Restitutional Factors in Receptive Group Music Therapy

Nordic Journal of Music Therapy, 2002, 11(2) 165

Introduction

During the last few years, I have conducted a slow-open music therapy group for patients suffering fromschizophrenia and schizotypical disorders. The

music therapy method used is a music and imagerytechnique originating from the tradition of GuidedImagery and Music - a receptive music therapymethod developed by music therapist Helen Bonny,where patients report their experiences while

Restitutional Factors inReceptive Group MusicTherapy Inspired by GIM-The Relationship Between Self-Objects,Psychological DefenceManeouvres and Restitutional Factors: Towards a Theory.

Nordic Journal of Music Therapy, 11(2), pp. 165-179.

Torben Moe

Abstract

This article is based on a study concerning music psychotherapy based on a Group Music andImagery method. The model used is based on patients’ listening experiences during selected,primarily classical music, specially designed for an inpatient setting. The patients report theirexperiences to the group after the music intervention and the material is used as a part of thetherapy process. The music listening is supported by verbal guiding from the therapist, to help thepatients to focus.Nine psychiatric patients diagnosed as schizophrenic or with schizotypical disorders participated ina therapy group during a six-month period, and the study focuses on restitutional factors in thetherapeutic process and the patients’ evaluation of their therapy.The methodology is primarily qualitative and the investigation is in two parts. Part one concernsthe patients’ evaluation of the therapy based on interviews, the GAF rating scale, and a qualitativequestionnaire including a mood test and aspects of the patients’ overall view of the therapy. Theresults of this part of the study were published in this journal. (Moe, Raben & Roesen, 2000.)The present article is based on part two. The experiences of four patients are analyzed, focusing ontheir imagery during the music listening period. The role of the music and the images is discussed.Data from the therapist’s log are categorized. The categories include restitutional factors in thetherapy process.Based on these findings a theory about the relationship between self-objects, psychologicaldefensive manoeuvres and restitutional factors is outlined and discussed.

Keywords:

ARTICLES

Nordic Journal of Music Therapy, 2002, 11(2)166

listening to classical music (Bonny 1978a +b, 2002).This article focuses on a modification of the GIMmethod, namely theoretical considerations based onmy PhD: “Receptive Music Therapy withPsychiatric Patients Based on a Modification ofGuided Imagery and Music (GIM)” (Moe, 2001).Summer (2002, p. 297) suggests the term “GroupMusic and Imagery” (GMIT), which I have decidedto follow in order to separate the model used fromthe individual treatment of The Bonny Method ofGIM. The Bonny Method of GIM (BMGIM) isdefined as an individual therapy, “a music-centered,transformational therapy” based on specific premises(Clark, 2002, p. 22). 1

My Ph.D. is an exploratory study of a new fieldwithin music therapy, and there is no existing theoryin this area that can give a detailed description ofcause and effect in Group Music and ImageryTherapy with schizotypical and schizophrenicpatients. During this study I decided that aninductive, empirically governed theory generatingstrategy of investigation would be preferable in orderto examine the data. I therefore chose a modelinspired by the qualitative research method ofGrounded Theory (GT) (Glaser & Strauss; 1967).Inspired by GT, I divided the “text”, consisting ofthe comments of 9 patients about their experiencesduring music listening, into small units. This wasdone in order to obtain a broader view enabling meto find active themes and coherences in the historyof the patients. GT requires that there is aconstruction of the categories. Serving as aconceptual support the method led to a general viewand the forming of core categories, making up the

first steps in a theory, the foundation of the theory.However, in this study a new theory did not emerge,but the results have led me to further examine thepositive results in a field between GT, ObjectRelation Theory (ORT) and narrative theory (Bonde,2000). Expressed in simple terms, the basis of ORTis that interpersonal relations are transformed intointernalized representations as described byFairbairn (1952), Ogden (1979) and Winnicott(1951). In my view the GT basis points towards anew understanding of ORT and towards a theoryon the meaning of narratives. This may serve as thefoundation of a theory on the relationship betweenrestitutional factors in GIM and self-objects, inparticular focusing on the conceptualising ofdefensive manoeuvres, and why music listening canhave a personality promoting effect. While it isbroadly accepted that individual BMGIM therapyin its classical form is too challenging for theschizophrenic patient, the suggested group musicand imagery method seems to be a useful and safetherapeutic tool for these patients. This expands thepossibilities of using GIM related techniques in thefield of therapy.

The Therapeutic Domain

The model in figure1 is an outline of the activetherapeutic field in the setting applied.

