Best practice, Countertransference

Do clients really die to meet our needs?


During the height of the primaries earlier this year, Meghan and I participated in a (rather heated) community discussion about the role misogyny and sexism played in shaping how the presidential candidates were perceived. In a private follow up with Meghan, I noted that my entrance into a feminist perspective began with my daughter four years ago, that before my daughter was born being white and male afforded me a position of privilege buffering me from the troubling hegemonies that affected others. But after my daughter’s birth, I argued, I vicariously lived my daughter’s interactions with the social cues – e.g., a cascade of pink clothing, affirmations of being “cute”, questions about her favorite princesses, etc. – that dictated how she “should” be, affording me new insights and expanded awareness.

Meghan offered a pointed reflection, noting that while my entry point into the feminist narrative that resisted such gender roles began four years ago, a woman’s entry point (as it has been for my daughter) was from birth. Consequently, my awareness of sexism was not experienced so much as observed, limiting my perspective due to my context of privilege. It was a clarifying comment that resonated beyond gender issues into end-of-life care, and led me to the question of what is our role as hospice music therapists when we enter clients’ life narratives at the very end.

A calling or a privilege?

 It is common to hear hospice music therapists refer to their work as a “calling”, suggesting that they are “born into” or “created for” hospice work. It is a perspective that says “I was made to be a hospice music therapist and be here to provide you this service” thereby positioning the client as an object utilized to achieve fulfillment. In essence, by designating hospice work as a “calling”, we are assigning our practice an existential function that places our needs for actualization before the needs of our clients.

This is a perversion of our intentions and obligations as healthcare professionals. Clients do not die from cancer to meet our need; they die from cancer because they have cancer and they are dying from it. Death does not come to an individual so as to address another’s need to feel validated or fulfilled. It is a natural function of life, and the eventual demise of our physical body is an objective fact unmoved by any subjective value placed on it. Being a hospice worker does not assign us the right to attribute personal meaning to the death of a client.

To be sure, there is great value to be mined from the work, but that is secondary to working with clients towards achieving good deaths. And it is that good death – that opportunity to die with the resolution necessary for peaceful transitions into postlife – at risk when we assign ourselves undue agency in a client’s life narrative. We are invited – not called to – the final hours, days or weeks of a narrative that began multiple decades ago. We are afforded the privilege by our clients to participate in the final chapter of that narrative, and perhaps even the epilogue if we are so honored to participate in a memorial or funeral.

What do we have to offer?

So what does it mean to enter into another’s narrative? How do we partner with our clients so that we can align with their experiences without appropriating them? One potential avenue has been paved by Martin Buber’s I and Thou (Note: Rudy Garred explores to a much greater extent the intersection of Buber and music therapy in Dialogical Music Therapy). In this seminal work, two types of relating are described: I-It, which is a subject-to-object interaction, and I-Thou, which is a subject-to-subject relationship.

When we engage with clients through an I-It interaction, we are acting on our clients as objects. For instance, the music therapist plays music at a client to lower anxiety or the music therapist responds to a client’s increased respiratory rate. Within this dynamic the therapist assumes the brunt of agency in the session: they make the assessment, they develop the intervention, they determine the goal, and they evaluate the outcome. If clinical practice is perceived as a calling, then the music therapist has pre-determined what the meaning from the session shall be (e.g., “This is what I have been born to do so my actions with my client will be in service to realizing that meaning for myself”).

Conversely, when we engage with clients in an I-Thou relationship, we are finding points of unity through which a shared resonance manifests within the therapeutic relationship. Such relating fosters authentic interactions defined by a mutuality wherein each individual shares with and receives from the other.

For instance, the music therapist engages with clients in co-constructed music experiences that assign both as stakeholders in the aesthetic experience. Here, the client is provided space to be expert on their experiences and the music therapist allies with them to facilitate client-directed experiences. These interactions support a resource-oriented perspective founded on the assumption that clients have intrinsic resources and attributes for complete personhood. I have nothing to give another that they do not already contain within themselves, and that surely includes music. If we truly ascribe to the notion that music is an intrinsic function of humanness, then “my” music has no place in another’s journey towards self-actualization and resolution. And, if we respect the autonomy of another, then my existential needs have no place in that journey either.

