Music Therapy
1990,Vol. 9, No. 1, 16-34
Symbol and Structure:
Music Therapy for the Adolescent
Psychiatric Inpatient
ANDREA FRISCH
MUSIC THERAPIST,WESTCHESTERCONSERVATORYOF MUSIC
AND BRONX PSYCHIATRIC CENTER.NEW YORK
Music therapy is a modality well-suited to the adolescent psy­
chiatric inpatient population. The symbolic and structural na­
ture of music provides adolescent psychiatric inpatients with a
unique framework in which both intrapersonal phenomena and
interpersonal experiences can be expressed and explored. This
article focuses specifically on the ability of music therapy to
assist these patients in the developmentof ego strength, identity
formation, and impulse control. Theoretical concepts in which
the symbolic and structural aspects of music serve asthe primary
tools available to the music therapist for facilitating growth and
change are presented. Important symbolic and structural ele­
ments of the musical activities, the session’s verbal content, and
the therapeutic relationship are analyzed as they relate specifi­
cally to the needs of this population.
The author’s exploration is based upon psychoanalytic per­
spectives of personality development and pathology: the stages
of ego development (Freud, 1966; Klein, 1964), and the concepts
of identity crisis (Erikson, 1968), transitional phenomena
(Winnicott, 1971), and peer group relevance (Sullivan, 1965).
Case illustrations, from the author’s work experience, are pre­
sented to demonstrate patients’ utilization of symbol and struc­
ture and to exemplify the author’s theoretical orientation.
Introduction
Music Therapy and the Adolescent Psychiatric Inpatient
Psychiatric hospitalization is one treatment alternative for adolescents
who are having great difficulty functioning in their environment. When
it occurs, they are most often hospitalized against their will. They are
16
Music Therapy for the AdolescentPsychiatricInpatient
17
placed in a structured environment­ the hospital-and often told that
they “must work in therapy to become well in order to be discharged.”
Adjustment to the hospital takes time; the therapy work is arduous and
sometimes grueling; the process of self-exploration is difficult and
painful, perhaps more so when it is “mandatory” A successful hospi­
talization, however, can mean the difference between the adolescent
giving up on life or experiencing it as manageable and fulfilling.
Music therapy can help the psychiatric hospitalized adolescent pa­
tient begin to work through the problems that have led to hospitalization
and enable the patient to grow and to develop. There are indications that
music therapy should be an integral part of adolescent inpatients’
treatment. Erikson (1968, commenting on a hospital activity program,
stated that, ‘This program has become an indispensable counterpart to
psychotherapy, and has proven fertile in testing and promoting the
inner resources of young people in acute crisis” (p. 11).
Many patients are hospitalized because they have “authority prob­
lems,” and rebellion directed toward the hospital and its staff is evident
from the outset of hospitalization. It is common for the early treatment of
the hospitalized adolescent to be met withbehavioral and psychological
resistance. Patients may break the hospital rules, “act out” behaviorally,
damage property, assualt people, and refuse to attend therapy sessions.
Early reactions to music therapy, typified by initial comments such as,
“Those are kids’ instruments,” and ‘That doesn’t sound like music at
all,” are usually quickly abandoned and replaced byrequests for a turn to
play the keyboard, a chance to set the beat of the instrumental improvi­
sation, or an opportunity to choose the song for the group to sing.
The hospital’s structure and rules may be felt as a deprivation by the
adolescent patient. This may account for the patient’s initial rebellion.
Such patients are sensitive to deprivation, since physical and emotional
deprivation are often the reasons they are in need of hospitalization. The
music, however, may be perceived as an offering, a concrete gift, amidst
the new structure. The music therapist can be viewed as an ally and the
music therapy group as a place of safety and understanding within the
larger context of the hospital.
At this point, a patient may be too young, and perhaps too sick, to
understand that care warrants constructive restrictions, as well as
nurturance. The adolescent’s acceptance of the nurturing qualities of
music may explain why a patient often “settles down” behaviorally and
opens up verbally in music therapy before being able to do so with a
verbal therapist.