In the therapeutic setting there is a constantmovement between the intrapersonal and theinterpersonal domain. The fixed points in the settingfunction as a “training framework” for the patients,so that they can practise how to move between anintrapersonal space, where they will come intocontact with inner object configurations, and aninterpersonal space, where these objectconfigurations can be divided and worked through.Thus, there is an ongoing movement betweenfantasy, reality- testing and intersubjectiveunderstanding. Also, it is important to note that themusic, the guiding, the image formation and the

TORBEN MOE is a music therapist, MA, Ph.D.stud. Head of the MUsic Therapy Dept. at Sct HansHospital in Denmark. He is also GIM therapist andchairman of the GIM association in Denmark.Addr.: Department of Music Therapy, KurhusetSHH, Roskilde DK. Phone (+45) 46 33 47 45. Fax:(+45) 46 33 43 52. E-mail:[email protected]

1 Summer (2002, p. 297) writes that the practice of group music psychotherapy, including Group Music and Imagery(GMIT) requires the education and training of afforded accredited music therapists. Summer presents three levels of GroupMusic and Imagery, namely supportive, re-educative, and re-constructive. In my opinion it is also an important advantage,and in some cases maybe even required, to be a trained, licensed GIM therapist in order to lead this kind of group work,especially with patients presenting a complex number of symptoms, or clients working with interactive group formats usedat the re-educative and re-constructive level. (Bruscia, 2002 p. 51).

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group, constitute a therapeutically effective whole.In addition, the therapy takes place in a socialcontext, which of course has an effect on the progressof the therapy.

The Importance of the Music

In the setting applied, the patient almostautomatically touches unconscious material. Sinceit is common knowledge in the clinical field thatpsychotic patients are weak in their distinctionbetween their internal and their external world,scepticism has understandably been expressedtowards the use of music and imagery techniqueswith psychotic patients. (Wrangsjö & Körlin (1995)states that GIM is contraindicated for the psychoticpatient.)

Nonetheless the analysis of the empirical findingsshows that music therapy supports a psychologicaldevelopment with the patients. I think there areseveral reasons for this. Firstly, the setting, which isaimed at making access to the unconscious brief andstructured. It could also be due to the fact that themusic is experienced in a space between the externaland the internal world, thereby matching theschizophrenic patient’s view or experience of himor herself in the world. Said in a slightly

commonplace phrase, “you meet the patients wherethey are”, knowing that schizophrenic patients haveweak distinctions between the external and theinternal world.

The feeling of having a self is a core theme andproblem for schizophrenics. Apart from structure,the music offers affective stimuli, which could becompared to the affective feelings (“ real lifefeelings” ) happening in the interaction betweenmother and child during the formation of the selfearly in life (Stern, 2000).

The most obvious effective factor is the abilityof the music to offer the patients an “affectivemirror”, which can function as a correlate. Becausethe music contains both concrete and abstractelements, the patients are promoted in theirimaginary treatment of themselves, which makes itpossible for them to experience their lives in a newway. The music creates a nonverbal “narrativemodel” through which the patients are inspired totell stories about themselves and thereby understandthemselves better.

I also believe that the positive result has to dowith the music mainly being experienced ascomfortable, and thereby decreasing the anxietylevel of the patient in the therapeutic situation2. Thisis one of the many potentials of the music, whichhas been shown to have great importance for the

Figure 1. Model of the active therapeutic domain in Group Music and Imagery Therapy -Projective movements

2 This is confirmed in a mood test questionnaire (Moe 2001 pp. 119), where several patients emphasized the feeling ofpeace, safety and harmony as the most prevalent feelings during the music listening.

RESTITUTIONAL FACTORS IN RECEPTIVE GROUP MUSIC THERAPY INSPIRED BY GIM


client group in question. Perhaps this sounds trivial,but it is important to consider that to the patient itcould be felt as “vitally important” to survive thefirst sessions.

Clinical observations showed that the patientswere generally more communicative after the musiclistening than before, and I have considered thereasons for this. According to the anamnesis of thepatients analysed by me, they were all characterizedby a lack of self-confidence and low self-esteem.As the patients learn that they can connect musicand imagery with dynamic forces in themselves, thiscreates in them a “mastering feeling” in the situation,which builds up their self-esteem and self-confidence. When the patient succeeds intransforming stimuli into internal, meaningfulsensations, which are further transformed intoimages and feelings (often entering into a correlationbased on the structure of the music), the patientsobtain a sense of self-coherence, inner continuityand affective attachment. It is these veryfoundational self-qualities, which are – in varyingdegrees – dysfunctional in the psychotic state.

A psychosis involves a regression to experiencesof a more malignant character, but a regression canalso serve the self. The most foundational functionof the music in relation to the patient in the clinicalsetting is to induce a comfortable feeling as a firmfoundation for their imagery experience.

According to psychodynamic theory, this stateof well-being can be described as a regression to astate similar to a symbiosis, where the “all-good”is, symbolically speaking, the mother feeding thebaby in a state of happiness. Supportive elements inthe music (e.g. soft tones and harmonies, apredictable structure, and pleasant tempo, as inPachelbel’s Canon in D) are intended to create afeeling of safety in the patient, decreasing the anxietylevel in the therapeutic situation, and in a wider sensedistancing the patient from the ultimate fear – the“ all bad” - (in Kleinian terms: the punishing absentbreast, which threatens to destroy the child.)

The intended therapeutic role of the music in thepresent setting is firstly to compensate for the fearof extinction, and later to assist in giving the patientthe experience of surviving and thereby integratingboth “bright” and “dark” or more dramatic feelings.The ambiguity of the music contains a possibility

of experiencing and tolerating important variationsof feelings.

