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Music Therapy: Death and Grief

br2007_082Sekeles, Chava (2007). Music Therapy: Death and Grief. Gilsum, NH: Barcelona Publishers.

The 150 pages of this book are divided into 10 Chapters, with a Foreword by the Director of an Israeli medical centre and an Introduction by the author. Each chapter ends with notes, and (where appropriate) a discography; extensive references are used in the text and listed at the end of the book.

This publication tells us much of the author’s own empathic approach to her clients and her therapeutic skills in the use of music to meet their needs. In preparing to review it, I have read the book in detail many times – but each reading has brought new thoughts. In today’s world, in which evidence-based medicine has become the sine qua non of all treatment, it is reassuring to see that intuition and (inspired!) guess-work are still seen as having value in our work. (See discussion on p.40)

Contents

The Introduction lists and summarises the contents of the various chapters and explains some of the terminology that is used. (The chapters describing case studies are interspersed with others which discuss the music that has been used in therapy.)

Surprisingly, the book has no index, only a Table of Contents. (Perhaps, in a second edition, this may be rectified?) The references are clearly set out, each chapter ends with detailed notes, and the book is comparatively short, so the lack of indexing is perhaps of only minor importance.

The author, Chava Sekeles, adopts a broad approach – using graphic arts, painting and other modalities; (some of the paintings created by clients are reproduced in colour). She also mentions the personal responses of the therapist to death, but deals with these at greater length at the end of the book.

The case histories she describes are not merely of academic interest but inspire us with new ideas, different approaches. The interventions are all related in some way to death and dying, and the associated psychological and emotional challenges. Only one described therapy which addresses a child’s fear of death, all the other studies focus on bereavement as such. Yet each of those case studies differs markedly from the others, in the needs which were recognised, and the interventions used to meet those needs.

The book is not a hard-line research text, in which similar or identical needs are addressed using the same approaches, and the results then analysed statistically. But it is highly realistic, and shows us that the author brings to her work a deep sensitivity to, and understanding of each individual’s needs. She also has insight into both helpful and harmful family relationships, and creates music therapy interventions through which relationships, in most instances, may be healed, improved.

Although no extended family therapy is described, the author recognises and empathises with the needs of family members, even when working with only one or two individuals. (She comments, for example (p.15) on the benefit of having a parent present during therapy for a child, in order to reduce the likelihood of the child developing a dependency upon the therapist.) The losses presented in the case studies, and the ages of individuals, are varied; all the studies are valuable, but it would have been helpful to learn about interventions with extended family groups.

Chapters 1, 6 and 7 describes work with young children, the first of these was traumatised by the violent death of her mother and brother and her own injury in a “human bomb” incident. Israeli songs were crucial in the child’s therapy, which included a closure visit to the cemetery with her supportive father; the author emphasises here the importance of sharing in that visit as therapist and not as a mother figure.

The third case history about work with children is also linked with terrorism, and describes a boy with multiple handicaps who was terrified by his long daily bus journey to a special school, and the problems arising from his parent’s requirement that he remain brave in this ordeal.

The second case study, however, is very different in that the boy’s difficulty in coping with the death of his beloved grandfather was, the therapist found, a consequence of his parents’ behaviour and attitudes.

In chapter 7, the stages of grief are mentioned. Although these emotional states are as valid today as when presented by Elizabeth Kubler Ross in 1969, we now know that they may not necessarily occur in the sequence originally set out. (Bright, 1985, pp. 49-50) We also find that, because of circumstances, one may revert to an earlier stage – as when someone with leukaemia goes into remission and his/her doubts recur (even if only momentarily) as to the diagnosis. And, even when close to death, and appearing to accept this peacefully, one may inwardly revert to anger and bargaining!

In Chapter 2, there is extensive discussion of Israeli music, its imagery, symbolism and therapeutic use, in which the author touches on some interesting questions.

In this chapter (p.28) there is a reference to an “enclosed disc” of Israeli music but I learned later that (due to Copyright problems) this was not available at the time of publication. It is a pity that readers are not warned of this by an Erratum slip pasted into the book. (I spent an anxious time wondering whether I had lost it!)

