Music therapy is now recognized as a valid aid in the field of palliative care. Even in Italy, one of the European countries where music therapy is attempting to make up for significant historical and cultural delay, it has been utilized for some time now in this specific field. In this contribution we will examine the case of a young man of 24, and focus on certain specific characteristics of our therapeutic intervention. We feel this case is particularly pertinent because it prompts reflection in more general terms on the meaning and objective of palliative care, and on how music therapy and the language of music can be inserted in this context.
From a medical standpoint palliative care acts on the physical condition of the patient to make the course of illness more bearable. Nevertheless, because quality of life is not a matter only of physical wellbeing, palliative care also addresses the psychological, social, spiritual and existential aspects of the patient, through the intervention of different professional figures such as psychotherapists, music therapists, social and spiritual workers and trained volunteers, whose efforts supplement those of doctors and nurses.
In the course of the illness, as the patient approaches the end of life, the psychological and existential aspects become increasingly important and decisive, because the pain and anguish can become total, and if not controlled and addressed can lead to a state of depression so void of meaning as to render any pharmacological treatment ineffective.
It is here that psychotherapeutic intervention becomes fundamental, in an attempt to reinsert the patient’s experience in a meaningful context, permitting the subject to process that experience and maintain a connection with his innermost reality. In fact, often in these situations the anguishing wound can actually trigger a process that brings the subject closer to his own inner truth. Our viewpoint is based on that of one part of psychoanalytical thinking, which takes its distance from the notion that individual history is totally determined by what has happened before and, in particular, by the experiences of childhood. Thus, for this current, individual history cannot be seen as mere repetition of crystallized structures of the unconscious. Outside of this determinism, the subject is seen as an entity that can and must fulfill itself in the future, as a precise ethical task to be completed. In this perspective, the therapist’s activity in the field of palliative care becomes crucial. The care takes on particular importance because it attempts to shift its direction from memory of the past to perception of an echo that comes from the future, a position that constitutes the possibility of freedom for the subject with respect to any determinism.
Serious illness faces the individual with the question of death, the most radical limit of human existence. What is this encounter with death, if not a sensation of the void, a wavering on the edge of nothingness? When, in the experience of the terminally ill patient, the world is emptied of meaning, brutally taking an inert material character, it becomes the place that silently awaits his disappearance.
The intervention of the music therapist comes into play when verbal work is no longer sufficient. The terminal patient finds himself in a borderline condition in which the brevity of space and time may force him, in spite of himself, into the prison of the inexpressible. In this sense music intervenes to form a filter that recreates the symbolic context that has been devastated by the traumatic experience of the perturbing impact of the real (the term is applied in the sense used by Lacan). This is a human condition that goes beyond the philosophical and religious convictions of each individual. This does not mean that faith should be considered merely a style of sublimation, but that even the most profound religious sentiment cannot help but come to terms with the sense of abandonment caused by the closeness of death, as is borne out by the phrase in the Gospels «Elì, Elì, lamà sabactàni?» (Matthew 27:46)
Our model of music therapy sees music, with its style and formal organization, as the main element with which the therapeutic process evolves. As in verbal psychotherapy, the relationship between the therapist and the patient is essential in this process. But in music therapy the musical language that develops in free improvisation is the fundamental therapeutic factor. One of the main functions of the music therapist, through free improvisation, is to work in real time on musical material suggested by the patient, in order to facilitate processing of psychic content.
The structure of the clinical improvisation may vary significantly, in keeping with the problems to be addressed, and the patient’s cultural context of origin contributes to create the conditions through which the improvisation is oriented toward a given musical style. Nevertheless, there is a close connection between the pathology confronted and the musical development of therapeutic treatment. Moreover, in the case of palliative care we must keep in mind that the trauma is truly connected with the breakdown of the body, and is therefore present at a psychic level without any veiling.
To clarify what has been said thus far, and to facilitate comprehension of the musical materials of the clinical case that follows, we would like to present a more general overview of how, historically, the irruption of the real has taken form in artistic and musical language.
Starting with the artistic experience of the Surrealist movement, the concept of the artwork as a revelation of the unconscious, of its impulsive force, laid the groundwork for a paradigm change that challenged the notion of the function of beauty in art, a function that had been eminently one of “veiling” and sublimation of the real through treatment on a symbolic level. In place of this notion of beauty, an increasingly literal representation of impulse appeared, a radical position that shifted the aesthetic center of gravity of the artwork toward an obsessive presence of the body, as we can see, for example, in the performances of the Orgien Mysterien Theater of Hermann Nitsch.
