Best practice, Countertransference

It’s About You

Music therapists who work in end-of-life care have the opportunity to develop deep and meaningful relationships with patients and families.  Sometimes we get the opportunity to work one on one with the same patient for months, visiting them regularly and talking with them about important, intimate topics.  Their life, their death, their fears, their struggles, their joys.  Even when the relationship has only a few sessions to develop, we are stepping into intimate space with this other person.  As therapists, we try to prepare ourselves for all of the various feelings that our patients may have, and for how to support them in that process.

We often don’t prepare ourselves enough for how much our patients have feelings about us, though.  It feels good when a patient’s reaction to us is positive — “you remind me of my daughter;” “I love talking to you;” “you have such a beautiful voice;” “your music always brightens my day.”  We take the comment as an affirmation and maybe we smile to ourselves later as we remember it.  Other times, we take comfort in the fantasy that we can come in to a patient’s space, play a few songs or a satisfying improvisation, and walk out again with nothing more having transpired than an improvement in mood and a decrease in pain perception.  We all have different levels of comfort with the intimacy that develops in a one on one clinical relationship.

Recently I had the opportunity to interview music therapists about their individual work with patients and how they felt about it.  My research led in a lot of interesting directions, but one minor theme had some significance that has stuck in my head, months after the research concluded.  Part of my interview process included asking music therapists to talk about a time when they felt conflict or discord in their clinical relationship with a patient.  And repeatedly, when negative feelings toward the therapist were described, that therapist’s reflection on those patient feelings focused around the phrase, “It’s not about me.”

Usually the patient in question, whose feelings were “not about” the therapist, was expressing something that the therapist found difficult to tolerate.  Anger, blame, destruction.  A supervisee of mine, who is a talented and deeply reflective clinician, also used the phrase “it’s not about me” when trying to make sense of a patient of hers who was overwhelming her with veiled accusations and rage.  There’s that phrase again, I thought to myself.  Why are music therapists so quick to try to distance, and perhaps absolve, themselves from/of their patients’ feelings?  We don’t have a similar reaction to the patient’s positive feelings.  I’ve never heard a music therapist relate a time when a patient told them “You really brightened my day” and reflected with the “it’s not about me” statement.

To be clear, the therapists in my study who used these words were music therapists who had advanced training, many specifically in music psychotherapy models.  But despite their training, I think some of what fueled their responses may be related to a misunderstanding of what transference is.  In our field, it is typical to receive inaccurate information about this phenomenon.  In the past, some theorists thought of transference as something that exists solely within the patient, something that is exclusively related to their own internal dynamics and issues from the patient’s childhood, with no validity in the here-and-now (in the literature, you’ll see this referenced as moving the patient towards a “real relationship” or “reality-based relationship” with the therapist).  Much of our music psychotherapy literature, especially American music psychotherapy literature, reflects this outdated perspective.  This misunderstanding of transference gives the therapist an “out,” because if the patient says or does something we don’t like then we can blame their feelings on the distortions of projection and resistance.  But the truth about transference is that it’s co-created.  Our patients know things about us — they are observing and tuning in to us as much as we are observing and tuning in to them.  Transference is influenced by the patient’s internal dynamics, yes, but equally as much by the therapist’s internal dynamics, and the reality of what occurs in the therapy session.

So why do we want to get away from our patients’ feelings about us?  Why are we so quick to distance ourselves?  Clearly, given that the “it’s not about me” phrase seems to arise in the context of negative or conflictual feelings, some of it is related to anxiety about being liked, or about having the patient’s approval.  When we discussed her case in more detail, my supervisee realized that she had a not-entirely-conscious belief that if the patient felt anything other than admiration for her then she must be doing something terribly wrong.  Also, it’s scary to have a patient “see” you, especially in a less than flattering light, when you’re the one who’s being paid to “see” them.  The idea that a patient could become angry with you for being judgmental, daft, irresponsible, withholding, or any number of other things, and that they could, in that moment, be right, is not generally a comfortable thought.

I think there are also some general reasons that music therapists might have a tendency to want to avoid this space.  One is our field’s inferiority complex.  We are always trying to prove ourselves, and this makes it hard to tolerate anything negative — what if the patient tells the nurse who tells the administrator that they don’t like something we did or said?  We get scared that anything other than positive feelings means we’re going to be out of a job.  Two: the complexes that exist within us individually.  They’re different for all of us, but they’re there.  They impact our ability to tolerate the intimacy of allowing someone to be displeased with us and still have the relationship endure.  Three is our literature.  Our literature has a very strong bias against conflictual feelings within the therapy space.  Music therapists are frequently taught that a good session is one in which everybody feels good, or maybe feels bad for a minute but then has a revelation or a catharsis fueled by our music and feels better.  Psychodynamically oriented music therapists publish books and papers that suggest that a positive transference is necessary for good work to happen.  But this is not only untrue, it’s also a destructive idea to disseminate.  Music therapists who internalize this thought are going to end up feeling lost, because not only is there no way to force our patients to have positive feelings for us — it’s counterproductive to be watching and hoping for positive feelings instead of welcoming and working with however the patient feels about us.

Our clinical relationships are just that — relationships.  Like all relationships, clinical relationships include a jumble of different feelings about the other person.  And in healthy relationships, we are able to talk about and work through the uncomfortable feelings, the hurts, the fears, the slights.  Learning to do this in a clinically appropriate way is a process (there are nuances about how and when to disclose our own side of the relationship, and learning how to navigate this space takes time, practice, and guidance), but it’s one worth embarking upon.  Because, like it or not, it absolutely is about you.

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2 thoughts on “It’s About You”

  1. This article is brilliant and starts a great dialogue I think we should all be having in any line of music therapy work. I work in a psychodynamic format as well, but have at time clashed with the concept that we need to distance ourselves starkly from the negative emotions of our clients and assume it’s entirely about them.

    1. Thank you so much for reading, Ceara! Yes, those are exactly the ideas in music therapy that are being talked about as if that IS psychodynamics, but that’s very outdated and incorrect. Even Freud evolved from that kind of thinking. Thanks so much for your comment.

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