke (Case 20) also draws attention to the interpretation of symbolic imagery as a manifestation of the disease. Grocke's long experience as a clinician and researcher of the Bonny method of Guided Imagery and Music is evident in this case. In particular, I would highlight her understanding of the influence of the music in the programmes to facilitate a pivotal experience in this case, the effects of Shostakovich's music in exacerbating experiences of pain that later emerged to be instrumental in evoking memories. This case reflected on the interpretation and implications of quite challenging, frightening imagery, (through a long term therapy process of 84 session of which three were reported in this chapter), and how it related to both the client's experience of physical pain, and relationships with members of her family. Finally in this section, Montello (case 15) writes about therapy with a client who also came to music therapy with a physical complaint (severe tendonitis in her left forearm), but also sought therapy to find a way to manage her stress and anxiety. What emerged should perhaps place this case in the area of adult psychiatry, as a history of physical and sexual abuse had wrought damage on a talented musician. Montello frames her approach with her concept of essential musical intelligence (EMI), and chakra psychology. The story that follows is remarkable - involving searching, regression, discovery and recognition. How many other child prodigies have experienced some similar experiences in their life journey, I wonder.

Adult Psychiatry

There are six cases from adult psychiatry, five from northern Europe, and one from the United States, which caused me to ponder on the invited authors for this text. Let me first offer comment on these last six chapters.
.....Metzner (Case 13) uses the case of a 23 year old psychotic woman as a background in explaining triadic structures in family relationships. This is quite relevant as the stimulus for psychotic disturbance in this case is centred in the family dynamic, while the origin is evidently more deep-seated in the history of the client. Metzner draws a parallel with the attitudes and relationships within the multi-disciplinary psychiatric team. Metzner has chosen to use her 'space' in this book for a theoretical standpoint, explaining the many aspects surrounding the therapeutic situation. The one limitation is a very small three paragraphs detailing musical experiences in therapy - which gave some illustrations of equally interesting musical process. De Backer and Van Camp (Case 14) also report on a case of psychosis, and can claim a particular uniqueness as the only chapter in this text that gives notated musical material as a documentation of the 'clinical data' of therapy. The authors theme is the process of therapy from sensorial (formless) play into musical form through the psychic space. This case forms part of a doctoral research, and the therapist (De Backer) analyses the musical process to find the characteristics of client's musical play. Musical form appears to develop, partly out of the provoking intervention of the therapist, the consequence of which is the 'musical' response of the client transforming the musical and therapeutic relationship.
.....Nolan (Case 16) offers one of two cases of neurotic depression in the psychiatric group, and also gives a perspective on the therapists` role in the music. The client, Rick, is a self-taught percussionist, and in a similar way to Montello's case, the musical skill acted as a defence mechanism where constant rhythmic playing prevented creativity. Nolan found the re-direction of musical playing into new areas - melody, lack of strong rhythmic patterns was influential. This developed further into the use of a variety of percussion instruments, the piano and the voice. Composition became a medium for the client, both at the piano and with voice - and Nolan reported decreased negative self-appraisal and improved self-esteem. Jahn-Langenberg presents the second case of neurotic depression (Case 18), documenting the process as a sequence of four 'scenes.' The musical descriptions are most helpful here, underpinning the therapeutic issues such as defensiveness in relationships, separation, regression, defining borders and dealing with conflict that are being addressed. Jahn-Langenberg crafts the therapeutic story well, and in her discussion and conclusions explains the potentials of music in psychoanalytically informed music therapy to meet needs for safety and security while simultaneously facilitating the 'living out of dissonant impulses which do not destroy, but colourfully augment.'
.....Pedersen (case 19) describes a case of personality disorder with specific anhedonic and obsessive compulsive features. There are several important and valuable aspects to this case. The musical process helped overcome intellectualisation, and promoted creativity. The improvisations described by Pedersen were often long. Dream material was bought to therapy, and the images were also represented in paintings by the client. Vocal expression changes and developed. This was a long-term therapy, and the process is well described in phases, where Pedersen also reflects on her supporting and challenging roles in therapy. The listening perspective and the importance of self-reflection by the therapist of the therapist is one of Pedersen's important contributions to music therapy method, and this is evident here. There is also an important post-script from the patient himself which compliments Pedersen's own understanding of the process. Hannibal (case 21) brings this book to a conclusion with a case from his PhD level research, a female client with emotional instability personality disorder of the impulsive type. In music therapy, she also revealed aspects of evasive and anxious personality disorder. The style of presentation is similar to Pedersen, providing detailed descriptions of an event (improvisational music-making plus discussion) in a music therapy session, from three out of the four phases of therapy he has divided the 63+ sessions into that he had with this client. Hannibal draws out the issue of low self-esteem, and the client's process through therapy of strengthening herself and reducing negative and self-destructive behaviour. Hannibal also emphasises the value of music therapy as an alternative medium to verbal therapy for psychodynamic work, and this case supports that argument.

