Lately I’ve been thinking a lot about fantasy and its role in the therapeutic process. Fantasy, among its other benefits as a force in therapy, is uniquely situated to challenge entrenched cognitive structures, bound emotional energy, and divisive power structures. Comprised of fundamental human features (e.g., imagination, creativity, etc.) essential to personal foundations of wellness, fantasy is a necessary ingredient in a person-centered practice. Fantasy plays a significant component in my current work, exploring such questions as “Who would I be without this illness?” and “How can I be a health, integrated person in the future even if this illness persists?” in order to foster an imaginative process that creates possibilities and activates potentialities.
There is always a shadow, however, so I have come to wonder how fantasy may also function as a barrier, one that locks the individual into a (seemingly) endless cycle of false expectations and beliefs that robs him or her of experiencing what is real in the here-and-now.
I clearly (and fondly) remember my first patient with Schizotypal Personality Disorder, a diagnosis frequently marked by an unhealthy affinity and attachment to fantasy. This patient would involve half the unit in an incredibly elaborate Dungeons and Dragons set-up. In hindsight, it was really a remarkable feat of community building; even though his chronically mentally ill peers were not able to fully participate, they joined with him, in his fantasy, in an act of collaborative play.
Despite those positive contributions to both his own wellbeing and that of the community’s, his reliance on these fantastical elements disrupted his ability to interpersonally relate in a more grounded here-and-now manner. He was challenged to confront a powerful element of fantasy: idealization, or the false representation of another person or situation by means of distorting or manufacturing their appealing attributes. He had to release the idealized image he held of what others were supposed to be and accept them for what they were; similarly, he had to free himself from what he perceived others expected of him and who he actually was. Collaboratively, we embarked on a process of balancing fantasy with reality by moving through this parallel process of idealization.
Over time we incorporated community music therapy elements into his care that more firmly rooted him in the here-and-now without blocking access to those fantasies that provided him support. This culminated in the performance of a song for the unit that lead to an interactive discussion with his peers about the meaning of both the song and the performance. It challenged him to offer an authentic version of himself and tolerate that vulnerability while accepting the different viewpoints and perspectives of others. In detaching from the idealizations of others and the pressures of the idealizations he felt projected onto him, he found incorporated his fantasy (through the creative process) into reality-oriented interpersonal engagements.
Despite the depth of that work, I never considered my own idealization of patients, or their idealization of me. I never actively worked on achieving that degree of balance for myself. From my end, idealization refers to the images I have nurtured of a patient’s relationship with music, the nature of their life to that point, the process of their dying and death, and their dynamics with loved ones. Coming from my patients, I experienced idealization as a powerful transference wherein I was expected to assume a certain role, or an expectation that I could manufacture a music experience that would elicit change with limited effort on their end.
Clinical manifestations of idealization
I was not aware of the power of this idealization until I began considering my stakeholdership and ownership of certain musical selections. There are certain songs, and even specific means of musicking, that have come to take on a profound relevance in relation to another person or event. That music subsequently ceased to be “mine” and became “theirs”. Reflecting on this further, this occurred via three different processes: Interpersonal tether, One-sided gifts, and Song dedication.
Interpersonal tether. There are some patients whose lived experiences are nigh impossible to discern, be it the individual with cancer who is fully alert but nonverbal due to treatment, or a patient with dementia who is cognitively disorganized but emotionally attuned. In much the same way a tracking device will be used to follow somebody elusive, I believe I assigned certain songs to these patients to create an interpersonal tether in the hopes that this connection would offer me greater understanding of their experience. Sometimes this would be literal (they would be the only person I would engage in this particular song) or figurative (I would engage others in the song but struggle to experience it from outside this other patient’s perspective).
My idealization was that I could be privy to the full depth of that lived experience, and their idealization was that they could make me embody it. Certainly music can create a bridge between two people, but each person is responsible for their own experience and my attempts to assume those burdens for them, and their attempts to pass those burdens onto me, created a false expectation. The false expectation was that I could be something I could not, and applied pressure to the patient to share a part of him/herself they were not ready, able to, or desiring to share.