Method

The Bonny Method of Guided Imagery and Music(BMGIM) is based on patients’ experiences whilelistening to selected classical music. In the individualsetting, the patient describes his/her experiences tothe therapist while listening to music in a relaxedstate. These experiences may be understood withine.g. a psychodynamic or a transpersonal frameworkof reference. There is emphasis on the patient’s ownunderstanding and insight. In Group Music andImagery Therapy sessions, patients can shareexperiences in turn, for example with the therapistas “conductor”, or they can share experiences afterthe music-listening phase is over.

In BMGIM the music listening provides anongoing stream of images and associations whichoften develop and transform, but because of the more“fragile” patient category I worked with, I chose amore structured session format.

The music-listening phase was limited to only10 minutes of a 1 hr.30 min session, and each patienttold of his/her experiences after the music-listeningphase. Following this the patients’ experiences wereseen in the context of psychodynamic theory, basedon Yalom. This method of therapy can be describedas individual therapy in a group setting (Yalom,1985). Yalom’s ideas on Therapeutic Factors inGroup Therapy elaborated in his book “InpatientGroup Psychotherapy” (Yalom 1983, p. 39ff), havebeen sources of inspiration for my work.

The clinical settingSessions were composed in 3 phases: 1) thepreliminary conversation (prelude), 2) the music-listening phase, and 3) a closing conversation(postlude).

In the preliminary conversation (prelude), thepatients shared in turn whatever preoccupied themhere and now: for example, how they felt, what theyhad experienced during the last week, or thoughtsthey had about the previous session, about the future,or about their relationship with their families or apartner. This was followed by the music-listeningphase. The patients chose whether to lie on a mattress

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on the floor or remain seated in their chair duringthe music listening. Before the music started, thepatients were prepared with 2 minutes of relaxationexercises, focusing on breathing. The music-listening phase was then initiated through thetherapist’s guiding. Guiding took place either beforeor within the first few minutes of music-listening orthroughout the whole selection of music. Examplesof the therapist’s guiding could be asking the patientto imagine a visit to a garden, or to explore a house,or going on a boat trip. It was important to make theguiding as simple as possible. Guiding was meantto help the patient in structuring inner experiences,but the patients’ own free associations were alsoaccepted.

As an important point, the music was not chosenbeforehand - the music therapist decided what musicto play just before the listening period – based onthe actual atmosphere in the group after thepreliminary conversation. Examples of musicchosen were Pachelbel’s Canon in D, and the secondmovements of Beethoven’s Piano Concerto No. 5and Mozart’s Clarinet Concerto in F major.3 Themusic-listening was followed by the closingconversation, which lasted approximately 45minutes. As in the preliminary conversation, eachpatient had a chance to be heard. The patients sharedimages, thoughts and feelings experienced duringmusic-listening. These experiences were related totheir current situation, based on information fromthe preliminary conversation and additionalknowledge we had of the patient. (Moe, Roesen &Raben, 2000).

Data CollectionAs outlined in an earlier article (Moe, Rosen &Raben, 2000) the research method included:

· An analysis of the patients’ experiences duringthe music-listening based on Grounded Theory

· A GAF test (Global Assessment of FunctioningScale, DSM IV) which is an assessment of thepatient’s psychological, social and work-relatedfunction level on a continuous scale of 0-100.

· A Questionnaire survey after termination oftherapy. A qualitative questionnaire used forclarification of issues concerning individual

therapy, e.g.“To what degree do you find thefollowing aspects have contributed significantlyto the positive outcome of your therapy?”

· A Semi-structured interview including questionsbased on “cards” with written qualities andadditional questions concerning the patients’view of the therapy.

After the end of therapy, the patients were presentedwith 10 different cards representing 10 differentemotions and another set of cards representing 10different written aspects concerning the process ofimagery formation during music-listening. Thepatients were asked to place the cards in an orderindicating which emotions and which aspects ofimagery formation were the most prominent forthem. The “card model” is based on Yalom’smethod for follow-up investigation of patientsparticipating in group psychotherapy, for the purposeof clarifying and structuring the experiences of thepatient (Yalom, 1985).Finally, and based on the following questions, thepatients were asked to identify aspects influencingthe course of their therapy:

A: External factors that had a positive influenceon the therapy.

B: Things you have felt were missing from yourpsychotherapy.

C: Particular events or experiences in the musictherapy that have made the biggest impressionon you.

D: Particular events or experiences in the musictherapy that you have benefited from most.

E: Additional comments.

FindingsMy preliminary theory or hypothesis regarding thefunction of the music was that the music – becauseof its structure, dynamic and non-verbal narrativecharacter – could help the patient create an innerpsychological structure in a divided and often chaoticuniverse. The empirical findings seem to confirmthis. The investigation indicates that the music canhave a relaxing effect, which is important when seenin relation to the sensitivity of schizophrenics tovulnerability/stress factors. (Moe, 2000 p. 21).

3 In the project 95 different pieces of music were used, categorized as: 73 from the area of classical music (of these 53single pieces from the GIM repertoire), 7 from “New age” inspired music, 3 jazz pieces, and 1 piece from a movie.



