Countertransference, General

There’s No Flirting in Hospice

Actually, yes, there is.  Let’s talk, for a bit, about the presence of sexuality between us, the end-of-life music therapists, and the people to whom we provide care — meaning our patients and whoever else is included when we come for our sessions.  Our music therapy literature barely acknowledges that sexuality exists — almost as if music therapists don’t have sex, or sexual thoughts, and neither do our patients.  But we know otherwise.

I have often wondered why we don’t talk more about sexuality in end-of-life work.  We arrive to our sessions during which our patients are often in bed, and in various states of undress.  We make music together, engaging our bodies, breathing deeply (heavily?) together.  The connection between sex and music is nothing new; I think of the Sirens of Greek mythology who lured sailors to their deaths with their beauty and their seductive song.  Sex is an implicit or explicit inspiration for much of the existing music that we can draw from to connect with our patients in session.  It seems a natural place to put our attention.

One of my first and most memorable hospice cases consisted of ten weeks of weekly visits with Matthew, a too-young man with ALS.  He was already losing his ability to speak when we met, but he told me the story of his history and internal world, and his struggles with his feelings of love and sexual attraction for me, with ten powerful song requests.  A few years later, I worked with Ann, who made frequent comments comparing my physical appearance to what hers had been before she became ill, and tried diligently to set me up with her son.  When I worked in the hospital, I saw Mr. C, who would attempt to kiss my hand at the end of every session, and change the subject to his undying love for me whenever we got close to discussing any of his emotional experiences.  Mr. B, another patient, was very old and frail, and he had a funny way of calling me “little girl” that brought up confusing feelings in me for weeks, until I realized that he was flirting with me and I was enjoying it.  Then there’s John, who would string elaborate fantasies for me of the life he wished that he and I had had together, had he been forty years younger, and punctuate them with crass, sexually aggressive statements that took me by surprise and left me feeling somehow violated.

Sexual content can arise for so many reasons, and in so many ways, in end-of-life music therapy sessions.  Sometimes it’s incredibly meaningful.  I still remember the emotional weight of working with Matthew, and seeing how our relationship was the idealized love affair that he wished he could have had before he died.  How important it was for Mr. B to have a final fling, and how fun it was for both of us to feel playful and intimately connected.  (It took some supervision for me to relax into that latter bit, but when I was able to do so it felt like something lovely and immensely valuable.)  Sex is a normal and healthy part of life, and our ability to be present to our patients’ erotic yearnings, and our own authentic reactions to those yearnings, can give us a lot of clinical mileage.  With these two men, both frail and in some senses emasculated, my openness to feeling their presence as a symbolic lover was paramount to the work.  The music provided an aesthetic container for our emotional experiences together, lending us context and structure and someone else’s words to communicate heart-felt sentiments too precious and vulnerable to voice outright.

On the other hand, in our culture sexuality represents other things besides love, appreciation, and connection.  Sexuality is also connected to shame, rejection, avoidance, control, violence. Mr. C’s injection of sexual desire into our sessions had a different feeling to it than what happened with Matthew and Mr. B.  His stated desire had a feeling of inauthenticity at times, and his flattery was fairly transparent as an avoidance tactic.  If he could distract me by knocking me off-balance with an overwhelming compliment, he wouldn’t have to feel anything about his very serious medical prognosis.  I had to try to walk a careful line, taking in the part of him that wanted to be received in his admiration for me, but also not allowing myself to be fully distracted from the work.

For Ann, my youth (I was 26 when I was seeing her) was a reminder of something she had once been.  I believe her frequent mentions of my beauty, especially in connection with the hard sell to consider her son as a potential (sex) partner, belied very complex feelings about her physical decline and what it meant to her.  Her music choices all held themes of youth and courtship (“Tammy’s in Love” was her favorite).  Her admiration of me was in some ways laced with resentment — her anger and fear about her prognosis projected outward.  I think there may have been a fantasy that she could avoid any potential rejection from others by taking control of me and her son, creating our courtship and successful sexual union.  There were complex dynamics for me to hold and try to explore with her around this issue.

The therapeutic process with John was the most complicated of all those I’ve mentioned, because he really succeeded at overwhelming and frightening me.  Eventually, at the suggestion of a supervisor who was also overwhelmed when I told her what he was saying to me, I simply cut him off, and told him I could only make music with him and not talk with him about his fantasies any more.  It immediately shut down and derailed the work that had been happening between us, and the next week he entered the ICU and remained intubated and comatose until he died.  If I was working with him today, I would take a different approach to the sexual and aggressive content that he had been introducing.  But I mention him because I think it’s important to acknowledge that sexuality sometimes scares us.  Scaring me may have been part of how he let me know how terrified he was himself, but at the time I didn’t have enough grounding in what projective identification really looked and felt like to envision a different response.  I also had yet to develop my own comfort as a therapist with that kind of dark content.

I want to draw attention to the highly varied details of these brief vignettes, all about sexual content arising in end-of-life music therapy sessions. There isn’t really a rubric to follow here. Ann and John were both scared, but they put that forward in radically different ways.  Matthew and Mr. B were both looking for a deep erotic connection, but Matthew portrayed it indirectly and soulfully, while Mr. B was direct and flirtatious.  John and Mr. C both professed their love, but one scared me while the other stimulated only mild annoyance.  Clinical navigation of this sort of content really requires attention to one’s own emotional experience, as this is where the deepest insights and most valuable clinical guidance lies.  To mine sexual content for the profound material that it often covers, we are called to know ourselves deeply through our own depthful therapy and supervision processes.

5 thoughts on “There’s No Flirting in Hospice”

  1. Thank you so much for this excellent piece articulating what is so little discussed but so often experienced. We also frequently experience projected sexualized feelings from family members; an attempt to help feel and/or avoid feeling the pain of loss through maintaining intimacy with the MT. I think this has happened at least once to each of my young female interns – great learning opportunities!

    1. Thanks so much, Deborah — I think once we allow ourselves to really talk about this topic, so many more angles of it are illuminated, which in turn call for more discussion. I would love to talk about what emerges with family members as well. Also, I’m really glad that your interns have a place where they can talk about this content and find meaning in it. I believe what you offer them in that is quite rare.

      1. Thanks Meghan. Having solid psychotherapy training helps me to recognize, tolerate and work with erotic, and other kinds of transference and countertransference. I wish there was more depth training in music therapy programs. Really appreciate your posts.

  2. Thankyou Meghan, for this brave and insightful piece. I hope you will share it with the wider MT community as this arises in work with so many population and settings, and is so rarely explored.

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