Music therapy also appeals to the patient because it provides an
opportunity to “self-express,” a strong adolescent need. As Sullivan
18
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(1965) states “. expressive play [is] necessary to provide the child with
equipment for showing what he feels” (p. 291). The fulfillment of this
need may have been denied during pre-hospital life, and theopportunity
for self-expression may explain why music therapy attracts and engages
adolescent inpatients so readily. Often before they realize it, they have
begun to “work” in therapy-music therapy.
Music Therapy and Transitions
Normal adolescents undergo massive and rapid changes during their
teenage years. They experience a tremendous increase in physical and
psychic energy, sexual energy, and accompanying this, creative drive.
Puberty is a time of transition, a juncture between childhood and
adulthood, and this “coming of age” can present problems. The hospi­
talized adolescent is experiencing these internal processes, while si­
multaneously making a transition from pre-hospital life to hospital life.
Music therapy can help adolescents cope with these transitions.
Music, itself, is filled with numerous successful transitions: Changes in
meter, tempo, tonality, register, volume, or instrumentation, for example,
are common occurrences in musical compositions. It is helpful for the
adolescent patient to be exposed to the transitions inherent in music and
to play through them. Music’s non-static nature provides consistent
potential for change. Its range of expressive possibilities naturally
attracts the patient to experiment with changes and transitions.
This phenomenon can be seen frequently with the patient who plays
at a fortissimo level. Sometimes simply suggesting an occasional cre­
scendo,or asking the patient to experiment with several intensities of
volume, leads to a natural widening of musical expression. It is the
enjoyment of the musical medium that motivates experimentation and
leads to an expansion of the patient’s musical expressive range. At this
point, the patient is no longer limited to only one style of expression, but
is able to make transitions between several ways of playing and ex­
pressing. Eventually this ability may manifest itself in other behavioral
aspects of the patient’s functioning.
Music Therapy and Identity Formation
With regard to identity formation, Erikson (1968) statesthat “we have
learned to ascribe a normative ‘identity crisis’ to the age of adolescence
and young adulthood” (p. 17); and further, that “[an identity crisis is] a
necessary turning point, a crucial moment, when development must
move one way or another, marshaling resources of growth, recovery,
and further differentiation” (p. 16).
Music Therapyfor the AdolescentPsychiatricInpatient
19
Music therapy’s greatest contribution to work with the adolescent
psychiatric inpatient population may be its ability to move the patient
into, and through, the identity crisis. This crisis is more intense in the
hospitalized patient because this adolescent often does not have the
inner resources to cope with this stage of development.
Ego strength is an essential ingredient in identity formation. The
ability to pass successfully through the identity crisis presupposes a
relatively strong ego. The adolescent inpatient’s lack of ego strength will
surely be confronted during hospitalization and can manifest itself in
several ways. For example, the patient may be unable to produce a
desired musical effect and, as a result, experience strong feelings of
musical incompetence. These feelings will not be derived from external
feedback or reality, but from an internal sense of dissatisfaction.
With the help of the music therapist, the adolescent inpatient’s use of
music can help to strengthen the adolescent’s ego. In the music therapy
session, patients can express likes and dislikes of the music, try out new
ways of playing, or being, with others, and put original ideas and
feelings into the words of an improvisation or a self-composed song.
Patients can receive feedback from peers and staff about their music, and
then accept, or modify, their music.
The music therapist focuses on facilitating the process of music­
making, and the patients are primarily concerned with the product of
their musical self-expression. Each experience of musical production
serves as a frame of self-reference and as a building block in the devel­
opment of the ego.
Symbol: Definitions
and Concepts
Symbol,n. Something that represents something else by asso­
ciation, resemblance, or convention, especially a material
object used to represent something invisible. (American
Heritage Dictionary of the English Language, 1969)
The Nonverbal Component
Jung (1971) defined a symbol asan entity for which no verbal concept
yet exists. It is the nonverbal, symbolic aspect of music that makes it a
nonthreatening andalluring mode through which tocommunicate. This
is especially useful when working with the hospitalized adolescent,
where it is helpful, and sometimes essential, to have an available
therapeutic tool that allows indirect, nonconfrontational, symbolic corn­
munication.