The active factorsThe main results of my investigation are presentedin figure 2 as a catalogue of categories. Accordingto my analysis, restitutional moments occur at morepsychological levels. Partly a cognitive level, wherethe primary focus is on the patients’ reflection onthemselves and their situation. Partly an emotionallevel, at which the patients get in touch withsubstantial emotions, and finally, an interpersonallevel, where the patients share their experiences fromthe music listening with other patients in the group.This means that the results can be seen inconsequence of both cognitive, emotional andintrapersonal and interpersonal activity.

This will show that group music and imagerytherapy is mainly operating with various restitutionalfactors, namely:

·The music·The image formation·The defense aspect·The Group

In order to explain theoretically how Group Musicand Imagery Therapy (GMIT) can positively affectschizophrenic patients, it is necessary to reflect onthe connection between the different elements in thesetting, and the therapeutic process. In the followingmodel, I have illustrated a possible connectionbetween the therapeutic interventions and the aimof the development process.

The aim of the treatment is that the patientundergoes a development process from a self-viewbased on a small and fragile ego in the direction ofa “separating ego”. This requires:

1) The patient experiences that it is possible totake part in a relationship2) The self-view of the patient (which from thestart is characterized by concrete thinking),moves in the direction of a more cohesive self-view characterized by a symbolic self-representation.

The development from concrete to abstract thinkingis a core theme in the treatment of schizophrenicpatients, as it is a prevalent opinion thatschizophrenic patients are not capable ofsymbolizing.

It is a psychodynamic axiom that schizophrenicpatients live inside a chaotic internal universe, andthe aim is therefore that after a psychotic episodethe patient obtains a sense of continuity, self-acting,physical coherence, sense of affectivity and inter-subjectivity. The reason for the often-presentprimitive aggressive impulses is continuouslydiscussed. However, there is a general agreementthat schizophrenic patients are easily influenced bystress-vulnerability factors. It is therefore alsonecessary to emphasize structure-building factorsin the therapy, first and foremost in order to keepthe anxiety level under control. If the anxiety levelis high there is a greater risk of a psychotic relapse,and the possibility of the development of symbolicthinking decreases proportionally. Because of theconcrete thinking, the schizophrenic patient oftenexperiences that he/she contains threateningimpulses, which will destroy both him/her andothers. This general opinion is confirmed to a certaindegree in the empirical material, e.g. when a patientfelt there was a monster within him, or another

Categories of restitutional incidents in thetherapy:

I. Cognitive levela. Self knowledgeb. Effort to solve problemsc. Improved experience of inner self-coherenced. Reflections

II. Emotional levela. Installation of hopeb. “Feeling the feelings”c. Ability to contain ambivalent emotions

III. Interpersonal levela. Interaction with important othersb. Improved management of aggression – in“here and now” defensive manoeuvres

IV: Images which express core problemsV: Images which give important informationabout the background of the patientVI: Significant metaphorical transformations

Fig. 2: Catalogue of Categories

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patient, who imagined a beautiful garden during themusic listening, but was convinced that herappearance in the garden would destroy it.

Theoretically I believe that both the music in aclose relationship with the image formation and thegroup matrix4 can help the patient dismantle theaforementioned imagined destructive fantasies (themegalomaniac fantasies), and thereby reduce theanxiety level in the patient. This enables adevelopment process, where the fantasies, perceivedas concrete threatening impulses by the patient, canbe transformed into symbolic images. The aids inthis process are: the music, the image formation andthe group matrix:

The music stimulates the individual experienceof dark, bright and dramatic states in a reassuringway. These are represented in the image formationin a way which makes it possible to work throughthese psychologically. The group matrix ensures

an interpersonal frame, which can contain thedramatic fantasies put forward by the patients. Theseideas are illustrated in the model presented infigure 3.

The analysis of the empirical material shows thatthe patients primarily experience the music as afactor bringing them into contact with their feelingsand their pre-history. The music has a catalyticfunction, which initiates an emotional and imagecreating engagement in the patient. This causes thepatient to purposefully step into a communicativespace where important experiences and problemscan be shared and worked through in the group. Ibelieve that the music “offers” the patients anopportunity to experience themselves in a “spatialforum”, and that via the narrative construction ofthe music, the patients are being placed in a timeframe, which assists in creating some structure inthe chaotic inner universe of the patients. The

Fig. 3: The connection between the restitutional factors in Group Music and Imagery Therapy

4 The expression “group matrix” comes from the psychoanalytic theory concerning groups, which has been described byBion.



individual notes of the music function not only asseparate units, but are experienced as contexts, whichare recalled. Thereby the patients – who are often“caught in the present” – may experience aconsciousness of the past, the present and the future.Because the notes are “pointing beyond themselves”,and are attracting or repelling each other, patternsand melodies are created out of this “foundation” oftension and relaxation, and these patterns andmelodies can be felt and related to by the patient.

According to the analysis, the music also installsfeelings of hope in the patients (Yalom, 1983) - asan example, when the music is experienced asbeautiful and optimistic - which assists the patientsin discovering new possibilities in their otherwisefixed and depressive view on life.