This irruption of the body in the artwork has also become common in pop music, where there is an increasingly evident allusion to the perverse presence of the body’s organs, in a sort of idealized exhibition of horror and obscenity. Just consider, for example, the self-destructive antics of Punk, or the music and images marketed by Aphex Twin, Nine Inch Nails and Marilyn Manson, just to name a few recent acts on the pop music scene.
Where symbolism collapses the Real bursts in, with devastating effect. Certain artforms approach psychosis. According to the teachings of Lacan, in psychosis the subject encounters a real without symbolic contours; a persecutory Real that assails the subject’s body and thoughts, abusively invading him.
Nevertheless, beyond extreme, literal forms, the irruption of the Real has also been expressed in contemporary art without a loss of its symbolic-formal organization, as in the case of Alberto Burri, who in works like the “Combustions”(figure 1) or the “Sacks” (figure 2) conserves an explicit reminder of the presence of the body, though the discourse moves in the opposite direction: from the presence of material it re-ascends to the level of art seen as dramatic representation and the realm of beauty.
In the last works of Paul Klee we can observe an artistic process that is interesting not only for its aesthetic implications, but also because it bears witness to a processing, through art, of the trauma connected with illness and death. These works belong to the final period of Klee’s output, when the artist was afflicted by systemic scleroderma, the fatal disease that gradually stiffens the organism, and killed Klee in 1940. In these paintings we find certain fundamental themes of the existential condition of a victim of a serious pathology: the degeneration of the body and its disturbing presence (figure 3), the separation from the human community and loved ones (figure 4), the gradual slide into anguish caused by awareness of the void, but also conscious shouldering of one’s human destiny (figure 5).
While in Paul Klee the attribution of meaning to traumatic experience is a spontaneous process, clinical experience demonstrates that the achievement of such depth in approaching anguish is a process that seldom happens spontaneously. Therefore the role of the music therapist becomes fundamental to support and guide the patient toward the possibility of accepting his own limit, to live his own individual path as fully as possible, in spite of the difficulties and timing imposed by disease.
In our discussion of the relationship between a work of art and the irruption of the Real, we have highlighted how an artistic experience can at times be similar to a psychotic experience. Starting from this consideration, this music therapy treatment had to deal with the need to adopt a musical language which allowed the patient to reconnect with his own personal story and his own emotional world. At the same time, as his musical experience was basically tied to decidedly hard rock, it was necessary to find a way to propose this style in therapy, mitigating the most harsh and explicitly destructive musical and symbolic aspects.
The anguish of the terminally ill subject may often resemble psychotic anguish, but when this happens the capacity to tolerate the psychic pain connected with traumatic experience remains structurally intact, though it is impaired. In fact, with the approach of death the subject often is no longer capable of bearing the impact of the real, because the pain and the perception of the void are so intrusive as to make any thought impossible. Music therapy can facilitate, through an approach that takes the extremely precarious state of the patient’s psyche into account, a path leading from the total suffering caused by the disease to a relativizing of that suffering, restoring the possibility of giving a new meaning to what has already happened, to redescribe experience in a new way.
Leonardo – this is the name of the patient whose case is examined here – was a young man of 24 suffering from neoplasia. His overall conditions had deteriorated seriously. After an unsuccessful operation, Leonardo was tirelessly assisted by his mother. The doctors attempted, in substance, to improve his overall condition as much as possible. The family doctor suggested music therapy, because Leonardo was a drummer, played the guitar, and had always had an excellent relationship with music. The music therapy began when he was already in critical condition: he was very thin, had difficulty getting out of bed, and was living in an evident situation of mute psychic isolation. He had very long hair and a long beard, and seemed to have completely given up on any personal grooming.