20
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At the beginning of therapy, the adolescent psychiatric inpatient may
trust and relate to the music more quickly and more deeply than to
another person. The fact that disturbed adolescents often function at a
preverbal level, that is, they have difficulty relating to others using
words, may account for this.
The Verbal Component
In music therapy the therapist’s words can serve an important func­
tion as an adjunct to the symbolic, nonverbal medium of music. Words
can increase the music’s effectiveness when they are used in a way that
structures, that is directs or highlights, the musical activities of the
session. Until the adolescent inpatients have acquired aminimal mastery
of the symbolic medium of the music, and can therefore relate in the
session on a symbolic level, they will need verbal directions (concrete
communication) to focus on specific elements of the music, elements
that are relevant to their particular stage in therapy.
For example, the adolescents may not yet intuit modulations,
phrasings, or endings. Instructions such as “fade out,” “get louder,”
“find a way to end, ” “listen to each other:’ and “find the beat” will be
needed from the therapist to support and increase the process of musical
competence and communication. In this way, the music therapist is
teaching them how to use the tool of music as a means of self-expression.
Therapeutic growth will take place when the adolescents are able to
make connections between their musical production and their internal
processes.
Projection and Transference
It is within the music of music therapy that the patient may take the
first step toward achieving relatedness. This begins with the utilization
of the mechanisms ofprojection and transference. The ambiguous nature
of all symbols calls forth an individual’s multiple projections and fan­
tasies. Symbols function as vehicles for transporting unconscious
thoughts and feelings into consciousness. The ability to create and to
utilize symbolism is a desirable assetin therapy, one that creates inroads
in an exploration of the self and one’s relationship to others.
When taking a psychoanalytic perspective, a major assump­
tion is that one’s music is a symbolic projection of uncon­
scious aspects of the self. That is, the musical elements, and
the processes through which they unfold and interact within
the improvisation . are symbolic representations of uncon-
Music Therapy for the AdolescentPsychiatric Inpatient
21
scious elements of the self and the processesthrough which
these elements unfold and interact within the personality.
(Bruscia, 1987,p. 450)
Through the symbolism of the music, patients can project. The projec­
tion will manifest itself by the manner in which the patient manipulates
specific musical elements (melody, rhythm, timbre, volume, etc.) in the
music-making. For example, a severely depressed or suicidal patient
may play barely audible music.
Eventually, and depending upon the severity and the permanence of
the psychiatric illness, adolescent psychiatric inpatients may transfer
their thoughts and feelings onto the music therapist. They can begin to
verbalize their feelings about the therapist and to relate their emotions
to their life experiences. Adolescents can benefit from this more mature
form of projection, transference, for it can help them relate to others
outside of the therapy session.
Ego Formation and Strength
A strong ego is a prerequisite for a healthy resolution of the identity
crisis, a normal adolescent occurrence. However, many adolescent in­
patients have immature egos. Their deficit of ego strength is manifested
by their inability to maintain school and familial responsibilities and is
often the primary reason for their hospitalization. Perhaps music is
attractive to these adolescents because, as a symbolic system, it is
directly related to ego formation.
The ability to symbolize, or fantasize, is a necessary step in the
growth of the ego (Klein, 1964).Adolescent psychiatric inpatients have
not sufficiently learned how to utilize symbolism during their childhood,
and this has hindered them from progressing into normal adolescence.
For these patients, making music can aid in the development of their
egos. When they manipulate themusical elements-tonal symbols-the
adolescents are provided with the necessary foundation on which to
build ego strength.