Towards building a theory

The Role of the MusicSeen in relation to the developmental aim, the roleof the music is partly to function as a safety-providingfactor, and thereby a structuring element, and partlyas a projection screen. In other words, when themusic functions as a container for the patient’sprojections, this also helps (along the way) todecrease the anxiety level of the patients. I thinkthat when the patients project their feelings into themusic they have the possibility of displacing theresponsibility for the result. Anyone can say that itwas the music causing the uncomfortable or violentfeelings (if, for example, it was violent or dramatic)rather than admitting that those feelings were withinthemselves. Thereby the music may carry some ofthe potential feeling of guilt. This decreases theanxiety level of the patients, so that they are notfixed in an unbearable feeling. The patients arethereby given the possibility of choosing whetherto carry the responsibility for certain feelingsthemselves or to place the responsibility on themusic.

The music legitimises and contains. On the otherhand it also becomes legitimate and allowable tohave violent fantasies (which the music contains),or to become intimate when the music gets persistentor gentle, or to experience conflict when the musicexpresses conflict. This is also the case when

experiencing passion, emptiness and loneliness,feelings which several of the patients came intocontact with during the music listening (Moe,Roesen & Raben, 2000. pp 36).

The music is metaphoric and stimulating in itself,and via the collective aim to listen to the same pieceof music in the group, talking about innerimaginations is legitimised. You can easily imaginethat for most it would be very provocative andexceed boundaries to talk about their fantasies, butwith a joint starting point in the music, the dialogueabout the fantasies becomes more legitimate. Inaddition, it is a commonly known phenomenon thatmusic supports feelings and images, e.g. in filmsand advertisements.

According to the analysis, the music often bringsthe patients into contact with important emotionalstates. When the patients have the experience ofsurviving, e.g. dark and light mood, the general fearof extinction is eased. The imagery, which is oftengenerated by the music, thereby indicates that animportant process of symbolising is initiated.

Via the music the patients is provided with a tool– a model – for working through their emotions at abasic level. The patients thereby become able tohandle their anxiety pressure in a more useful way,which involves a strengthening of the self. Atherapeutic development spiral is thereby initiated,where the patients little by little experience andinternalise more models, which can be used forprocessing. So, when the patients discover that theyare able to handle the challenges presented by themusic, they obtain an embodied experience of innertension (or fear of the unknown) being neutralizedor transformed into something else – an importantpsychological competence or coping-skill. Figure 4is a model showing foundational modes ofexperiencing the music

The Importance of the GroupThe most important function of the group is tofunction as a container in order to test difficultemotional states, whereby an opening is created forthe patients to begin to reflect common problems.The group creates an intersubjective foundation, inwhich the patient’s fantasy material meets reality.As mentioned, the group has a containing function.The patients are motivated by each other’s stories,

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and this engagement can help breaking the autism,which is one of the symptoms most disabling to aschizophrenic person. According to the casedescriptions (Moe, 2001) feelings of isolation areexpressed as part of the problem for all the patients,and all the patients have expressed a wish to workthrough this problem.

Because the patients are presented to a collectiveintroduction through the opening images, a commonground is created in the group, which reduces thefear level and increases the possibility of bothidentification and variation in how the groupmembers understand each other. The patients gainan insight into each other’s experiences of the music,which enables an increased understanding andmirroring on an interpersonal level. Joint experiencesof the music create “twinship” experiences (Kohut,

effect. Such experiences ina group are veryimportant, as we live in asociety consisting ofgroups. It is thereforeimportant that the patientshave the opportunity ofassimilating theexperiences from thetherapy group into theirlives.5 When the patientsfind that their destructivefantasies are contained inthe group this increasestheir belief in thepossibility of a relation,which is a premise fordevelopment. (Moe, 2001,p. 91). The patient findsthat both positive andnegative feelings arepossible and allowed,which makes a beginningintegration of good andbad objects/states possible(Yalom, 1983).

The Importance of theGuidingThe guiding is part of theFig. 4: Foundational modes of experiencing the music

1971), both between the individual patient and themusic, and between several of the patients – incertain cases the whole group and the music. Thiscreates feelings of affinity and communion. Apartnership is developed, which is very importantas regards the relations in the group.

Views which may be closely connected to aconcrete way of thinking, may thereby – whenshared and contained in the group – be transformedinto a fantasy in the inner symbolic representationsystems. As an example, a patient explained thatshe felt there was a monster inside her which coulddestroy the whole group and the patient herself. Byexperiencing that the group survived the “story” –they saw each other the following week - the patientfound that the fantasy was dismantled anddedramatized. The fantasy thereby lost its concrete



setting and also functions as a structuring andthereby safety creating factor. Through the guiding,the patients are offered a joint starting point and afocal point in their either chaotic or empty innerworld – all according to whether they arecharacterized by positive or negative symptoms(expressed in their anamnesis).

Like the music the therapist (the guide) functionsas a projection screen, as the patient can displaceunbearable or unwanted feelings by saying that itwas the therapist who decides the focus image givenin the beginning of the session, and the music chosen.It is also important to note that the guiding is an“instrument” - the “instrument” heard by the patientjust before and/or during the music – the tone ofvoice and the way of speaking must be adjusted tothe music.