We can observe three different phases in this therapeutic path. An initial phase, devoted to reconstruction of a protective context with respect to the traumatic experience, involving listening to and discussing pieces of music that were a part of his memory. In a second phase characterized by free improvisation Leonardo discovered the possibility of playing freely, together with the therapist, and of dealing with certain elements connected with the trauma in the improvisation. The central focus of the third phase of the treatment was the emergence of a song Leonardo had already composed but had never played for anyone before. The music therapy sessions were conducted in the house in the country where Leonardo lived with his mother, not very far from Florence. The sessions varied greatly in terms of duration, depending upon the needs of the patient and the timing imposed by the session itself. In our first encounters, as he was to tell me later, in another session, Leonardo was skeptical about the possibility of music therapy to help him, essentially because he thought that a music therapist would never be able to understand his musical style: he had always listened to and played rock. The initial moments of our first meeting were difficult, because I sensed that Leonardo’s outer silence reflected an inner emptiness, and I knew I would have to respect that silence, weighing my every word, as it could have an enormous effect in determining whether the therapy would continue. The first two music therapy sessions were devoted to an attempt to revive his inner world, listening to some of his favorite records and talking about them. Some of his favorite songs were particularly striking, and though they were not literally utilized in the improvisations, they contributed to create a shared musical context. I would like to listen to two short examples from these songs:
Listening to this music gives us an indication of the particular musical language utilized in this treatment. In fact, we can notice that this music was the inspiration for certain harmonic, rhythmic and formal characteristics of the improvisations. It is starting with these premises that we can interpret the musical material utilized in this clinical case, namely taking into account the fact that certain musical elements like repetition and functional tonal (and at times modal) harmony are normal features of rock music. Obviously the choice of a given language is, in any case, connected with a psychological need. In this case the repetition typical of rock constituted a useful scaffolding to contain the emotions of both the therapist and the patient.
After having listened to these songs and talked about them, at the end of the second session Leonardo told me, “I agreed to see you because my doctor advised it, but I wasn’t really convinced that undergoing this therapy made sense; I thought you would be different. Now that I’ve gotten to know you, I think I would like to continue with these sessions”. He also talked about the loneliness he was going through. He told me certain friends came to visit him now and then, but that he felt increasingly uncomfortable in their presence. When he was with them he felt excluded, and he noticed they had trouble looking him in the eye. This difficulty caused him particularly pain, because he could glimpse the sign of an unavoidable sentence. Before we parted he said, “You’re the only person with whom I feel at ease, because you’re the only one who doesn’t look at me like that”.
In the days leading up to our next session I improvised many times on the guitar, trying to make contact with the resonances that had emerged from our encounter. At this point the difficulty in the treatment lay in finding the right musical instruments for the improvisation. I decided to bring a violoncello, two different types of lyres and a guitar. I selected these instruments for their timbral qualities and their harmonic and melodic possibilities.
At the start of the third session I asked Leonardo to choose the instruments for the improvisation. He chose the smaller lyre for himself, an instrument with both drone strings and strings tuned in a modal scale, and asked me to play the guitar. After a few moments of silence, the first improvisation began.
In these initial bars (figure 6) we can already find some important elements of the therapeutic process. This first musical dialogue created positive conditions for the development of the improvisation. From the first notes I tried to insert Leonardo’s musical output in a formal structure, creating the conditions for the development of further variations.
The first measure is characterized by the guitar’s imitation of the B from the E-B fifth played by the patient on the lyre. The initial A of the guitar is an appoggiatura of the B, and has a structuring function for the melody line. The first note of the second measure of the guitar is a B that descends to A. The structure of these two bars, the specular development of the melody, indicates interdependence between the therapist and the patient in the musical construction. The third bar returns to the rhythmical scheme of the first. The guitar pauses for a quarter-note rest. This rest allows Leonardo to develop the musical discourse while I listen, with the aim of developing the material he generates. The construction of the melody brings both instruments to the finalis E. The second semi-phrase (bars 5-8) features an inversion of roles with respect to the previous measures. The tenor role in bars 1-4 was played by the lyre (figure 7).
In bars 5-8 (figure 8) the tenor role is passed to the guitar.
Leonardo developed the melody of the guitar, then entering the region of the dominant together with it (bar 7) and resolving the cadence toward the finalis (bar 8). The polyphonic structure of this phrase is evident in its oblique direction and its distribution between the two instruments. I would like to emphasize the fact that Leonardo was struck by how this musical construction could emerge in real time in the improvisation. While in the first bars the melody is constructed in the Doric mode, starting in the ninth measure the lyre hints at a melody in the Phrygian mode. The guitar’s imitation (bar 10) moves under the light sound of the lyre, which defines a space composed of bichords and single notes that gravitate around the region of the subtonic and the fifth. After stopping on E, the guitar plays an ascending scale with repeated notes until A, in unison with the lyre (bar14).
