What does it mean to do “deep” work in end-of-life care? Does deep just mean that we feel deeply? Does it mean that we feel like we deeply understand the patient or family member that we are working with? I’m considering this post to be a sort of primer to depth work in end-of-life care, as I conceive of it, and a place to introduce some concepts that all the editors will probably be writing about at some point or another.
In psychology, “depth” has a very particular meaning. Depth psychology typically encompasses all kinds of analytic work, including psychoanalysis (based on the work of Sigmund Freud, and the followers who branched out and extended his work, including people like Winnicott, Klein, Bion, Kohut), and Jungian analysis (based on the work of Carl Jung and his followers). There are a lot of differences between these two psychologies and among the various followers of each, but what they have in common is an acknowledgment of the presence of an unconscious mind, in both patient and therapist. Many of our leaders in music therapy have wisely recognized that these tenets have strong applicability to our work as well.
What does it mean to say that the human mind has an unconscious? This is a bigger question than this post can fully explore, but for the purposes of this discussion let’s say that our unconscious mind contains all the content (thoughts, feelings, memories, pieces of personality) that we can’t and/or don’t want to know about. Some of it is that which has been most useful to forget about, repress, or hide away, for whatever reason. Despite its being pushed out of conscious awareness, though, this content will continue to impact our decision-making, the way we connect with others, and how we react to various situations. It comes forward in our dreams. It impacts how we choose our romantic partners and friends, how we choose our career or clinical focus, how we do or don’t experience things like anxiety and depression, and much more.
So of course our unconscious mind becomes very important when we’re doing therapy, especially music therapy, where we are using an art form that connects so deeply to human emotion, relationship, and struggle. To distill this down to its most basic application: when you are in the room with a patient and/or family, there is always more going on — psychologically, interpersonally, intrapersonally — than either of you are aware of. Our presence in sessions, including what we say and do, how long we stay, the qualities of the music we use, the relationship we develop with the patient, and the feelings that we become aware of, are all influenced by our unconscious minds. The same is true of our patients’ behavior, music, words, and affects.
The place where the patient’s conscious and unconscious material and the therapist’s conscious and unconscious material all mingle together, independent of our conscious intentions for it, is known as the transferential field. Talking about the transferential field is another way of talking about the concepts of transference and countertransference and how they interact and meld together in a session. And this might be a good time to define these terms.
Transference refers to the patient’s reactions to the therapist that are based on the patient’s internal content, often (but not always) unconscious. So if the patient has a long-standing belief that musicians are inherently irresponsible people, she might have a hard time believing that you will return at the time you two arranged next week. Say another patient was criticized by his father constantly and he was also frequently put in the position of helping his mother manage her emotions. If you’re a male therapist, he might be very reluctant to take risks in front of you (such as attempting improvisation on a new instrument) because of the unconscious anticipation of criticism. If you’re a female therapist he might constantly be trying to take care of you — agreeing to sessions at times when he isn’t up to it, maybe, or avoiding sharing his own strong negative emotions about his impending death — to assure that you will never get upset. This hypothetical patient is most likely not aware of the dynamics he is acting out (that’s why they are unconscious) but that doesn’t make them any less powerful, or the therapist’s conscientious reaction to them any less important.
Countertransference is essentially the same thing as transference; Freud came up with a different term just to specify that this transference was coming from the therapist back to the patient. Countertransference can be your own unconscious material, born out of genetic qualities and early life experiences: for instance, a therapist who has been taught in his early life that mistakes have dire consequences might expect, unconsciously, that his patients will judge him harshly if he stumbles in his finger-picking, and make clinical decisions based on that countertransference rather than the reality of the clinical situation. Your reactions to the patient’s transference and other material in the transferential field are also considered part of your countertransference. Returning to the example above with the patient who hides his negative emotions from a female therapist, we can imagine the therapist’s various reactions to the patient based on her unconscious content, from not even noticing his caregiving behaviors to becoming angry or sad when she does realize them.
Experts used to believe that countertransference was a sign of a problem in the therapy or in the therapist, but that’s not the case anymore. We know that our psyches will mix with our patients’ psyches in ways that are unpredictable. When you imagine all of the unconscious material flying back and forth between you and your patients in session (and how much more is there when you add the music and any family members who might be joining in), that’s not hard to imagine. Watching for your countertransference and using it to understand what might be happening in the transferential field can be an extremely interesting, exciting, and helpful process. It enriches your work, helps you provide the best therapy to the patient, and helps you grow as a therapist for your ongoing work with every patient.
Before I end this post, I want to emphasize that the unconscious mind is not more important than the conscious mind. Both are important. But the unconscious is the part that we want to forget, disregard, or downplay, and that is often what leads to therapist pitfalls like burnout, ethical missteps, or lousy therapy. So, as we use our conscious mind to do all the things that we already know it can do — like getting us our great end-of-life music therapy job, helping us manage our schedules, retain and utilize the skills and information we picked up in our training, and reach out to make appropriate connections to patients, families, and co-workers — we must also focus it toward trying to develop a relationship with the unconscious, the unknown parts of ourselves. And of course, the best way to learn to foster a relationship with your inner self and to understand how it operates in sessions with patients is with psychotherapy (music psychotherapy if possible) and supervision.