The music therapy or grief therapy session takes place in a room with armchairs,
a box of tissues, a whiteboard on the wall, and an electric keyboard. (It
is important for the patient to realize that he or she will not have to perform,
otherwise the atmosphere may be marred by misunderstanding and apprehension.)
I use a touch-sensitive keyboard as a convenient substitute for a piano.
It has the advantage of producing many other authentic sounds, such as waves
on the seashore, as well as the full range of orchestral and other instruments.
Assessment is not simply a preliminary to therapy but continues as ongoing
appraisal throughout the session. Nevertheless, a self-assessment scale used
early in the session is helpful, and it often forms the basis for further
work, in words and in improvised music. Although it has long since proved
its worth with patients of varying diagnoses, this scale was originally developed
by the author for those who had alcohol-related brain damage with consequent
difficulties in abstract thinking (Butters & Cermak, 1988; Walsh, 1978)
and who therefore needed a concrete method. Perhaps the scale has succeeded
with other patients because, during major difficulties of experience and
emotion, their capacity for abstract thought may be similarly impaired, so
that a visual presentation facilitates insight for all those in crisis.
The scale is drawn afresh for each patient on the whiteboard in the therapist's
consulting room. A computer printout was tried but proved less effective than
a large drawing done by the therapist while the patient watches. (It is helpful
that the author is not gifted artistically, so that the sketch is quite simple,
giving some patients a pleasing sense of superiority over the therapist. For
most patients, this is probably a unique experience while in the hospital!)
The sketch is then explained: "The bottom step represents feeling pretty
hopeless. The top step shows someone sitting down because it has been a huge
effort to reach the top, but the person will not stay there. The arrow pointing
ahead shows that soon the person will move on." The therapist then asks
the patient: "So can you draw yourself in, where you are today?" The
answer may reflect the patient's situation. For example, an answer, "There
are not enough steps downwards at the bottom," may indicate suicidal ideation.
Someone who draws the figure between two steps but on the way down also indicates
difficulties, whereas the person who places the stick figure on one step but
walking upward to the next suggests hope.
Placing the figure with both feet on a single step can represent various feelings: "I'm
stuck"; "I'm consolidating what I've done so far"; or "I'm
planning how far I can go next!' and so needs elucidation. For this reason,
the stick figure now has a flag (not part of the original scale) to hold, and
the patient is asked to write a key word on it. Commonly used expressions include "Hope!
.... Thinking, .... Stuck," "???," "HELP!" and "Getting
Sometimes obscenities are used, even when the person otherwise uses polite
language. The possibility of using obscenities informs the therapist and also
helps the patient, because it allows the expression of anger that is otherwise
socially hidden. (I reassure the patient: "Having worked for over 30 years
with people from jail or off the streets, I know all the forbidden words and
nothing will shock me!") From this sketched assessment scale, it is easy
to move on into the life story.
Understanding the life story
I avoid questions wherever possible, preferring to make statements in a fairly
gentle tone of voice and leaving silence for a few moments afterward. For
example, when working with a patient coping with the death of a spouse, I
may say: "As we look back over a marriage, we remember lots of things,
don't we, some of them good, some of them not so good." On rare occasions,
the patient's response is, "Oh, really?" (i.e., "I'm not ready
to talk about problems yet"). Sometimes the patient replies, "I
was one of the lucky ones. Most of my memories are happy ones." Because
my work is with people who have difficulty resolving a bereavement, more
often the response is, "Huh!! You can say that again!" or a similar
The next statement after such a reply would be, "I often find that when
a relationship has been really difficult, the survivor is left with a guilty
sense of relief after the death." This statement gives patients permission
to be open in a way that would be impossible if they were responding to a question. "Did
you have a feeling of relief when he died?" will almost certainly be met
by denial. Moreover, because the statement begins "I often find," it
helps people to know that they are not alone in their feelings of relief and
so it takes away undue guilt or shame at acknowledging the reaction. (All comments
are worded so as to be appropriate to the circumstances of the loss.) We should
note that tears after the death of a difficult spouse or child often result
from disappointment that the relationship was unhappy, when the opposite had
I do not always avoid asking a question. For example, "Can you tell me
what happened, or is it too painful?" allows freedom to maintain silence
but also gives permission to speak because it has acknowledged the painfulness
of the process. Usually the patient then tells his or her story, although often
only in a factual outline.
Using music in the session
At this point, I introduce music into the session. In many instances, it is
only through music that the affective content of the patient's story emerges.
Familiar music associated with a lost relationship often helps to bring suppressed
thoughts and feelings to the surface.
1. Songs of courtship may reveal the bitterness over a relationship that
2. A childhood song may help a patient ventilate grief over
the child who "went wrong" and share a yearning to return
to a simple childhood when parents could nurture and protect from harm.
3. After a stillbirth or an abortion, the woman who was not
allowed to cry because grief was "bad for her" finds relief in
hearing, perhaps singing, the songs she wished she could have sung to her
lost child, and in being allowed to cry as she does so.
