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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 there!"
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
Using music in the session
It is helpful to have a good repertoire of music of all
genres, not only from the 20th century but also earlier.
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.)
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,
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
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.
Reflection Exercise #7
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I don’t know about you but I’m an over-thinker. I like to think. I like to ponder. I’m an intellectual, and intellectuals think the answer to every problem lies in how they think about that problem.
There are some circumstances where a client should find a new therapist. And by therapist I mean a mental health therapist. I understand how difficult it is being a client in a new therapeutic relationship.
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