It appears from the empirical material that theguiding functions as a structuring factor and is asupport to the patients. Several patients expressedthat the guiding was a support to them in creatingimagery (Moe, 2001, p. 239 ff)

The Importance of the Image FormationThe image formation symbolizes the patient’s innerobject (con)figurations, and the development of thepatient is reflected in the transformation andreconfigurations of the images. The patient canunderstand certain images and metaphors veryconcretely, as the image formation immediatelycatches configurations from the subconscious, butthe contact with this “space” creates a basis fordifferentiating. My analysis shows that the fear ofthe concrete understanding – e.g. a configuration ofa core problem - can be discussed with the therapistsand the group and thereby be better controlled.

Image formation is a form of thinking whichmakes possible a further understanding of sensuousexperiences. According to the data, perception,memories and fantasy are combined and re-combined. The patients thereby obtain a newunderstanding of sensuously based connections andthe sense of new differentiations and coherences 6 .The image formation is closely related to sense

impressions, and the imagery often evokes feelings.This means that narration of memories is oftenexperienced as present and alive – the “here andnow” principle (Yalom, 1983). Another substantialreason for imagery is the importance of images inconnection with working through traumas. As lexicalrepresentations and visual representations areorganised and stored differently in ourconsciousness, it is important to describe bothrepresentational forms in order to work through andintegrate the traumatic experience as completely aspossible.

As an example, a patient relived a train journeyconnected with a traumatic core experience, wherehe was obsessed by the thought of throwing himselfin front of a train. After the music listening phasethe patient told about his feelings and thoughts inthis connection. The imagined situation therebybecame both present and processed, both lexicallyand metaphorically. The patient experienced nothaving suicidal thoughts in the imagined relivedsituation, and this concrete sign of restitution createdspace for working through also the traumatic part(or illusion) of the experience, which was therebyliberated from a psychotic basis.

Finally, the images often express an immediatequality or degree of an emotion. Images are wellsuited for describing complex affective levels andthe re-experience of traumatic events, which can behard to explain verbally. The imagery caused bythe music and/or the guiding, is the pivotal pointbetween the patient’s understanding of him/herselfas a concretely thinking person or as a symbolicallythinking person. The patients’ self images enable adiscourse about the patient’s history. Even talkingabout – and thematizing - the self, creates apossibility of also reaching more problematic areasin the prehistory of the patients. Often the imageformation configures object relations, and bycomparing the various sessions, specific problemswithin patterns of object relations appear. The imageformation can also illustrate different aspects of theself-experience of the patient. As an example, in asession a patient experienced herself as alternately

5 Further, it was observed with a few patients that they adopted the whole “therapy ritual” and group idea. After theconclusion of the therapy period, they established a set time in the week where they met in a less formal setting andlistened to classical music on the ward.6 Horowitz (1983) states that the connection between fantasy, memory and perception allows a person to reviewinformation for new meanings, to contemplate objects in their absence, and to seek new similarities and differences.

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aggressor and victim. An aggressive part inside herwas throwing stones at a little bird – another part ofher. The image can be seen as having a ”role model”quality, which can be discussed in the group (forexample feelings of guilt or a sense of shame can beworked through). Because of the passing narrative“movie” it is possible to catch alternately consciousand subconscious self-identifications, which can bedifficult in a normal lexical situation. Another aspectof the meaning of the imagery is the metaunderstanding. According to the identification of themetaphoric process (Moe, 2001 p. 287 ff; Bonde,2000), the metaphor is a symbolic representation ofself-states. The differentiation inherent in thedefinition (namely that one thing is describedaccording to another, so that a third thing is createdout of this comparison), involves a possibility ofpsychological development seen in relation to thetheory about the patients’ concrete one-dimensionalthinking. Via the metaphor, the patient (and thetherapist) obtains a possibility of experiencing thesituation from a new angle. Siegelman (1990)stresses a very important point in relation to thedevelopment of schizophrenic patients, namely thatthrough the metaphor itself something is developed.Furthermore the metaphor is connected with thelanguage of the primary process – oftencharacteristic of the thinking of the schizophrenicpatients. In my view, the language of the primaryprocess is symbolic (e.g. the language, which weuse when we dream), but the schizophrenic patientin a psychotic state sees, forms and acts out fromthe symbolical language, as if it was concrete. It istherefore important that the schizophrenic personcan get to understand the language of the primaryprocess as a metaphoric and non-concrete language.Further, I would like to stress that I do not view thephysical way of thinking, and the metaphoric wayof thinking, as simply primitive, early versions ofthe lexical mode of thinking. Rather I am of theopinion that all three forms of language aredeveloped analogously through life. Another wayof describing the aim of the development of thepatients is that they obtain a greater free flow in theway they move between the two different ways ofthinking, as this freedom has been limited becauseof various blockages in the inner representationalsystem. A possible causation of a blockage could

be that the processing of stored traumaticexperiences has not been able to take place becauseof repressive circumstances earlier in the patient’slife. This could result in the suppressed imagesappearing as very unpleasant and invadingconfigurations, as the unprocessed psychologicalmaterial always tends to find a way of emerging atthe conscious level. This way of creating space fornew experiences seems plausible seen in relation tothose traumatically coloured images presented bymy patients. To a certain degree this can serve as anexplanatory model for the self-destructive images/fantasies of several patients. In addition to this, atoo high level of fear will block the patient’s imageconfiguration of stored traumatic material. This is afurther reason for focusing on how the stress levelin the group can be kept under control.