It is helpful to have a good repertoire of music of all
genres, not only from the 20th century but also earlier.
Playing (if one can) this familiar music, or talking about the music if it
is unknown to the therapist, leads to significant disclosures about relationships.
The therapist can respond with some fairly general comment, such as "It
sounds as if life has been really rough for you" or "You've really
been able to show me something of what life has been like for you (over the
past few years, all your life, most of your life, since your father died, or
whatever is appropriate)." If the patient requests an unknown song, the
therapist might say, "Tell me about why this song means so much to you." On
one occasion, my patient found reassurance and comfort by teaching me the melody.
After using familiar music, I introduce musical improvisation. I may say, "I'd
like to try to improvise some music for you, which may describe some of your
feelings as you look back over the past and deal with the present." It
is important not to define dearly the feelings the therapist has perceived
at this stage but to leave this verbal reflection in general terms. Music is
then improvised to reflect the content of the session so far.
The range of volume may vary from very soft to very loud, and the discords
used can be powerful. Some improvisations focus mainly on one emotion (such
as sadness or anger) if this is concordant with the life story that has been
told, but there is music suggesting other emotions as well, even if these were
not mentioned by the patient.
It is important that the music leave the way open for the patient to interpret
it according to personal need and experience. Projection often causes the patient
to "hear" in the music emotions that differ from the general direction
of the improvisation. As noted earlier, delineating the affective content before
the improvisation is restrictive. If the therapist says, "I'll play music
to illustrate something of your sadness (anger, confusion, fear, or whatever)," then
the patient may hear only the named emotion and other feelings are less likely
to be perceived. By avoiding any clear identification of the emotions portrayed,
the therapist clears the way for hidden feelings to be recognized and acknowledged,
and for projection to reveal previously undisclosed affects.
The improvisation leads to further verbal interchange of thoughts and feelings,
with informal whiteboard sketches to illustrate key issues. The sketches are
done by the therapist, the patient, or together as a shared task (see Figure
2). Sometimes this is followed by further improvisation whether by the therapist
or shared improvisation at the keyboard by therapist and patient; perhaps with
percussion instruments, too. (Drumming can externalize anger to a frightening
extent and decompensation can occur, so one must make a therapeutic decision
as to whether drums are used and, if so, when.)
Songwriting is a helpful tool, but it is generally used only when a series
of sessions is possible, to avoid overloading the initial sessions. The responsibility
for words, melody, and accompaniment is shared according to the skills of the
patient. Some patients feel competent to write only words, whereas others--despite
ignorance of musical performance--are willing to try the keyboard and find
some kind of melody that fits their needs, which the therapist writes down
on manuscript paper. (For reasons of confidentiality, sessions cannot be recorded.)
Occasionally, the therapist writes both words and music. For example, the
following song was written with a simple melody for a depressed elderly man
with extremely low self-esteem. It was "prescribed" for him to sing
16 times a day!
"I'm an OK person,
I'm not the best,
But I'm not the worst,
The consultant's opinion was that singing this song of self-acceptance quietly
to himself several times each day was a key part of this patient's recovery.
Ending the session
At the end of each session, what has transpired is discussed and summarized,
ideas are discussed for dealing with difficulties, and tasks are suggested
to prepare for the next session (e.g., a road map of one's life, a poem,
ideas for change). The patient receives a paper copy of the sketches done
on the whiteboard to take away as a reminder. Although the patient knows
that the content of the session will be discussed with colleagues, he or
she is invited, as a symbol of confidentiality, to clean the whiteboard so
that nobody else will see the sketches and self-assessment scale. Finally,
a familiar theme song is suggested that the person can recall. Such songs
include "Climb Every Mountain," the theme from the movie Chariots
of Fire (the waves in the opening scene of the film symbolize a powerful
force that can either overwhelm or strengthen one, as it did for the athletes
in the film), and "The Impossible Dream" (because dreams are not
always impossible, we must keep hoping). One young woman wrote words to the
Finlandia theme by Sibelius: "I won't give in, I'm going to keep on
When suggesting a theme song to take from the session, the therapist should
choose familiar music after discussing this with the person. Improvised music
is useless because it will not be remembered (probably not even by the therapist
in any detail!) and the person must be able to recall the theme as a reminder
of the session content in times of difficulty.
When the session is known to be the last before discharge, appropriate separation
techniques are included in the final summary. Finally, the work is described
in the file of progress notes and, whenever possible, discussed with colleagues.
- Bright, Ruth; Music Therapy in Grief Resolution; Bulletin
of the Menninger Clinic; Fall 1999, Vol. 63, Issue 4.
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #7
The preceding section contained information
about music therapy in grief resolution. Write
three case study examples regarding how you might use the content of this section
in your practice.
Online Continuing Education QUESTION
What should the therapist do if the patient requests an unknown song? Record the letter of the correct answer