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Conference Papers and Powerpoints




“It’s not very nice Henry, is it?” Music Therapy with a boy who had been sexually abused.

Henry Dunn, Music Psychotherapist

Henry Dunn works for the NHS in a Creative Therapy Team, where the mental health needs of adults with or without learning disabilies are addressed through music, art, drama and dance/movement therapies. Previously he worked in a school for children with visual impairments and learning disabilities and in other schools for children with learning disabilities He has a special interest in working with clients diagnosed with Autistic Spectrum Conditions  and coordinates the Autistic Spectrum Conditions Network for the Association of Professional Music Therapists.

Introduction
In this paper I will be presenting some clinical work I did with a young boy, David, who had been sexually abused by his parents and other family members for the first five years of his life, until he and his siblings were taken into care. At this time I was working for a charity, Sound Waves South West Music and Music Therapy Trust, in two schools for children with special needs. David was diagnosed as having mild learning disabilities and autistic spectrum disorder. I will show how, through music, play and our relationship, he was able to express some of the horror of what had happened to him. I will look at the impact of abuse on his emotional literacy, and also look at evidence that links childhood abuse to learning disabilities. I will also be looking at the question of whether childhood abuse can cause symptoms of autism. This will be done with reference to the work of Donald Winnicott, Daniel Stern, Daniel Goleman, John Bowlby and Sue Gerhardt.
Case Study
I started seeing David [1] for weekly music therapy sessions at the start of the autumn term 2006, when he was 10 years old. He was at a school for children with mild to moderate learning disabilities. Although he was now with good foster parents, he and his siblings had been repeatedly sexually abused by their parents and other family members for the first five years of his life. As they all had moderate learning disabilities, their evidence was not considered sufficient for a conviction, so their parents are still free. However, there was sufficient evidence for them all to be removed, and placed with different foster carers. No one was fully aware of the extent of the abuse, but it seems certain that it involved video recording and sexual exploitation. This made it totally inappropriate for me to record the sessions..
          Each session lasted up to thirty minutes, though sometimes David asked to leave earlier. They were at the end of the school day, so he often spent time looking out of the window to see if his foster parents had arrived. The sessions were unstructured and led primarily by David. The room had a selection of instruments, including an electric piano, cymbal on a stand, wind chimes on a stand, some drums and various items of small percussion. This term was very much a settling-in period, and David gradually stayed longer and engaged with me and the instruments more, as the term progressed.