The Cases from the Music Therapy Education Viewpoint

In this section of the review, I want to draw out aspects from the cases that can inform music therapy students and their educators. These aspects may include the relevance of theory to a specific case, the way in which the author described music therapy methods that were used, or aspects of the documentation that were helpful. This section will attempt more to give examples than provide systematic commentary.
.....Mahns (Case 3) offers interesting perspectives on method, where the pictures of his client provided both the inspiration for therapy, and the externalisation of experiences in improvisation. On one occasion he provoked verbal exchange through using an internal telephone from one room of the school to another. Mahns also, at the request of his client, involved another child in the individual therapy sessions, later in the therapy. Kwoska's study (Case 5) gives excellent insight into the potential chaos of music therapy improvisation, the relevance of holding and containing, and the countertransference experienced when confronted with disruptive influences and resistance in therapy. This gives good examples for students of both goals of therapy with these children, and an effective structure for group work. Wesley's case (Case 6) is informative as the use of combined media (music making, song-singing, and music and imaging) were used. The use of a song-tape with this client to provide a therapeutic tool to be used for coping outside the therapy sessions is of particular interest, and was evidently relevant to the client, and confirmed as effective after discharge. Wesley's use of the image of a cocoon, a safe place for coping, is also one of a number of symbolic images that come up in this book which have been of pivotal significance, and also demonstrate therapy technique within a process. This case helps students see music therapy alongside other, simultaneous interventions in dealing differentially with extremely disturbed behaviour.
.....Rogers (Case 7) contribution in the field of childhood sexual abuse helps trainee practitioners understand what a complex process is involved in helping a child find their way to trying to resolve such traumatic experiences in therapy, and how to contain very controlling behaviour by a client in therapy. Rogers also gives a well structured frame for therapy sessions in this particular case. Robarts (case 8) again illustrates the symbolic value of songs in therapy, and how improvised songs act as a container for traumatic experiences, fantasies and strong emotions. For learning about the potential of improvised songs, there is interesting detail here about the lyrics of the songs, and the musical characteristics. Robarts reflects on the effect of this child's behaviour, and emphasises the importance of supervision. Schonfeld (Case 10) is very informative in alerting one to the influence of physical problems, and how the practicality of everyday life in helping a child dealing with complex physical problems has to be balanced against more psychological processes. Other media (puppets) can be considered (although this borders on other arts therapies work for which additional training may need to be considered), and the potential of symbolic role-playing is present in the case. Fruchard and Lecourt's case is one of few that employ primarily receptive methods. The influence of different voices is important, both in receptive music therapy, and in active music making. Nirensztein (case 11) introduces the idea of musical 'leitmotives,' which I have found important in the music therapy relationship because they can form a consistent musical theme around which the musical relationship develops. Nirensztein calls this their 'common playground', and this can be something to look closely for in beginning music therapy clinical practice.
.....The cases reporting therapy with children and adults with developmental/learning disability reveal a further insight into method and professional technique, and the therapists approach to challenges. Tyler's study (Case 2), gives further useful examples of the use of symbolic representational play, where the therapist responds to the client's need to act out situations. Di Franco's report of his work with an autistic boy is informative from two perspectives. He documents information gathered during a systematic assessment procedure that he commonly uses (and trains others in the use of), and also relates his therapy techniques and choices to what he determined from the assessment. Dvorkin and Erlund (Case 9) provide another example of the value of spontaneous, improvised song-singing. The text of the songs shows the therapist empathically mirroring and reflecting the client's verbal expressions. This is an increasingly common and effective technique with children that borders on 'singspiel' in style. This case also introduces the potential place of a mother in therapy, and the mothers influence on her child, as well as the therapist's role as a good enough mother figure. Rafieyan's study gives a very good insight for music therapists in training by describing in quite some detail the experience of the 'first session'. She acknowledges her own inexperience in psychodynamic music therapy in letting something happen, and the temptation (arising from her countertransference) to create an 'agenda' for the session.