In our conversation following this first improvisation Leonardo spoke of the deep emotion he felt at the appearance of this unison. As in the case of the first cadence, once again the unison marked the most recognizable moment of synchronicity generated in the improvisation. As Jos De Backer and Jan Van Camp have pointed out, generally in this moment of the therapy the patient and the therapist have the impression of being able to freely make music together, simultaneously experiencing interdependency in creation of the musical structure, and autonomy in the free development of the musical material. At times, with certain patients, this moment is achieved with great effort, and most of the therapy can be said to be directed toward the achievement of this objective. In the case of Leonardo, the instantaneous appearance of this moment indicated that the starting point for the therapy was this synchronicity. Undoubtedly the first two sessions devoted to listening and discussing pieces of music had created the conditions for the opening that happened during this first improvisation.
After this introduction, my accompaniment begins on the chord of E minor, in this case corresponding to the first step of the Phrygian scale proposed by Leonardo in the ninth measure. While initially the lyre and the guitar interweave in an arpeggio, as the improvisation develops Leonardo begins to vary the musical material, suggesting new melodic solutions.
As Jos De Backer and Jan Van Camp have pointed out, in the music therapy context every musical event is born from a preparatory silence that grants the therapist the possibility of resonating with himself and the other. In this silence the music therapist becomes receptive to the presence of the patient. This condition leads to perception of an “anticipated inner sound”, or the perception of the musical presence of an inaudible sound that arises in the therapist in the moment he focuses on making music with the patient.
Another musical example, still from the first improvisation, demonstrates the importance of this principle in the development of the improvisation. After several moments of silence the sound emerges, almost imperceptibly, simultaneously from the lyre and the guitar, turning the improvisation in a new direction.
In all the encounters with Leonardo the verbal part of the session was always devoted to comment on the moments of music that emerged during the improvisation, with only indirect mention of the problems connected with his illness. The music therapist could sense Leonardo’s reluctance to even touch upon any theme that might have a direct link to the emotions and sentiments involved in his situation. Only in a few fleeting moments of the first improvisation was it possible to recognize the emerging of the trauma, usually in variations on the musical material, as in this fragment that particularly intrigued Leonardo.
In this fragment an A-D?sharp tritone in the lyre inserts itself in the circularity of the sound. The guitar gathers the note, making it part of the accompaniment. In the recording one also hears the microphone as it falls, noisily, accentuating the traumatic character of this passage. When he listened to the recording Leonardo remarked on the dramatic quality and the discontinuity caused in the harmony by the introduction of this “harsh” interval. The diminished fifth was to play a crucial part in another very important moment of the therapy, as we will soon see. It is interesting to note that a musical framework based on a tonal-modal syntax, in which variations and harmonies remain limited to a sphere of great predictability, offers possibilities for confronting the most difficult and at times painful moments by starting with minimum discrepancies within the musical fabric.
The following week Leonardo’s appearance was quite different. I found him sitting on the bed. He had cut his hair, keeping it long, but trimming it for a more orderly look. Instead of the beard he had a well-groomed goatee, and his overall condition seemed to have improved. As soon as I sat down beside him on the bed he showed me the catalogue of a store selling percussion instruments. He said that during the week he had thought about buying a new drum set, and he described the characteristics of the models that interested him. He also asked me if I could help him set up his laptop computer so he could use it to make music. Rediscovering music through the aid of the therapist had revived his relationship with the world. He had rediscovered the energy and vigor that had been erased by the disease, and a new enthusiasm led him to plan projects for his musical future. The vitality Leonardo communicated was in evident contradiction with what he was experiencing because of the tumor. The transfer that had emerged in therapy had brought with it the negation of mourning.
He also told me something about the musical experiences he had had with his group. From the story I understood that in the past Leonardo had suffered in his role as a drummer. He felt excluded behind the drum set, and had the impression of having to passively adapt to the musical decisions of the other musicians.
When I suggested that we improvise together he agreed with enthusiasm. Leonardo felt capable of playing the guitar while seated on the bed. He asked me to play the violoncello.
In the earlier improvisations I had tried to accompany him in order to facilitate his free expression, creating a musical context in which he could feel himself contained. As occurs at the beginning of many music therapy treatments, Leonardo tended to try as closely as possible to produce what he thought I expected of him. In this third improvisation, on the other hand, he strove to introduce new musical elements, some of which were connected to his experience as a musician.
This new approach became evident toward the end of the improvisation. At the beginning of the sequence the violoncello and the guitar move in a rarified musical dialogue that takes the form of a rhythmical movement over which harmonic and melodic variations are developed. After several measures, an arpeggio of the guitar on the A chord suddenly appears, slightly shifting the start of the measure by a crotchet, making a break with the previous musical order.