Music is an activity which is initiated by the ego. The ego
uses musical activity as a means of attaining various goals,
among them: gratification of given needs, defense against
various forces, or assistance in its synthesizing and integra­
tive functions. (Ruud, 1980,pp. 20-21)
The ability to master a symbolic mode of communication can also help
the adolescent inpatient to achieve improved relatedness and the ability
to cope with reality, for “upon [symbolism] is built up the subject’s
22
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relation to the outside world and reality in general” (Klein, 1964,p. 238).
Anna Freud (1966)believed that one of the ego’s main responsibilities
is to harness the instincts of the id. If this occurs a sufficient amount of
the time, an individual is assured relatively normal functioning. Con­
versely, when the ego is impaired, functioning suffers. The opportunity
to channel impulses is present in music-making. For example, ‘The
components of rhythm are usually considered as manifestations of
instinctual energy” (Bruscia, 1987, p. 450). Therefore, when a patient
“organizes” a particular rhythm, or melody, the adolescent is experienc­
ing a measure of self-control; the patient is gaining mastery over musical
impulses.
It is very rewarding to observe this development in adolescent inpa­
tients. The patient who must bang out a loud and elaborate drum roll­
at the beginning of, the end of, or in the more extreme case, during the
music therapy session-will, over a period of time, desire to play their
part at the musically appropriate time. This accomplishment can bring
great satisfaction and pleasure. Not surprisingly, this growth usually
coincides with a decrease in verbal and behavioral outbursts, and in an
increase in the ability to verbalize needs and to wait for gratification.
The association of affects and instinctual processes with word
representations is stated to be the first and most important
step in the direction of the mastery of the instinct which has
to be taken as the individual develops. (A. Freud, 1966,
p. 162)
For the patient whose verbal expression is inadequate because of
immature ego development, music therapy can be a good first step. The
ego development achieved in music therapy may eventually result in
improved verbal expression.
When working musically with adolescent psychiatric inpatients who
have a previous history of problematic behavior, the music therapist
must make a distinction between nonverbal expression and “acting
out.” Often, for these patients, the two are synonymous, and these
adolescents may begin to use the music in a destructive manner. They
come unable to formulate and to manipulate symbols, both verbal and
musical, and teaching them to differentiate between expression and
action is adifficult task. When they can make the distinction and express
their feelings, a working therapeutic alliance can begin; the therapist
and patient can begin to address the adolescent’s underlying problems,
instead of focusing on the constant disruptions of the work due to the
patient's “acting out" of symptoms.
Music Therapy for the AdolescentPsychiatric Inpatient
Structure: Definitions
23
and Concepts
Structure, n. Arrangement of parts, elements, or constituents;
modes of building, construction, or organization; [composi­
tion] of parts arranged together in some way; a pattern of
organization. (Random House Dictionary of the English Lan­
guage, 1987)
Structure in Musical Form
The structure of a musical composition, that is, how its musical
elements are arranged, has an effect upon the individual playing or
listening to the composition. The elements of a composition (melody,
rhythm, harmony, tonality, tempo, phrasing), its form (rondo, sonata,
binary), as well as its style (folk, “rap,” classical, rock ‘n’ roll) can be
helpful or detrimental to the adolescent psychiatric inpatient. The ele­
ments of a piece of music may support, soothe, or confront a patient’s
current functioning. The patient’s personality, current mood, stage in
therapy, and possible previous knowledge of the piece are also factors in
how the adolescent may relate to the composition. Therefore, it is
important to be aware of the music’s potential influence on a patient
before using it.
Music, itself, is a contained form of energy. When it is structured in
some way, by the original composer or by the therapist, it becomes
predictable. This predictability may account for why adolescents are
often amenable to working within the musical modality. As Barclay
(1987) states, “For individuals whose experiential contact with the world
is reduced by disability, the presentation or production of music provides
shape, form, figure and a sense of completion.. . .” (p. 230).
The adolescent may find comfort and reassurance in a system that is
clearly capableof successfully containing impulsive and forceful energy.