.....In the three studies that don't fit easily into the major clinical categories a number of aspects stand out. Sweeney (Case 1) shows how adaptable the therapist has to be in very short term, or inconsistent therapy for a child with terminal illness. This was a good example of how the needs of the client directed the therapy, and the therapist supported that process. In contrast, Grocke's use of BMGIM with a patient with rheumatoid arthritis teaches other lessons. Here the therapist reflected very much on the use of musical stimuli that, through immediate perception and imagery appeared to exacerbate rather than diminish the pain of the condition. Grocke provides a good example of how the intuitive direction she followed resulted in difficult, painful experiences for her client that consequently led into important pivotal experiences. It is unusual for music therapists to report situations where they think they have 'made a mistake', therapeutically, although what transpired here was a process that unearthed 'significant and important early memories'. Grocke reported on three sessions in a therapy process that last for 84 sessions, and exemplifies how much the therapist has to contain, and follow through, over long term therapy. It would be fascinating, as with many other of the cases reported in this book, to read a more comprehensive account of these lengthy periods of therapy. Case 15 from Montello presents us with a different perspective - and challenge. The client was a talented professional musician, and the medium of improvisation is seen to hide the real issues this client needed to explore. She was a skilled jazz improviser, and Montello reported how she found a way to encourage the client to 'break' the pattern of her 'elegant, improvisational style'. There is a great deal of material in this case - the theory of EMI, chakras and archetypal themes, and increasing complexity as the 'true self' of the client unfolded. Working with vocal and instrumental improvisation with a very talented musician also can require complimentary resources in the therapist - which are very present in this case. Yet another aspect emerges in Metzner's study, relevant to music therapy students - especially those in practicum, in the discussion on the effect of this client (Case 13) on the multi-disciplinary team involved. Metzner reports how all staff had a special interest, 'adopted' the patient, did not develop rivalry, but at the same time avoided (consciously or unconsciously) exchanging information with each other. When the team did start to share opinion about the success of different treatments, the response from the client was to discharge herself as an act of resistance. I also feel it is a really useful example of the difficulty Metzner describes experiencing in the first meeting - also reported by Rafieyan. De Backer and Van Camp (Case 14) present an interesting process, because their case was first treated for 8 months in group therapy, with apparently little change. In individual work - after four sessions, there was a significant change from formless playing that apparently lacked either musical or emotional expression, to playing within rhythmic and musical structures - musical form. I think this is particularly relevant, to counter the perception of improvisational music therapy as an 'unstructured' form of therapy. The creative process developed here because of the client's development into musical form.
.....Nolan (Case 15) echoed the role of the music therapist in working with a skilled musician in therapy. This case has many lessons for music therapy education, particularly the very clear example of how musical improvisation needs to adapt, and dominating musical elements - in this case rhythmic patterns need to be skilfully reduced in their influence to allow more exploratory musical creativity. I also think that Nolan has drawn attention to composition as part of the music therapy process - and how this became an important issue of creation and ownership for the client. Jahn-Langenberg's study (Case 15) has a nice balance to it, and I think is a good example of showing a process in a limited space - by describing four sessions, and the relevance of the events that occurred for the client's therapeutic process. By describing the musical events - what was happening musically between the client and the therapist, one can understand the nature of the therapists' responses and interventions, as well as the implications. Pedersen's study (Case 19) is very well constructed using a model that I am familiar with in Aalborg of reporting therapy process in a sequence of phases. This help's one understand the overall process of the therapy, and how occurring changes both in the client and the attitude or role of the therapist connect together. One can learn much from the exploration of dream material in this case, as well as paying close attention to the client's own feedback at the conclusion of the case revealing that over the 57 sessions, a significant process of change had occurred. Hannibal's study (Case 21) is another good example of how to document a case in a way that connects musical-therapeutic events with therapy process. I liked the structure of therapy in phases, and the fact that Hannibal also referenced and acknowledged other concurrent treatments (pharmacology). The case also highlights how vulnerable, inadequate and despairing clients can be at the beginning, and how music therapy develops autonomy and strength over time.