A pivotal point for the therapeutic value of thepatients’ image formation is also the question ofwhen the patient’s contact with the fantasies involvesan increased withdrawal into an autistic universe,and when the fantasy contains the seed of increasedself-realization. According to the empirical material,the foundation of an increased engagement in realityoften seems to rely on the experience of fantasiesconnected with hope. The installation of hope(Yalom, 1983, 1985) is necessary in the building ofa basic trust, which is naturally connected to theability to establish connections and relations.

Self images, Transitional objects, andDefensive Manoeuvres

One part of the categories of restitutional incidentsI categorize as the defensive manoeuvres of thepatient. In the therapeutic situation it is possible forthe therapist (and the patient) to gain an insight inthe constitution of the defensive manoeuvres, andthereby the patient’s aggression management.

Goldberg (1994; 2002) states that defensivemanoeuvres in BMGIM are an adaptive means ofcoping with deeply or potentially stressful orthreatening experiences. A defensive manoeuvre isessential to avoid fragmentation or disintegrationof the ego (Goldberg 2002, p. 364).

From the data of the empirical analysis I get theimpression that the defensive manoeuvres are



functioning as ‘buffers’, to protect the self againstoverwhelming stimuli. An example of this can beseen when the metaphoric configuration simplifiesa complex problem into a single platform.

Hereby an actualisation of the metaphor happens,underlining certain aspects, but concealing others.Depending on the context, any metaphor, e.g. apatient’s experience of being a ‘chief’, can beunderstood as the ability of the patient to picturehim/herself in a positive light. The “chief” could bea desirable role, but at the same time this could beinterpreted from an opposite point of view asbeingthe patient’s hidden/unconscious fear of feelinghelpless and powerless. I understand the ambiguityof the defence based on this context. The patientbeing capable of dividing positive and(subconscious) negative experiences could becompared to the defence mechanism called‘splitting’. The therapeutically important potentialis the fact that the configuration can be produced,whereby positive and possible negative perspectivescan be shown.

I also reach the conclusion that defensivemanoeuvres can be “assisting images” or assistingstates, which strengthen the ego. These images areoften generated from the dynamic of the music,thereby having a vitalising effect, which the patientcan absorb as a kind of “empowerment” which againstrengthens the patients’ sense of their self. This isa configuration that gives the patients a feeling ofresistance, which is of primary importance, as thisis exactly what schizophrenic patients are oftenlacking. Whether this phenomenon can becategorized as defence manoeuvres is debatable.

To begin with, an almost ‘magic’ resistance cancharacterize the assisting images. However, as theself is developed, the images could adopt a moredifferentiated character, e.g. a more common beliefthat action is worthwhile in certain circumstances.

Therefore, I suggest that the phenomenon“assisting images” can be understood as a type of(inner) transitional object in the Winnicottian sense,where the patients “play” with their inner powers.

“Assisting images” or “safe places” can also beunderstood as a “twin phenomenon” or an idealized

self object, according to Kohut’s theory of acontinuous narcissistic development all through life,which is based on an ongoing development ofcreative elements in the psyche. Kohut states (inSand & Levin, 1992, pp.161) that “self objects donot refer to specific persons or caregivers, but ratherthey are seen as performing vitalizing, psychologicalfunctions that pertain to the lifelong maintenance,restitution and transformation of the self experience”.

All in all, Kohut’s theories on self objects(reflecting objects, twin objects and the idealisedobjects) go well with my empirical findings, and asan explanatory model they can support thedevelopment tendencies of the patients.7 Viaidealised wishful tales and fairy-tale like stories, thepatients seek to satisfy basic needs and to realizethemselves. (For example, one patient’s wishful ideaof being “the first engineer to sail the seven seas”).When the patient, assisted by the music (which initself can be a self object), configures self objects orself part objects in himself, in the form of “wishfultales”, these configurations constitute an importantcomponent in the inner restitution of the patient. AsStolorow (in Sand & Levin, 1986) points out, thedevelopment of the self is related to integration ofboth new and conflict filled affective experiences.Stolorow suggests that a subjectively experiencedobject obtains the function of a self-object, whichpertains fundamentally to the affective dimensionof self-experience. When the psychologicalintegration of an individual is threatened, thecoherence and the continuity in the self-experienceare diminished, which results in a fragmented selfexperience. Stolorow mentions that thefragmentation is often a consequence of aninadequate affective responsivity, and that therestitution of the self is a restitution of a sense of anaffective context. Stolorow writes, “it is the subtleshifting and interplay of these internal self-states thatare the organizing agents for every individual”(Stolorow, in Sand & Levin, 1986). In the processof (re)establishing the integration between objectand effect, the music plays an important role as anintegrating/connecting “agent” and bridge builder.

