Vulnerability and Threat Perception

Widely held assumptions about the innocuousness of the music therapy process in hospice have been challenged on this blog in the past. In this post, guest author Cathleen Flynn, MA, MT-BC offers reflections on navigating very common and very precarious dynamics with hospice patients. (See Cathleen’s bio here.) She digs into the roots of what feels dangerous in music therapy, and overturns notions about the harmlessness of music, therapists, and elderly patients. We hope she inspires you to do some digging, too.

Vulnerability and Threat Perception

Perhaps it’s the popularity of Brenè Brown’s writings on vulnerability or perhaps it’s a shift in my awareness, but vulnerability in music therapy practice seems to be an area of interest for many clinicians. I have recently wondered, though, how complete an examination of vulnerability can be if we do not also examine what it is we are vulnerable to in this work – that is to say, it is important to examine what feels threatening and requires our willingness to be vulnerable. Acknowledging vulnerability is one part the process, but another deeper part involves looking into the contours of our fear (of the patient, Self, and process) as well as the patient’s fear (of us, the patient’s Self, and process). It is this examination of fear and threat that gets less attention and about which I will discuss three fallacies I notice in end-of-life music therapy.

Music as Non-Threatening

Many music therapists differentiate and justify our work by describing music as non-threatening. The implication is that music cannot hurt but can only help, and that hurt and help are mutually exclusive. But music can and does hurt (see Jessica’s post for more on this). As a medium that reaches the deepest parts of us and is linked with emotionally charged memories, music can elicit pain, dissociation, and overwhelm. It exposes wounds we guard and externalizes parts of the Self we hide, all rather quickly.

I think of an assessment with B. She requested music therapy probably out of curiosity, and the team felt it could provide a social outlet. Her social worker and I visited together; after some conversation, I asked about B’s relationship with music and if there was a song she wanted to hear. She chose “I’ll Fly Away”, saying she always loved hearing it in church, and I began a bluegrass-y interpretation, guided by my awareness of her culture and our upbeat conversation. Almost immediately B. became tearful and tense with discomfort at this unexpected emotion. She was having trouble breathing, and I intuitively slowed the accompaniment and stopped singing to give her space. She asked me to stop the music and we sat quietly as she recovered. When I inquired about her experience, she indicated a struggle to tolerate the music’s resonance and my presence with her inner world by stating, “It’s just too much. I don’t think I want music; thanks for coming, but we won’t need to schedule again”. This song she had heard many times before was, that day, too threatening.

At the time, I left not long after the music ended because I couldn’t sense how to move forward or stay with B., and knew the social worker with whom she already had a relationship would continue processing with her. My practice has evolved since I saw B. and I would respond differently now, expanding my attention in the moment and afterward to hold compassionately her rejection of these feelings and our emergent process. She helped teach me that music can, indeed, feel threatening in its pervasive power.

Therapy or Therapist as Non-Threatening

There seems to be a belief among music therapists that patients should generally be fond of us and ready for this work, since we come with a genuine desire to help and meet patients where they are, establish safe space, and co-create music experiences based on their unique situation. Of course, attunement, safety, and shared investment in therapy are important parts of this work. And sometimes patients do feel fondness and readiness. But what of the other feelings patients experience toward us, and we experience toward them? What of ambivalence, hostility, or despair within us and between us? Those feelings are as deeply human as affection, silliness, or gratitude that occur over the course of relationship, yet, when expressed subtly or overtly by the patient, are often perceived as evidence that (a) we have done something wrong as the therapist or (b) the patient’s feelings couldn’t possibly be about us and must be displaced (see Meghan’s post for more on this). When experienced by us toward the patient we might feel confused or ashamed and attempt to win back the patient’s, or muster our own, fondness, as if these feelings will interfere with rather than enable and deepen our work.

I think of L. She’s an intellectual, charismatic force, which served her well in accomplishing much as a community advocate earlier in life; she often demands, “Did you get something out of this time?” as sessions end, demonstrating her interpretation of meaning in experiences based on external validation. L. periodically discusses efforts to distract herself from feelings of loneliness or meaninglessness. As a person whose adult identity was built on promoting systemic progress and propagating hope, she perceives despair as a failure of her rational mind. Connecting with despair threatens her worldview and sense of self. Once during a tender musical interaction, she said she could “feel the tears behind [her] eyes, but could not let them out”; the vulnerability required to fully experience her despair was too much. My presence with her as she searches for meaning heightens the risk of this task because I may not only witness her despair but may also empathically resonate with it, threatening her fantasy that I’ll experience only hopefulness during our time. L. has taught me that, over time, even threatening feelings can be held in moments with an attuned witness. By acknowledging – in words, music, or quiet knowing – the threat inherent in our therapeutic relationship, we’ve continued attending to an unfolding process over many months rather than remaining in a comfortable pattern of two-dimensional encounters in which music is a distracting or distancing agent rather than an exploratory or connecting one.

Elderly Patient as Non-Threatening

It’s not unusual for me to hear from students that one draw to work with older adults is that they are a “forgiving” or “non-threatening” population. While aging and dying do involve diminishing physical and cognitive function, my experience has been that older adults still have very human capacities for aggression and destruction.

As a highly independent person with significant unresolved anger, R. shared on several occasions that she hated needing care as a result of terminal illness. As she coped with multiple physical, social, and psychospiritual losses, she struggled with how personal she wanted our process to become. After a few months working together, she shared with me her feelings of kinship with a violent criminal featured on the news. I felt scared hearing this, as it called into question my idealized notions of her virtue; perhaps she felt scared acknowledging aloud this fantasy, too. She at least sensed my unconscious retreat from the threatening material, and rebuked my fear by refusing sessions for five weeks before allowing me to see her again. Had I not been engaged in depth-oriented supervision at the time, I probably would have discharged her from music therapy due to consistent refusal of sessions, even though she consented each time to me checking again the following week. Through supervision I was able to clear the internal space needed to hold compassion for her rather than yield to her aggression and my residual fear and anger. This allowed me to continue showing up, inquiring about her experience, sharing my vulnerability, and co-creating opportunities for her to trust our relationship, and me, more fully. R. taught me it is possible to hold conflicting desires for injury (as with her retribution and aggression) and relational attunement (as with her continued consent of me checking in and eventual continuation of our relationship) toward another who sees or hears the most threatening parts of oneself.

In considering these clinical examples that demonstrate the threatening capacities of music, therapy, and our Selves, we sense the transformational power of this work. If we step into this power, do we risk confronting vast landscapes of the unknown and a wider range of emotion and aesthetics? Yes. But with the support of a supervisor, our own therapist, and our music, we can journey with courage and discover new ways of being in this work and this world.

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