General comments and conclusions

This is a really contrasting and exciting collection of material that, as Hadley says at the beginning, compliments Bruscia's book The Dynamics of Music Psychotherapy (from 1998). I have concentrated on discussing the contributions from a clinical point of view, and in considering them as valuable to the trainee music therapist, and music therapy educator. From the latter point of view, all the cases offered an aspect from which we can learn. Particularly in cases from music therapy in psychiatry, video recording is not used as a method of case recording, which means students (and teachers) of music therapy are reliant on good enough case examples to learn the practice of music therapy. This is well reflected in this text, with a particularly relevant focus being placed on transference and countertransference by contributors.
.....There are one or two points of critique, or perhaps I should just make them as questions. I wondered about the choice of contributors - although I hasten to add I was not at all surprised by any one person in the contributor list - they all have worthy reputations in this field. It is noticeable that only 7 out of 21 are from the United States, reflecting perhaps that undergraduate education does not prepare you for insight based therapy without further training - a comment I picked up at the beginning. Nevertheless, the remaining 14 contributors, with the exception of one, are European - mainly from Northern Europe. There is also a dominance of child, adolescent and adult psychiatry (14/21 cases), which may seem logical, but I missed some examples from the elderly population, neurology, and more from the field of terminal illness. I would also comment that inevitably the temptation is to include more people and limit their contributions. It works pretty well to give, in most cases, enough information to see the frame and process of therapy and the reflections of the therapist. However, in many cases one was still left with an appetite for more information - particularly more detail about other events in other sessions (given the number of long-term therapy studies among these cases). Description of therapy process, and of music events appeared sometimes to be limited in order to allow space for explaining the theoretical frames. It is true, however, that the underpinning theoretical frames give important depth to the book - and as always there is a balance to be struck. Finally, I would like to comment that this is the most interesting and creative collections of titles in any book of edited chapters I have seen! It is undoubtedly appropriate that where a process of symbolic representation is occurring in the therapy process, that can be represented in the title. It was sensible, however in almost all cases that the contributors added more concrete descriptors through sub-titles to enable their cases to be found in key-word searches.
.....Overall, the cases are well structured, and the authors have evidently followed the format created by the editor. Hadley is to be complimented on collecting together an experienced group of clinicians giving such a variety of clinical examples. The material is readable, the quality of editing evident, and the presentation up to the usually high standard of Barcelona Publishers. I will recommend this book not just to music therapy students and practitioners, but also to colleagues from other disciplines working within a psychodynamic framework.

PSCYODYNAMIC MUSIC THERAPY
S. Hadley (Ed.)
Reviewed by Katrina McFerran, PhD, RMT
(Music Therapist, Very Special Kids
Music Therapy Lecturer, University of Melbourne)

The Australian Journal of Music Therapy (2004), 15 (1), 84-86

Reprinted with permission of the AJMT

This new text, edited by Susan Hadley, is the direct descendant of Bruscia’s original case studies book (Bruscia, 1991). Also published by Barcelona, Bruscia’s company, Psycho-dynamic music therapy is set out with consistent sub-headings, offered to the various authors as a guide for their writing. However, in contrast to its predecessor, Hadley’s book conveys a more diverse array of voices, where author individuality is a striking theme, an there is much less uniformity between the various tales of psychotherapy that are shared.