Content of the sessions

David and I developed a repertoire of games and interactions. The first of these to happen was what I term the “go to sleep – boo” game .  From early on in our work David would say “Go to sleep”, I pretended to sleep, and then he shouted “Boo”. Variations were added to this, such as David going to sleep, asking me to shout “Boo”. Also, instead of shouting, David “woke me up” with very loud music, such as crashes on cymbal and drum, dissonant chords on piano, often using church organ sound effect. This had quite a sinister feel about it, and I wondered whether it reflected past events for David, when he had been told to go to sleep. This initial feeling was reinforced by the way the game developed. The wake up part became more and more violent, and David requested that I fall over when he shouted Boo, or played the instruments loudly. He played the cymbal very aggressively, and then pretended that he was going to hit me with the stick, as I lay on the floor. He stood over me, brandishing the stick. The following week, he took one of the legs of a drum (they are meant to come off and be adjustable) and used that to play the cymbal, with incredible power, then brandished it at me, while I lay on the floor. He then said, “It doesn’t feel very nice does it, Henry?” This may seem a dangerous thing to let a child do, but I was confident that he was representing something to me and was not going to act it out fully What it achieved for him, as well as a sense of power, was that he showed me what it might have been like for him in the past, feeling vulnerable, threatened, and powerless. It is common in therapy for clients who have had traumatic pasts to reverse the roles within the therapeutic relationship, so if they were victimised, they make the therapist the victim, and they become the perpetrator. During one of these types of interactions we got into some different vocal sounds, shouting “Yeah” very loud. I had to use a deep voice at first, then a baby voice, and then we got into “yeuch” type noises expressing disgust in a babyish voice. He then said “sticky”. This could refer to all sorts of things, but in the context it felt like it had rather sordid overtones, that he had been made to feel dirty.
          I want to pause briefly here to think about how I felt at the time, and the importance of reflecting on this. Not surprisingly I felt quite intimidated, shocked and a bit scared. As an adult, I probably felt less scared than a child would, so my feelings weren’t as strong as a child’s would be. Nevertheless, David was passing on feelings he had experienced to me in a very direct way. If he had just told me “I felt really scared”, the impact on me would not be so strong. I might acknowledge these feelings intellectually but not as deeply. Through the mechanisms of transference and countertransference David made me aware at a far deeper level of just how terrifying his experiences had been. These mechanisms are so helpful, where the therapeutic relationship takes on elements of an earlier significant relationship. In this case, it also involved reversal of roles, to make the effect even stronger. I was being abused, in role play, and it aroused strong feelings of countertranseference in me. David was becoming the abuser, I was being the abused After the sessions I felt exhausted, drained of energy.  I often compare therapy to dialysis - our clients come with their toxic emotional waste, and we help them process and purify it. This process, of receiving, processing and returning emotional communication is at the core of therapy work, and has to be based on a strong client-therapist relationship. This relationship is very similar to that between mother and infant, and Daniel Stern (1985) describes a process he calls Affect Attunement that usually starts occurring at about 9 months. The mother responds to the child’s sounds by mirroring them closely. Stern uses musical terms such as timbre, volume and intensity to describe this mirroring, so it is very appealing to a Music Therapist. However, it is more than just mirroring; it is an acknowledgement by the mother of the infant’s communication, a processing of it, and a communication of it back to the child. As Leslie Bunt  (1994:94)writes: “The connection is read not simply as an imitation but as a real attempt to connect with the child’s feelings.” This is the essence of therapy. I explore it further later when talking about Containment. According to Tessa Watson (2007:102) , Stern “describes this process as more sophisticated than imitation, giving the indication of a capacity for psychic intimacy, and allowing qualities of feeling or vitality affects to be shared.”
          Although I was confident that David would not carry out any actual violence towards me, I considered it a very positive development when he found another outlet for these feelings. We were looking in a cupboard for some instruments, when David noticed a pop-up crocodile puppet, and we brought this into our sessions. David gave it several different names at first, including Charlie, Colin, and Mum, before settling on Alex. We then had play fights involving Alex, and I had to chase him. We also had variants on the peep-bo type games we had had before, with Alex hiding in his cone, then peeping out. Unfortunately, Alex got broken, but I was able to get a new similar puppet, though a different animal, which I thought was a dog, but David called a sheep. He too was called Alex. The significance of the puppet was reinforced one week when I was unable to get to the cupboard where it was stored. David became aggressive in the session, taking it out on the instruments – he tipped over a cymbal and jumped up and down on the stand, before apologising to me. The instruments and stands are very strong and can take this sort of treatment, but it did show what role the puppet was playing, giving David a channel for his aggressive fantasies. Also with the puppets, I had to make Alex chase me into a corner of the room, where I would collapse on the floor. David would play a demo track, fast forwarding it, giving the chase a very manic feel. I felt like a “remote controlled therapist”. This was giving David a chance to exert control over an adult, a reversal of the usual roles in his early childhood.
Another game that we played was racing round the room and back to the window. David was usually the winner, unless he said, “You beat me” (a phrase with many meanings), in which case I got to the window first. Also, David dragged the instruments on stands around the room, and they made tracks in the carpet. I had to “follow the tracks”. To me, this was David’s way of asking whether I could “follow” him, as he represented to me aspects of his past life, and present experience. This was a significant invitation, asking me to come into the darker parts of his life and to explore them with him.
          A significant development was when David discovered the “demo tracks” on the keyboard, one of which is Mozart’s Eine Kleine Nachtmusik. We danced around to it, and David asked me to pick him up and spin him around, facing outwards. There was a real sense of innocent joy about this play, and it felt like we were in the roles of Father and Son in a healthy relationship. This could be seen as a positive way of making reparation for his original relationship with his Father.  Alternatively it could be a sign that he is too trusting and therefore vulnerable to abuse. I would like to think that the former is more the case, but there may also be elements of the latter. It is often the case that abused children use that abusive relationship as a template for other relationships, that they expect to be abused, and therefore unconsciously invite abusive behaviour. Their identity becomes entwined their abusem so that they see themselves as only fit for abusive relationships. As therapists we have to be aware of this danger and always keep within appropriate professional boundaries. This has to be balanced by a warm and caring attitude which may include some physical contact within acceptable limitations. To avoid contact could be felt by the child as a rejection
We also played along to the demo tracks, David playing recorder, me playing clarinet. David liked me to copy his playing and his facial expression when we did this.
          One concern I  had was that there was a suggestion of sexualised behaviour from time to time, just in the suggestive way David played. There was one session when D put his hand down his trousers, and when I asked what he was doing, said “Playing with my willy”. He agreed that this wasn’t the best place to do this. He also likes “Alex” to tickle his nose a lot, which I have to make Alex do. Again, this could be totally innocent, but it made me feel a little uncomfortable.
          David spent a lot of time exploring the technicalities of the instruments, particularly the legs of the drum and the stands that could be adjusted and moved around. He liked to see how things work, and to know where they come from. He also liked things to be tidy, taking control of his environment. This may have been related to his diagnosis of autism, as people an the autistic spectrum often feel the need to control things around them, to make them more predictable. This can then reduce their levels of anxiety