The musical structure can provide tremendous stability for the patient’s
unstable psychic structure, enabling therapeutic exploration and ex­
pression; the patient can relax and take risks in experimenting with new
ways of being in a context that offers predictability and familiarity. This
is especially true when the patient knows the musical composition, as is
often the casewith popular song music.
The structure within music can provide the adolescent with a safe
container for the self-expression so crucial to the resolution of the
identity crisis and the further development of personality. It can enable
the adolescent to channel internal experiences into external expression
in safe and growth-producing ways. In turn, the concrete aspect of
24
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music’s structure operates as astrong motivational force for thepatient’s
internal organization.
When a patient’s emotional expression can be channeled into a musi­
cally pleasing product, the adolescent may desire to do more therapeutic
work. As the need for feedback is gratified, the patient's ability to
tolerate structure may increase. For example, patients who start out
playing “against” the established beat of a structured improvisation
may change to a rigid adherence to the pulse. Patients who may have
previously complained about any musical structure may begin de­
manding structure with the same intensity with which they objected to
it in the past. The final step in the management of the instinctual
impulses manifests itself in the patients’ decreasing requests for a pre­
established external structure and in the display of an increasing flex­
ibility. For example, patients may suggest their own musical structures
or be willing to freely improvise.
The structure of the music plays an important role when working
with emotionally withdrawn and depressed patients. Their feelings are
inaccessible so they can neither verbally express nor behaviorally dis­
play them. Outside of the therapy session these patients are likely to be
neglected unless they are suicidal, asthey pose no management problem
to the staff. Music therapy can help activate these patients and thereby
integrate them into the total hospital environment.
For depressed adolescents it is often the music that opens the initial
inroad into the profound pain that has lain dormant for many years.
However, as the music taps into the adolescent’s psyche, painful feelings
may come into awareness, and the patient may be frightened and
overwhelmed. A patient at this point rarely wants to improvise but,
instead, desires familiar or predictable music. There is a need for struc­
ture that allows therapeutic work to begin.
Structure in Musical Activities
The concrete aspects of a structured musical activity are helpful to the
psychiatric adolescent population. For example, poor impulse control,
an area in which many patients need help, can be addressed with highly
structured musical activities. Learning to play and to stop, to take turns
playing instruments and specific musical parts, all strengthen impulse
control. The infinite combinations of musical elements offeran unlimited
realm of structured activities that can address specific problem areas.
The structure of a passive music activity can assist the therapist in
diagnosing a patient’s core issues and assessing where the patient is in
relation to exploring these issues. For example, during music-listening
Music Therapy for the AdolescentPsychiatricInpatient
25
patients will frequently make song choices that are congruent with their
problems. The quantity and the quality of their verbal explanations
about their choices is a good indicator of their stage in therapy.
Structure in the Session
The structure of the music therapy session is very important with an
adolescent psychiatric population. A maximum of freedom coupled
with a minimum of guidelines-a combination that allows for optimal
therapeutic growth--can be created for this population only when
concrete structure is maintained throughout the session. Giving too few
verbal directions, or making too few musical interventions, especially in
group work, can result in the anxiety level of the patients rising so high
that they may “act out,” or may result in frenetic enthusiasm and
massive musical production with no noticeable behavioral or emotional
change during or after the session.
On the other hand, overstructuring the session will similarly yield
unfruitful results. If the therapist projects an over-controlling quality or
requires rigid adherence to rules and directions, marked reluctance to
attend the music therapy session and resentment toward the therapist
may follow. Achieving a balance within the session between freedom
and limit setting, direction and nondirection, is essential. The patients’
reactions and behaviors will reflect the state of balance or imbalance.
Structure in the Relationship
Patients often come to music therapy in a defensive manner. Every­
thing about them-their manner of dress, bodily stance, and verbaliza­
tions-says, “Leave us alone.” They may come to the session unable to
relate, with feelings of anger and fear about the demands a relationship
implies. They may feel overwhelmed, perhaps assuming that they will
be unable to meet the expectations of this “required relationship.” They
may feel trapped and incompetent and will often project these feelings
of inadequacy onto the therapist or their peers during the first few
sessions.They may complain about how “bad” the music is and that “no
one can play.” A frequent comment, “None of you knows how to play, so
why are you trying?” Indicates their lack of optimism and confidence
regarding their own abilities and capacity to relate.