The diversity portrayed in this text exists at many levels. Culturally, there is a relatively even representation of work from the United States, Europe, Scandinavia, and the United Kingdom, as well as individual contributions from Australia, and Israel. Geographical location aside, there is also diversity in theoretical orientation and clinical emphases. Hadley introduces this in her opening chapter, where she outlines the various models of psychodynamic theory that are drawn upon by the authors, namely Drive Psychology, Ego Psychology, Object Relations Theory, Self Psychology and Jungian Theory. This is a useful framework to provide for the novice reader, who may have assumed that psychodynamic theory was a more cohesive body of work. However, it is difficult to effectively communicate the rudiments of this many theories in one chapter. Should the editor have pitched this material to the experienced clinician, who may have preferred more substantial reminders of theoretical detail? Or should this chapter have made sense to the newer reader who is gingerly tipping their toes into psychodynamic theory, in which case the material may be seen as overly dense and off-putting.

Despite the challenge for Hadley in addressing this broad readership, she is successful in convincing the reader of her commitment to the pedagogical and personal value of psychodynamic work. The depth of her dedication is felt in her ability to accept and publish the range of stories provided. The editorial hand has gently guided, suggesting that Hadley is indeed aware of any control-oriented countertransference that may have made her feel somehow responsible for the nature of the work, and therefore attempt to make it more cohesive. Instead, projections are portrayed uniquely by each author, with Hadley accepting the cultural and personal influences of each, and thereby allowing the reader to have their own responses to the material.

Some authors emphasize research and theory—such as di Franco, Robarts, Fruchard & Le Court, Janh-Langenberg, DeBacker & Van Camp—although this sometimes results in a lack of real detail about the case itself. Other authors make little or no reference to theoretical constructs—such as Sweeney, Tyler, Mahns, Dvorkin & Erlund, Montello, and Hannibal—and simply convey the tale of therapy, with varying reference to the impact of therapeutic dynamics. The occasional case study conveys no real understanding of countertransference at all although, as a whole, the contributions are of a high quality.

In attempting to consider this text within the Australian context, where clinicians frequently work dynamically with clients but may not always have a grasp of the language popularly used to describe this, the case studies should be reassuring. Indeed, the level of work described in this text is frequently encountered at conferences and in other presentational forums within the Australian community.

As stated above, a number of the authors do nt draw on the psychodynamic vocabulary in order to convince the reader that they are working with semi-conscious and unconscious material; their own as well as the clients. Few of the case studies describing work with children use verbal consolidation of the symbolic work being achieved through the musical experience, instead considering the musical material to suffice in this regard. One case study describes work with a client who rarely uses music in therapy, instead relying on play therapy strategies. The author, Schonfeld, questions why she has chosen this particular client to share, however again there is a sense of familiarity for clinicians who may have faced this predicament in their own caseload. As Pederson notes (p. 376), it is very easy to share the “sunshine story” as they call it in Denmark, when in fact there is a great deal to be learned from less successful or unexpected work.

The Australian case presented can be read with some excitement; a success story for a woman with Rheumatoid Arthritis, Grocke describes a GIM treatment that lasts over five years, resulting in the “Healing of an Inflamed Body” as the chapter is titled. The case is touchingly illustrated through a selection of three significant moments that illustrate the relationship between the client’s pain and her life experiences. This includes significant moments for the therapist where she questions her own decision-making, and examines her countertransference.

Experienced author and clinician, Rogers, also relates a moving tale. In this case study the young client is ultimately able to return to a mainstream school setting, having resolved the majority of her learning difficulties. Rogers begins by outlining the multiple contexts that impacted on the quality of her engagement with her client, including her own therapeutic beliefs and approach to therapy. Significant events are selected and outlined that give a powerful sense of the process undertaken, without becoming verbose. In addition, Rogers incorporates some detailed commentary on aspects of her musical material that add fascinating depth to the story.