The therapeutic relationship

Therapy depends on their being a "good enough" relationship between the therapist and the client, to borrow Winnicott's phrase [2]. The client needs to know that the therapist can listen to them and acknowledge them; provide a safe, containing environment; survive anything thrown at them (metaphorically and literally); and treat them with warmth and respect. This provides a secure base (cf Bowlby (2003) from which they can explore past events and current emotions and difficulties.
          There was one session when David and I spoke to each other in “baby-talk”, and this seemed symbolic of one of the paradoxes in David: that between his childish and adult behaviour. He is a child that has experienced and witnessed things that a child should never experience, and which most adults find it hard to imagine. He knows too much to be fully childish, but these experiences have stunted his emotional and psychological development, so that he is a long way behind the “average” child in these areas.
          The go to sleep – boo type games continued, with David accompanying his “boo”s with loud crashes on instruments or shouts. Sometimes this became very loud, and it seemed to me that David was trying to express overwhelming emotions. At first he didn’t seem able to identify individual emotions, but experienced them as one large mass that were too big to understand rationally. This kind of expression seems to act as a kind of pressure-cooker valve, letting out emotions in a controlled way, in a safe place.         
          Another form of play in our sessions  involved David sitting in a small percussion trolley and asking me to push him around the room. He would go towards a table, calling it a “dark cave”, then to the “dark piano”, the “dark chair” and so on. This seemed to me to be an invitation to go with him to the darker experiences in his life, and his play, especially the sleep-boo game, seemed to reinforce this view. Children’s traumatic experiences are often represented in their play, rather than verbally, and I think that David was using our sessions in that way. Rather than asking him to disclose his past, in a way that I want him to, I was allowing him to disclose at his level, in his time, and in his own way, without actually asking him to tell me anything.

After 55 sessions David was showing greater awareness of his emotions and a greater capacity to express them in a communicative and creative way. This was shown clearly one week, when he said to me, “I’m not very happy”. This was the first time that he had spoken to me or anyone else directly about his emotions, and was a sign that he was developing emotional intelligence. This was one of the primary therapeutic aims of my work with David, so this was massively encouraging. According to Daniel Goleman (1995), who was the first to define the concept, there are five keys to Emotional Intelligence:
  1. Knowing one’s emotions as they happen
  2. Managing emotions
  3. Self motivation and deferred gratification
  4. Recognizing and working with emotions in others
  5. Handling relationships
          David was certainly showing signs of having the first key, and was perhaps getting better at the second.
We had about 90 sessions before our work ended. This was because I was offered a full time post with my NHS employer and left. I was able to give David half a term’s notice (i.e. 6 weeks) I am not sure if funding has been provided for this to continue.

Theoretical framework:

Importance of Play
            In Music Therapy, play is meant in the widest sense: not just musical play, but the ability to think and act creatively, to play with ideas, with ways of living in relation to others. We can go with our clients as they begin to understand more about themselves, letting the unconscious find a form in which it can be revealed. For Winnicott, playfulness is the essence of psychotherapy:


“Psychotherapy takes place in the overlap of two areas of playing, that of the patient and that of the therapist. The corollary of this is that where playing is not possible then the work done by the therapist is directed towards bringing the patient from a state of not being able to play into a state of being able to play” (Winnicott 2005: 51).

“…playing facilitates growth and therefore health; playing leads into group relationships; playing can be a form of communication in psychotherapy; and lastly, psychoanalysis has been developed as a highly specialised form of playing in the service of communication with oneself and with others” (Winnicott 2005: 56).