The A chord that marks the sudden change in the improvisation is the first chord of the initial arpeggio of the song composed by Leonardo, which became the basis of the last improvisation.
Let’s compare this with the arpeggio of Leonardo’s song in its complete form, as he played it in the following session.
It is interesting to notice how this arpeggio is varied in the third improvisation. The shift of the beginning of the measure causes a moment of instability in the rhythmic continuity, and this creates a pause and a change in the relationship with the therapist. We can also notice how the first two bars of the arpeggio in the third improvisation follow the harmonic structure of the song, while the third bar, similar to the first, differs from it in the last interval, which instead of a fourth becomes a tritone. Leonardo had waited for the right moment to satisfy his desire to play his song. This desire was accompanied by great tension, since he did not know if and how the Other (the therapist) would have accepted his music. The appearance of the tritone, which once again symbolically as a differentiation in the improvisation, indicates the anxiety filling the patient’s expectations (how will the Other see me? What does he want from me?). In the subsequent chromatic scale of the guitar we can sense an escape, an ascending movement that reaches a different musical space where the violoncello, whose presence is marked by the neutrality of a repeated octave, contains the constellation of the fragmented sounds of the guitar: the harmonics, the material character of the fingered strings, the groups of irregular notes. In a rarefaction bordering on silence, the last four harmonics of the guitar conclude the improvisation.
In this example we can see how, in music, a structure is expressed that relates to an extramusical matrix, regarding the emotional sphere of the patient. This matrix is the source from which the structures of the dream, the symptom, and certain musical forms in free improvisation emerge, always different but always similar in their dynamic. Therefore in this arpeggio declared and immediately denied, the repetition of the suffering contained in Leonardo’s story resurfaces (“I can’t show my music to the members of my band. I know they wouldn’t like it”, he told me later). In the music, through the transfer, Leonardo relives the pain connected with the repetition of the experience. In the fragmentation of the last measures we can sense the abandoning of any attempt to comply with the demands of the therapist, and Leonardo’s improvisation becomes pure representation of the void.
He commented briefly on this improvisation. He listened to the recording in silence, at times underlining something with his gaze, or murmuring approval for certain musical passages. He thought the last measures were strange, different from what we had played previously. He asked me if I could leave him the recordings of the improvisations so he could listen to them in the days before our next session. Two days later I sent him a CD of the recordings.
When I arrived at his house for the next session the situation had changed. He had been through a terrible night, and the pain was much worse. I asked him if he would rather just listen to some music instead of playing, but he said he wanted to play. I asked him to choose an instrument for the improvisation and he selected the guitar again, asking me to play the lyre. With some difficulty Leonardo sat on the bed and began to play.
He concluded the improvisation with a chord on the guitar, and a soft vocal sound, almost a sigh. When we put the instruments down he smiled at me, satisfied. He told me what I had heard was a song he had written, and that I was the first musician he had ever played it for. He hadn’t ever played it for the other members of his group, in the belief that they would not have appreciated it. At the beginning of our encounters the therapeutic relationship had had the function of making the music – the true therapeutic factor – emerge. In this process where the figure of the therapist, deprived of the function of repository of truth, shifts increasingly toward the background, Leonardo had gradually reached the point of assuming his own subjective truth, starting to recognize the nature of his own desire, symbolically putting his song at the center of the therapeutic discourse, a creative act that ideally placed him on the path of his realization as a subject.
The following week I found him half asleep. He greeted me with a smile. Once again he hadn’t slept all night, due to very severe abdominal pain. He was about to fall asleep. He looked at me, smiling, and said, “I wanted to thank you for being with me in this period. I never felt so in tune with another musician before. Without you I never would have been able to let someone else hear my music”. I thanked him for the kind words, telling him I would return in a few days. Before leaving, I waited for him to fall asleep.
Two days later I received the phone call telling me that Leonardo had passed away during the night. We can say nothing in the time when this happens, nor can we try to know what function music therapy had in helping him to confront this last moment. We can say that his last weeks were not spent in silence, and that this therapeutic intervention helped him to take one more step along his individual path. At the same time, this consideration tells us something more about our work as music therapists: that as long as life is possible, even to the slightest degree, we have the capability, and perhaps even the duty, to help those who suffer to live that life to the fullest.
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Antonio Gabbrielli (Psychotherapist)
Adriano Primadei (Music Therapist)
Pallium, Center for home assistance of oncologic and chronic patients, Florence, Italy