In selecting favorites, Nirensztein, Pederson, and Sweeney also contribute stirring tales of psychodynamic music therapy that succinctly capture both the process of therapy and the role of music in supporting clients who are working through issues related to previous or current trauma that has a powerful influence on their lives.

In sum, this text is relevant to the Australian music therapy readership. The collection of case studies makes it easy to skim through and to find material that is engaging and inspiring. Alternately, when a chapter does not resonate personally with the reader, it is just as easy to move on to something more interesting. Hadley has provided a diverse range of material for the reader to explore, and it is recommended for purchase and exploration.

References
Bruscia, K. (Ed.). (1991). Case studies in music therapy. Phoenixville, PA: Barcelona Publishers

Jennifer A. J. Nicol, Ph.D., R.D.Psych., M.T.A. Assistant Professor, Department of Educational Psychology and Special Education; and Associate Member, Department of Music.

Hadley, S., Ed. (2003). Psychodynamic music therapy: Case studies. Gilsum, NH, Barcelona Publishers.

Whether a music therapy student, seasoned practitioner, music therapy educator or researcher, and whether psychodynamically inclined or just “psychodynamically curious,” this book offers something for everyone. Dr. Susan Hadley (MT-BC) has edited a collection of 21 case studies that illuminate the psychodynamic music therapy practices of music therapists working in Australia, Belgium, Denmark, England, France, Germany, Israel, Italy, and the United States. Before starting in with the case studies, there are brief biographies of each contributor. Hadley’s preface identifies her pedagogical influences; a personal affinity for psychodynamic understandings, past meaningful experiences as a client in analytical music therapy (Priestley), creative music therapy (Nordoff & Robbins), and Guided Imagery and Music (The Bonny Method), emphasizing her strong desire to see more music therapists excited and keen on pursuing advanced training in music therapy. Hadley does not suggest, however, that psychodynamic music therapy is the only legitimate avenue for pursuing advanced knowledge, nor a blanket solution for each and every client. She writes,

Psychodynamic music therapy consists of useful constructs, not ‘absolute truths,’ which are adopted by clinicians and provide a framework within which to analyze and interpret behavior. This framework provides conceptual tools that are used to enhance our understanding of our clients and their experiences. It is very important that we, as music therapists, use these tools in relationship to the distinctive nuances that each client brings to the therapeutic situation. By applying these conceptual tools to the unique needs of each client, our thinking is informed in such a way that we are able to create innovative ways of using music to help each individual client lead a healthier life within the context of his/her particular issues. (p. xx)

Psychodynamic music therapy’s history is overviewed in a 14-page introduction that follows the preface. Key influential music therapists are identified (e.g., Tyson, Alvin, Bonny, Priestly, Nordoff and Robbins, Benenzon, Bruscia, and Eschen), five psychodynamic theories are summarized (Drive Psychology, Ego Psychology, Object Relations, Self Psychology, and Jungian Theory), and key constructs are defined (defences, transference, counter-transference). Last is a six-page reference list for those who want to know more. These opening chapters are helpful. They give readers a clear map for navigating the upcoming terrain of the 21 rich and varied case studies.

Because psychodynamic music therapy has no singular representation, case studies provide an effective, accessible way in which to convey the range and reach of music therapy practices identified as psychodynamic. The unifying thread through the book’s case studies is an exploration of the subconscious/unconscious as revealed in the music and between the client and music therapist. All psychodynamic theories assume that intra-psychic conflict is at the source of an individual’s problems. Improvement requires insight of the conflict. Consequently, psychodynamic music therapists consider early childhood development of conflicts and motives, interpret their manifestations in the music and client-therapist relationship, and use these understandings to facilitate therapeutic change.