7 Kohut originally described his theory based on the case “The tragic Man”. It was his view that the patients tried, on thebasis of their core self, to realize ambitions and ideals, and that the degree to which they succeeded in this reflected eitherjoy or satisfaction versus feelings of despair and loss/rejection.

TORBEN MOE


The Theory construction seen in adevelopmental psychologyperspective

Seen in the context of developmental psychologyKohut (1971) and Stern (2000) seem to have someinteresting theoretical views, which contribute to ourunderstanding of why schizophrenic/schizotypicalpatients could perhaps benefit from the model ofGroup Music and Imagery Therapy.

In several sessions it was observed that thepatients were active at several psychological levels,as illustrated in the model shown in figure 5 withan example from the clinical material.

Patient A experienced himself as an ice dancer.The music induced “a whizzing feeling” in him8

(kinaesthetic/senso-motoric influence). Thesensation spontaneously caused a configuration ofhimself as a skater (a positive self object), dancingwith a skating princess. Everyone was there, andthe king and the queen applauded (the therapists?).The image is placed in a brief narrative context,which can be interpreted in the group. A “is puzzled

about himself – he usually does not daydream”, andhe reflects on himself. (Cat. I-d in the categorymodel).

Integration between several of these levels canbe observed, which can be understood in adevelopmental psychology perspective. In figure 6,I have tried to illustrate such connections accordingto the outline of Stern’s developmental theory.

On the right side of this model I have indicatedStern’s theories about the developmental levels ofthe child. Further I have added Horowitz, asHorowitz has worked on theories about “the imagerepresentation system” (Horowitz, 1983).

The more controversial aspect of Stern’s theoriesis that – in contrast to traditional psychoanalytictheory (i.e. Klein, 1946; Mahler, 1975) – the“primary” and “secondary” processes shouldontogenetically be exchanged, as the child onlygradually learns to symbolise, and that the sense ofreality is present already at the time of birth. Sternalso assumes – contrary to Mahler – that the childnever enters into a symbiosis with the mother, butthat it already at the time of birth has a dawning

Fig. 5: Active Operational Levels

8 Which Stern calls a vitalizing effect (Stern, 2000).



sense of its self, and experiences “attunement” andlikeness versus separation at a sensing level.According to Stern the children experiencethemselves as physically limited, and gradually alsoemotionally limited, very early on in theirdevelopment. After the establishment of the basicsenso-motoric competence the child enters into anattachment relationship, which can activate innerimages as self-representations. Stern expresses that,what dominates the consciousness of the child isthat it experiences being the origin of its own actions,and that it has a will (experiencing the core self).This is different to Klein’s theories, about the splitfantasy universe of the child and the split self-awareness at the same time in the development(Klein,1946).

According to the empirical material, the patients’image representation system is activated andfunctional. In my category system areas arehighlighted where the imaging is activated – as wellas examples of image transformation. It also appearsthat the patients are capable of structuring andmaking emotional connection of certain images,which thereby become self-objects, and also theyare capable of connecting images in inner objectrelation patterns.

How then, is this to be understood indevelopmental psychology terms?

From the empirical results it seems to be the casethat, if the ability to symbolise/create inner imageshas been established, it is possible topsychotherapeutically process “stranded” and

fragmented self images and object relations withschizophrenic/schizotypical patients in the settinggiven.

My theory is – and this contradicts Klein, Mahlerand Wilber (1986) – that this is due to the patientshaving a sense of an inner core self, and that basedon this sense, a contact is created via the music withthe experience of the damaged subjective self, whichthen enters a “repair” process where exactly strandedobjects are identified and picked up.

A sense of hope and trust is thereby generatedin the patients, and in connection with a detoxicationof megalomaniac fantasies in the group; a positivetreatment spiral is activated. In this process, thepatients’ awareness of their core self grows, andthereby the patients become more able to produceand incorporate vitalising self-images, thusstimulating an increased autonomy and self control.The development of the patient is to be understoodin the field between the production of self-objectsand psychological defence manoeuvres.

References:

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Bonny, H. (2002). Music Consciousness: TheEvolution of Guided Imagery and Music.Barcelona Pub. Salina, USA.

Bonny, H. (1978a). GIM Monograph #1:Facilitating GIM Sessions. Salina, KS,

Fig. 6: Ontogenic Model

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Bonny Foundation.Bonny, H. (1978b). GIM Monograph #2: The

role of tape music programs in the GIMprocess. Salina, KS, Bonny Foundation.

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with psychiatric patients based on amodification of Guided Imagery and Music(GIM). Nordic Journal of Music Therapy 9(2) pp. 36 – 50.

Moe, T.(2001). Restituerende faktorer igruppemusikterapi med psykiatriskepatienter. PhD dissertation AalborgUniversity, DK. Also in: Aldrigde D. FachnerJ. (2002). Info-CD ROM IV. Music TherapyWorld. University Witten Herdecke, 2002.

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Summer, L. (2002). Group Music and ImageryTherapy: Emergent Receptive Techniques inMusic Therapy Practice. In: Guided Imageryand Music: The Bonny Method and Beyond.Ed: Bruscia, K. & Grocke, D. BarcelonaPub., Gilsum, USA.

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Restitutional Factors in Receptive Group Music Therapy

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