As in Chapter 2, the author focuses in Chapter 5 on therapeutic uses of music as such, and here she uses the term “Art music” in her discussion of different genres of compositions. (The term “classical” is often used to differentiate ‘”serious” music from ephemeral “pop” music, but “art music” refers to serious music which sets a scene, portrays an emotion.)

Music therapy with adult clients is described in Chapters 3, 4, 8 and 9.

Chapter 3 gives an account of music therapy (which included the use of poetry) with a man facing death from cancer.

Chapter 4 .describes two stages of complex therapy with a mother and (separately) with her son, grieving over the war-related death of the older son – killed by what is ironically called ‘friendly fire’, so that the aura of heroism about his death was lacking. Help was also needed later in order to cope with the death of her husband.

Chapter 8 focuses on eclectic work with a bereaved young man, whose borderline personality disorder affected the processes of dealing with the death of his mother, who had died after a long struggle with cancer. Although therapy was not completed, we read of the young man’s increasing insight as a result of therapy.

Chapter 9 differs from the rest of the book in that it takes place within a psychiatric institution, describing work with a forensic patient in his late 20s who had been diagnosed as having schizoaffective disorder, and who had killed his mother. He had been an active folk musician and enjoyed playing the instruments in the hospital’s music room, gradually working toward greater insight.

Chapter 10, which focuses on the grief of the therapist over the death of clients, is moving and valuable to all readers. It can be difficult to deal with one’s own emotional trauma, yet there are potential risks to our own emotional health if we “sweep it under the mat” – leave it unresolved.

Termination of therapy can be complex: ideally (p. 58), it is by mutual consent, which improves the prospect for independent decision-making by the client. But therapy may be left unfinished for various reasons (as with suicide, as mentioned above), but also if the decision is made (as with Bobby’s parents (chapter 6) because of difficulties in coping with change, and this too can be painful for the therapist.

When the termination is by suicide, the difficulties are of major proportions. Although Edwin (chapter 8) killed himself, this occurred several years after his 5 years of music therapy had ended, and there is no specific discussion about the impact upon the therapist of suicide by a current client.

General Comments

In this publication we read of the constant threats to life and safety which are engendered by the conflict between Israel and its Arab neighbours, but the book is not a political manifesto – we are reminded that people on both sides of this conflict are suffering. (p. 20) .Discussing the varied cultural backgrounds of its citizens, Sekeles uses the image (p.130) of Israel as the melting pot because it consists of people from all over the world, speaking different languages, and having different cultural traditions, etc.

Israeli songs, semi-folk songs and other national items are mentioned throughout the book, and it is clear that Israeli people place far greater importance – politically, religiously, emotionally – upon their national music than is commonly seen in countries such as UK, USA, Canada and Australia. Nevertheless, these discussions have especial implications for therapists in countries to which Jewish people came for refuge, and for all of us who work with migrants and refugees from other countries where the folk tradition is important.

We know that songs originating in someone’s country of origin are not necessarily appropriate in meeting the needs of that individual: any one item may have particular associations – happy, tragic – or even humorous. But these associations help a client to externalise hidden feelings, and the value of this comes through strongly in this book.

Eclectic Interactions

Throughout the book, the author demonstrates her awareness that music can externalise complex matters which require resolution by various means, such as graphic art, poetry, verbal discussion and psychotherapeutic techniques linked with music, rather than through music alone.

“Process” and “Product”

Some readers may question the comments on these concepts (p.127): the end product is indeed important – the song which a dying individual gives to someone who has been significant in his or her life, or the satisfaction of someone with a severe mental illness when he looks at a song or a poem he has written about this experience. But, in the journey towards healing (for which the therapist is the guide) the process of doing something is equally important, giving opportunities for growth in the on-going creative acts, whether working on a collage, improvising or anything else.

Perhaps we can compromise by agreeing that creativity is important, however we use the word!

References

Bright, R. (1985). Grieving: A handbook for those who care. St Louis, MMB.

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