How the music therapist uses the music is a key factor in facilitating
initial trust. Utilizing music as a transitional object (Winnicott, 1971),
mirroring, reflecting, and “holding” are some techniques that will help
to establish the initial therapeutic alliance. It is through this musical
alliance that the patient may begin to learn how to relate, thereby
26
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satisfying the tremendous need that occurs during adolescence-the
desire to gain a sense-of-self in relation to others (Sullivan, 1965). To
sustain the therapeutic relationship, the therapist’s role is to address the
patient's needs, taking care not to require or expect reciprocity of per­
sonal needs. As patients feel the safety provided by a unilateral structure,
they can relax and begin to work.
The music therapist must keep in mind that these patients have
fragile egos. It is the structure of the music and of the therapeutic
relationship that becomes the patient’s “surrogate” ego until their own
ego strength permits a measure of autonomous functioning. In this way,
initial dependence, or temporary regression, may be necessary before
ego growth and accompanying independence can occur. At this stage of
therapy, the adolescent may look to the music therapist for complete
direction, or may desire complete approval in autonomous decision­
making. The patient may absorb the therapist’s opinions and habits and
may literally attempt to cling to the therapist throughout an entire group
session. Great care must be taken at this stage not to misdirect the
patients improved relatedness. If the patient’s clinging is encouraged,
the adolescent may move from a healthy reliance on the therapist to a
state of total dependence and eventual stagnation. A balance must be
maintained between necessary dependence (that is, one that promotes
growth) and unhealthy regression.
The adolescent psychiatric inpatient needs both the structure of the
therapeutic relationship and of the music itself to explore the locked­
away feelings that are causing tremendous emotional pain and the dis­
ruption of functioning. Itis the patient’s strengtheningego, the therapist’s
role, and the music that combine within the therapeutic relationship to
form a structure that theadolescent patient can lean upon to tolerate and
work through the pain in order to arrive at a state of health.
Symbol and Structure: A Framework for Treatment
Improvisation-The
Case of V
Structured and free instrumental improvisations are frequently re­
quested musical activities in adolescent psychiatric music therapy
groups. Improvisation provides external structure and the potential for
symbolic expression and mastery. There are numerous clinical examples
of adolescent inpatients who utilize structured improvisations to im­
prove impulse control, frustration tolerance, ego strength, and self­
esteem.
Music Therapy for the AdolescentPsychiatricInpatient
27
One patient, V, an l&year-old, was admitted in a state of agitated
depression after recovering from a suicide attempt. His problems began
at age 13, after he experienced the unexpected death of his mother. His
behavioral presentation was aggressive and oppositional. He was full
of unexpressed grief with an overlay of normal adolescent energy. His
ego was unable to successfully mediate between societal reality and his
inner feelings and urges. His self-esteem was poor. When verbally
confronted with his inappropriate and destructive behavior, he would
first protest, saying, “It’s not my fault,” and accuse everyone but
himself of misconduct. Then his posture would change and he would
say, "F--k it all. I hate myself!”
He loved music, particularly drumming. Although uncontrollable
much of the time on the unit and unable to “settle down” and talk in
psychotherapy, he would come to music therapy willing to be controlled,
that is, to play within an imposed structure at least some of the time. He
was able to play “on the beat” during improvisations and to act as a
conductor for his peers to produce a desired musical effect. He was
willing to accept my instructions, and over time often helped me to
explain directions to the group, or, as he described it, “to get their a---s
in gear.”