One-sided gift. There are other patients with whom it is a struggle to reach due to guardedness or, in more rare cases, a pathology that made therapeutic joining much more difficult. In those instances, losing ownership over a song has been almost a plea, a gift that I would extend so as to create a bridge between me and a difficult patient, as opposed to collaboratively building that bridge. In wielding music like such a blunt tool I was attempting to make the music a catalyst for a reaction that was not going to happen.
Idealization here manifested as a false hope for what was possible or even necessary. It became an over-extension of my role as therapist (i.e., a personal investment) and an over-extension of my self (i.e., gifting resources I could not sacrifice without risking my own wellness). As with the interpersonal tether, it also applied a parallel pressure to myself and to my patient: pressure for me to extract a deeper knowledge that may not have been mine to know, and pressure for my patient to provide access to it even if they were unable to or not willing. Truly, whose needs were being met in that moment?
Song dedication. And then there is the song dedication, which I have highly romanticized. While a sign of respect to my patients, a subtle tip of the hat that they had made a profound impact on my life and I wished to pay the proper deference, those dedications also became a crutch. By dedicating the song to one individual, the emotions housed in that song could stay safely contained, and the thoughts that formed around it would concretize in an accessible manner that felt safe. This tucking away of my emotional content into a song deprived myself of an emotional experience that could have better informed me about what was occurring and where I was in relation to it. By allowing my thoughts to become concrete, i.e. static and unchanging, they were never allowed to evolve or mature, remaining developmentally arrested in a musical purgatory. In truth, I believe in many of these instances that I knew the deeper truth but was afraid of the music exposing it to me. My idealization here was that I could indefinitely ignore that deeper truth.
A common theme throughout all three of these processes is avoidance. It was an avoidance of accepting that which I knew on an unconscious level but was not ready to accept consciously, be it the reality that a patient was not able to sustain meaningful interpersonal connectivity or that a process of deep exploration into the real issues would no longer be possible. Avoidance creates a space between therapist and patient, and here that space was filled with fantasies that, instead of promoting a deeper “knowing” that fantasy has the potential to create access to, waylaid me from a more authentic and effective therapeutic process.
Personal roots and influences
Another dynamic emerged specific to the last process of Song dedication. By not engaging with music in a manner that exercised my right for creative expression, I robbed myself of my most valuable medium for exploration and self-knowing. It’s an extension of the aftermath of childhood bullying that I still actively confront. When you’re bullied your vision of the world becomes distorted, and the new idealizations that replace these disrupted ones become goals that you work that much harder to attain. At the same time, bullying teaches you that you have no rights beyond that which are granted to you. Self-esteem is ruptured, autonomy is stripped, and self-awareness is infiltrated by gnawing self-doubt and hypervigilance. These traits have developed over time into a willingness to cede control over a powerful object or experience in pursuit of the unattainable because (I would tell myself) what right did I have to something another laid claim over? As such, it has been a continual process of owning my stakeholdership in creativity, and negotiating the boundaries of my stake with my patients’ stakes.
Having recently reclaimed lost power in other areas of my life, I have felt better prepared to move through these idealizations, and the enmeshed ways of relating they propagated. Individuating from these enmeshments has been challenging work, but coming out the other side with greater perspective on what is real and substantive and what is merely imaginative and alluring has been illuminating.
To be clear, I am not consigning fantasy and idealization as a destructive force, but rather framing my interactions with fantasy and idealization as unhealthy. As such, I have been committed to reworking those interactions by regaining my power in the creative domain. No longer will I cede my connection to these works because another has laid claim to them, either passively or actively, or because I have given up my own claim. And, by extension, no longer will I deprive myself and future patients of access to the wisdom and energy housed in these songs by subjecting musicking to empty, fantastical elements at the expense of what is real and substantive (which does not preclude fantasy, but rather a certain use of fantasy).
I want my musicking with patients to be informed by principals of reciprocity, shared experience, and collaborative engagement. I wish to embrace and explore the fantasy and its accompanying idealizations, but without losing anchor in the other available truths embedded in the here-and-now reality. I am in search of that balance and can see it taking shape ahead of me.