Subtle shifts

What I hope to see moving forward is a substantive shift in how we conceptualize end-of-life care work by

  1. Moving away from focusing on how we are impacted by the work and how we experience fulfillment when musicking with a client, and re-situating ourselves from the client perspective of what impact and fulfillment means for them.
  2. Acknowledging that placing our needs before that of our clients represents countertransferences that are not to be shamed but worked through so that they can inform rather than obstruct the clinical process.
  3. Changing our language so that our articulation and framing of that clinical process speaks to the client experience instead of our own.

I believe in both the validity and value of our practice and in our ability to ensure our clients’ narratives are honored and empowered.

6 thoughts on “Do clients really die to meet our needs?”

  1. Thank you for your writing Noah. I appreciate this change in perspective you recommend. I nodded my head many times in the beginning of your blog, saying “yes, I do this,” and later, “yes, I want to to do this instead”. I am in the primary stage of accepting the “invitation” to be part of music therapy in EOL care. Although I have and currently work with a couple people who are on hospice, I’ll be taking my first course towards certification in the fall. This path is a journey for a music therapist and it calls for constant self-reflection and self-examination. I enjoy reading this blog as it a great catalyst for taking the time to constructively examine myself and my actions as a music therapist in hospice care.

    1. Thank you for those thoughts and kind words, Melanie. For the very reasons you list here – reflexivity and self-examination – I find writing these posts to be instrumental in helping me to sort out my thoughts. We’ve reached a place in hospice music therapy where it’s clear something is happening but we don’t know WHAT, exactly, is happening. While there are many roads to walk before we start developing those answers, I believe ethically locating ourselves in relation to our clients is crucial. We have to be able to see beyond our own needs and wants to “live” the client experience in the music. Thank you again for your contribution here and good luck moving forward with EOL care! I hope to hear more about it down the line.

  2. Thanks for beginning an important and thought-provoking discussion, Noah. As I read the post, the idea that struck me most is agency. While I can relate to the experience of assigning myself undue agency within a client’s narrative, I have also had the experience of censoring or suppressing my own agency in the therapeutic relationship, and believe this tendency to do so (particularly with clients whose interpersonal styles I experience as dominant) is related to my own wounds of woman-ness rendered by the existence of patriarchy. It takes a great deal of self-reflection, supervision, and therapy to unwind the complexity of how I (Self) can co-create with Thou (Other) as our agency is combined and shared, because I can only make space for the full expression of a client’s agency when I’ve spent time getting to know the wounds in my own agency.

    Another curiosity I hope to hear other clinicians’ experiences with is the nature of co-constructing music experiences with clients whose expression of agency or accessing of internal resources is affected by progressed dementia, Parkinson’s, Huntington’s, ALS, or other terminal, degenerative diseases. For me, music, presence, and awareness of countertransference are connecting and potentially empowering forces with these clients, but I feel less clarity in my interpretation of these clients’ expressions of agency, and in my perception of the music created in response. However, when relating with these clients, whose expression of agency may be compromised by disease and dying, perhaps it is the very task of connecting with the woundedness of my own agency that can enable deeper resonance with them.

    1. Thank you for these thoughts, Cathleen – very stimulating ideas. While as a man my experiences with loss of agency are undoubtedly different than yours, I can relate in some way because I was a bullied child and I routinely have to fight the instinct to “surrender” to a charismatic client’s desires or demands. That idea of remaining anchored in yourself while temporarily blurring the boundaries between you and your client speaks to a liminality that I am noticing more and more in music therapy.

      Liminality is that “betwixt and between” phase wherein you shed some of yourself to embody new roles and self-concepts. To me, it’s a naturally occurring therapeutic process, and speaks to the type of deep relating that you write about here. The challenge is having parts of your Self that you remained immutably anchored in so you know where you are in relation to your client when relating in that I/Thou liminality. This concept applies your thought that you develop deeper empathic resonance with clients by remaining in touch with your experiences of vulnerability.

      1. Since I read your response last week, Noah, I have been considering how I experience liminality as you’ve described it above. It’s a sensation/awareness I have been aware of before, and has come up in recent conversations with colleagues and interns, and it’s helpful to be reminded of the word that describes the phenomenon. Naming things not only makes communication easier, but has a way of validating the experience, too…so thanks for your response.

  3. I like your reframing of “a calling” to “an invitation.” I have felt that my music therapy journey (so far as a student, and now as an intern so I am definitely doing clinical work) as being a calling, and I never thought of it as self-serving and personally I still don’t. But I think an invitation is just a much nicer overall idea and it seems useful to apply that invitation to every interaction.

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