In the beginning of my work with him, V repeatedly played crescendi
and was frequently unable to produce decrescendior to play at a less than
fortissimo level. This caused his music to become disorganized and his
behavior to become uncontrollabe. On several occasions when this
occurred, I asked him to leave the group and he was very unhappy. His
initial dissatisfaction usually brought about a slight increase in self­
control and ego strength, which was manifested in the next group
session by his ability to decrease volume. He began to enjoy some
autonomy, desiring not just to follow the beat, but to set it. He was
complemented by his peers and by the staff. My reports to his primary
therapist seemed to result in improved psychotherapy sessions. (With a
patient who was as difficult to manage as V was, it was easy to assume
that improvement was impossible until it occurred. This was a case in
which music therapy provided evidence of the patient’s potential.)
When I told V I was leaving my job at the hospital, he thanked me for
the opportunity to make music. “Yeah,” he said, “you were really cool.
You always let us play on our own beats.” He had realized the impor­
tance of improvisational music in his treatment, but he had not fully
realized that he was in dire need of structure in order to be able to find
his own beat (sense of self) and to express it in a constructive way.
28
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Songwriting
and the Cases of T, N, R, and L
Songwriting is a very popular musical activity with the adolescent
psychiatric inpatient. The inherent symbolism in songs, their lyrics, and
their musical elements can provide the adolescent with a medium for
self-expression. Songs can function as transitional objects Winnicott,
1971) thereby assisting the adolescent in coping with anxiety and
working through important personal issues. Songs can make powerful
statements that neither words nor music, alone, can. A song is a vehicle
that carries in it a person’s elements-me’s rhythms, melodies, feelings,
thoughts, the deepest parts of the soul-and expresses these elements in
a creatively encapsulated form that is integrated and unique.
Song composition gives the adolescent the opportunity to make a
transition between the expression of musical and verbal symbols; hence,
it is an activity that can assist in ego development. The combination of
words and music can be an effective agent of change. (Songwriting
should be utilized after theinitial stage of therapy because it presupposes
some level of symbolic mastery and of creative expression.)
After six months of hospitalization, T, a 16-year-old female honor
student admitted after a suicidal gesture with a diagnosis of “borderline
personality disorder: wrote the lyrics of “Reflections” (see page 29). I
sat with her at the piano and composed the music, and when the song
was finished, she burst into tears. “I can’t believe it,” she said. “I can’t
believe how good it sounds.” The impact of my previous verbal support
of her poetry was minor in comparison with the effect co-creating this
composition had on her self-esteem.
Adolescent psychiatric inpatients are often able to express intensely
painful emotions in originally composed songs. Loss is a common
theme, yet one that is not frequently verbalized in psychotherapy until it
is symbolically expressed.
For example, the lyrics of the verses in “Leaving” (seepage 30) were
written by N, a X-year-old female admitted for “severe depression,”
with an official diagnosis of “dysthymia.” N had been abandoned as a
child by her mother. After she wrote this song, she came to me and said,
“You know, I’m upset that you’re leaving, but I think that this song is
also about when my mother left me.” I agreed. She then took the sheet
music to her verbal psychotherapist and began exploring her issue of
abandonment. To continue working on this issue, she needed a tangible
form to keep it present in her awareness. “I sing the song every day,” she
informed me.
Music Therapy
for the Adolescent Psychiatric
Inpatient
29
Reflections
Words by T
Gm
F
Music by Andrea Frisch
30
Frisch
Leaving1
Words by N
D
Music by Andrea Frisch
A
just you and me­
12
Be- ing to- ge- ther hap- py and free
G
liv-ing
the way­
With- out­
we
you,
2) Oh how I wish, I wish it was true, I only want to be with you.
But you left me, left me alone, and I’ve grown up, an my own.
3) One day I’ll wake up and see how you hut me so deeply
But it’s so hard, I’ve tried to go on, without you, I’ll really try to go on.
4) Since you went away, life’s carried me away, now I’m grown up and on my own.
And so I thinkit’s time to let go. Still you’re my one and only (mother) and Ilove you so.
‘Author’s note. The words of the chorus were
written
by the members of the
songwriting music therapy group, after learning of my decision to resign from
my position at the hospital.