The case studies are grouped developmentally (i.e., children, adolescents, adults) and exemplify a range of client problems, music therapy methods, treatment time frames, and work settings. For example, Catherine Sweeney, Helen Tyler, Juliane Kowski, Penny Rogers, and Viola Schonfeld write compassionately and honestly about the trials and tribulations of music therapy with children and adolescents who have been abused and neglected. Jacqueline Robarts articulately describes the power of songs in music therapy, their ability to be both a “container and transformer of feelings” (p. 142). Susan Metzner provides insight specific to multidisciplinary teamwork. Both Paul Nolan and Louise Montello explore the unique dynamics and implications of working with highly skilled musicians. Denise Grocke manages to simultaneously acknowledge the genetic/biological etiology of Rheumatoid Arthritis while convincingly justify a focus on the symbolic interpretation of client symptoms and psycho-emotional needs. Roia Rafieyan movingly details 7 years of work with Rich, a man with autism and profound retardation who lives in an institution, while Wolfgang Mahns advocates for school music therapy and details his work with Ira, a boy with selective mutism.

Each case study follows a general template: (a) abstract, (b) introduction, (c) background, (d) treatment, (e) discussion and conclusion, and (f) references. Without doubt, the treatment sections offer the most consistently compelling reading across all case studies. Windows are opened into the private space of music therapy practice. The authors write expressive and evocative texts, accompanied by scores, artwork, direct client quotes, and transcribed client-therapist dialogue, to uncover and reveal the lived experience of music therapy practice. This rich detail allows readers to reach their own conclusions about meaning, interpretation, and therapeutic decision-making alongside the authors’ psychodynamic interpretations. Some authors weave their analysis through the case study whereas others present it separately in the discussion and conclusion. In either case, the reader understands how music therapy interactions are conceptually linked to theoretical constructs such as transference, counter-transference, resistance, and defenses.

Enacting these theoretical constructs require ongoing therapist self-exploration and awareness. Consequently, many of the contributing music therapists share the visceral and emotional responses that are evoked in session. This makes for intimate reading, especially those moments of therapist uncertainty, vulnerability, and “not knowing.” These offerings are validating and permission-giving for readers, ultimately inviting readers to engage in the same self-reflexivity and the same continued use of supervision. Supervision is repeatedly underscored as a necessary part of psychodynamic music therapy, and a place where sharing, learning, and discussion occur.

Finally, the case studies that clearly revealed the music therapist’s “analytic lens” were most effective in establishing credibility. These authors explicitly identified pre-existing motives, assumptions, and personal history, which increased the case study’s coherence.

A lack of critical perspective was the book’s only shortcoming. Contributors varied in their writing styles and perhaps there was a decision to let each case study reflect the author’s voice. However, no information was provided on Hadley’s role and activities as editor. How were contributions solicited? Which case studies involved a language consultant for translation purposes? How much editing was done in the shaping of the final case study? Was there a deliberate reason for using certain terminology?

In particular, the continual use of the term “psychotics” rather than “people with psychosis” in one case study and “autistic children” rather than “children with autism” in another was disconcerting. Another example was the use of “patient” rather than “client.” Phrases like “feminine energy” and “masculine energy” referenced stereotyped understandings rather than directly naming what is meant. In another case, resistance was described as a “constant field of battle” (p. 99). What happens if instead, resistance is conceptualized as a “constant field of negotiation?”

Words do matter. And even though Hadley comments on page 9 that “although many psychodynamic theorists emphasize the mother-infant relationship, it does not necessarily have to be the mother, but a significant primary caregiver,” more could be said. This would ultimately increase the book’s readership, and importantly, make the significant understandings of psychodynamic theory accessible and more palatable for music therapists—such as many of those in Canada—who incorporate varied music therapy methods filtered through a humanistic lens.

Nonetheless, Psychodynamic Music Therapy: Case Studies remains a valuable resource for any library. It provides an effective introduction to psychodynamic theory and how this informs music therapy. The case studies make for both dramatic and intellectually compelling reading. Students will appreciate the explicit linking of theory and process, and practitioners will appreciate the immediate relevance of the content and injection of new ideas to keep their work alive. Also rewarding is the languaging of “difficult-to-language” music therapy experiences. Educators can use the book as a springboard into important conversations about theory, practice, supervision, ethics, client issues, and work context, and researchers will be reminded of the importance of working with research methods that capture music therapy’s complexity. Even skeptics and critics will enjoy the chance to critique and recast the contributor’s analysis. There is something for everybody in this book.