Music Therapy for the Adolescent PsychiatricInpatient
31
“Crying” has a similar theme. R, a 14-year-old female, was hospital­
ized because of uncontrollable behavior at home and at school, and for
polydrug and alcohol abuse. She was diagnosed as being a “schizoid
personality.” She had been abandoned by her mother as a young child
and later in life by her father. R did not want to discuss to whom this
song applied, and although the “abandoner” seemed more likely to be a
lover than a parent, it was most important that she could express her
feelingsof abandonment, Theexpression and explorationof her feelings
about her parents came with the passage of time.
Crying
Words by R
(Chorus:)
33 let
it
be
once
a
gain
just you
Note: Usetheintroduction,an octave higher, for the ending.
Music by Andrea Frisch
F
and
me.
32
Frisch
Another potential application of songwriting is to help adolescents
cope with and adjust to the loss of an inpatient nearing discharge. In “L’s
Goodbye Song” both the patient and the patient’s peers in the
songwriting music therapy group were encouraged to participate in the
composition. L, a female admitted at age 12 for promiscuity, non­
attendance at school, and oppositional behavior at home, wasdiagnosed
as having a “borderline personality disorder,” and had become a much­
loved member of the hospital family. The “weeping-tone” of the music
portrayed the mood of the group and inspired the words. Although
unable to directly tell L how they felt about saying goodbye, group
members frequently could be heard singing the song during their free
time until the day L left, and for several days afterward. This song
functioned as a transitional object (Winnicott, 1971) and helped these
patients cope constructively with a loss.
L’s Goodbye Song
Words by C, J, C, K, L
Music by Andrea Frisch
Music Therapy for the AdolescentPsychiatric Inpatient
33
Summary
Music therapy is a form of therapy well-suited for utilization with the
adolescent psychiatric inpatient population. It offers nondirective and
nonconfrontational control, which is very important in adolescent de­
velopment. The music respects the adolescents’ autonomy and offers
repeated opportunities for the self-expression so critical in finding
resolution of the identity crisis.
In their quest for health, adolescent psychiatric inpatients often make
unhealthy demands, such as no environmental structure, no boundaries
with peers, and no accountability for their behavior. Music therapy,
through its symbolic and structural components, provides these patients
with the potential to receive what they need: a sense of self, a healthy
connection with others, and joy in the responsibility of creating. They
are helped to progress through the identity crisis with an ego strong
enough to utilize their new-found adolescent energy in a beneficial way.
The types and frequency of the symbolism that patients employ (loud
or soft, rhythmic or arhythmic, consonant or dissonant musical ele­
ments), as well as the structures that attract them (particular musical
styles, precomposed compositions, structured or free improvisations)
indicate where they are in their identity formation and in their self­
development. The interactional qualities of their music-making indicate
their level of relatedness. Their musical flexibility is a good measure of
their relative ego strength. Their use of specific musical symbols and
structures portrays their unconscious, subconscious, and conscious
feelings and ideas.
The symbolic and structural elements within the music of music
therapy provide a safe medium for introspection. These elements can
facilitate the mastery of impulses and the development of ego strength,
enhance the therapeutic relationship, and provide for healthy related­
ness and communication. The structures of music therapy encompass,
protect, and enable the adolescent psychiatric inpatient in the therapeu­
tic work, and the symbols are the tools for the adolescent to use in the
exploration and fortification of the self.
34
Frisch
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Andrea Frisch, MA, CMT, is the coordinator of music therapy programs at
the Westchester Conservatory of Music, White Plains, New York, and a staff
music therapist at the Creative Arts Therapies Center of Bronx Psychiatric
Center, New York City She is the Editor-in-Chief
of the AAMT newsletter,
‘Tuning In.”
It is the author’s hope to generate dialog about this population. Feedback is
encouraged.
This article is dedicated to the adolescent psychiatric inpatients who shared their stories
and their souls with me, and who taught me about the pain and the beauty in life.