          The Arts Therapies (Music, Art, Drama, Dance) and Play Therapy are clearly well equipped to work in this way, giving our clients the most natural way of engaging with and expressing their psychological states.

How David used play – the importance of survival
Winnicott emphasises that the therapist has to survive the destructive impulses of the client for therapy to be effective. He uses object relations theory to explain this. This theory has it’s roots in Freud’s work and his analysis of the relationship between therapist and client, and was more fully developed by Melanie Klein. It is an attempt to understand how people relate to others externally, while holding an inner representation of this relationship.[3] He believes that the following process occurs:
          “ (1) Subject relates to object. (2) Object is in process of being found instead of placed by the subject in the world. (3) Subject destroys object. (4) Object survives destruction. (5) Subject can use object. “ (2005:126)

          Stage 2 needs some further explanation; it describes moving from a state where the person controls people in their environment, choosing who to engage with, to a state of allowing others to come to them as separate individuals, in control of their own actions.
In my work with David these stages happened as follows:
1)     David gradually formed a trusting relationship with me, increasingly able to stay in the room and playing music with me.
2)     Our relationship developed into one of collaboration and warmth, although some of David’s play treated me as an object to be controlled. This was particularly the case when he played speeded up tracks on the keyboard and I had to run into the corner of the room, pretending to be chased by the puppet.
3)     Through our “sleep-boo” game, culminating in David standing over me with the leg of a drum, David represents his violent fantasies, pretending to destroy me.
4)     I survive this attack, and refuse to disengage from our relationship, instead continuing the therapeutic work and remaining warm and respectful to David.
5)     The therapy is able to continue, and we are working at a deeper level, David having expressed some of the horror and violence of his early childhood.
Understood in terms of transference and countertransference, David was using our relationship to represent an earlier abusive relationship, but by putting himself in the person of the abuser, was enabling me to experience his abuse, as well as enabling him to reverse the power balance.

Importance of a Secure Base
Bowlby defines a secure base as:
a)     in childhood “the provision by both parents of a secure base from which a child or adolescent can make sorties into the outside world and to which he can return knowing for sure that he will be welcomed when he gets there, nourished physically and emotionally, comforted if distressed, reassured if frightened.” (1988:12)
b)     in therapy first task “is to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and on occasion, guidance.” (ibid:156)
Consequences of the lack of a secure base
a)     in childhood – attachment disorders. There are two main forms of attachment disorder, as described by Bowlby: “anxious resistant attachment in which the individual is uncertain whether his parent will be available or responsive or helpful when called upon. Because of this uncertainty he is always prone to separation anxiety, tends to be clinging, and is anxious about exploring the world. This pattern, in which conflict is evident is promoted by a parent being available and helpful on some occasions but not on others, and by separations and…by threats of abandonment used as a means of control.”  (ibid:140)
     The other form “is that of anxious avoidant attachment in which the individual has no confidence that, when he seeks care, he will be responded to helpfully but, on the contrary, expects to be rebuffed. When in marked degree such an individual attempts to live his life without the love and support of others, he tries to become emotionally self-sufficient and may later be diagnosed as narcissistic or as having a false self as described by Winnicott”.  (ibid:140)
     There is also another form that Bowlby describes, where the child does not fit into either of these. These are termed “disorganised attachments” where the behaviour of the child is very unpredictable, and is most often found in children that have suffered some sort of abuse or neglect, or where the parent has a mental illness. I feel that David was more like this – he could be very distant sometimes, then surprisingly affectionate at other times, as if he had not been given an example of how to relate.
b)     in therapy: “..unless a therapist can enable his patient to feel some measure of security, therapy cannot even begin” (ibid:159) With David, there needed to be a secure base for him to express himself fully. This was provided by several factors: consistency of place and time, privacy, my ability to survive anything he threw at me, my enforcing of some behavioural limits, and my constant Unconditional Positive Regard, to use Carl Rogers’ term. Without all these in place, it could have been a very dangerous piece of work, both physically and psychologically. We cannot encourage our clients to express the horror of their experiences if we are not able to hold that expression in a safe place, otherwise the client will be overwhelmed by that expression, and consumed by guilt for inflicting it on us.
Containment
This leads us to another important concept: the importance of providing containment, which Bion (1962) describes as follows:
          “It is the creation of a psychic space in which each and every communication, however confused and painful, is received by the therapist, retained and mentally digested with the aim of removing any unbearable qualities from the patient’s feelings. These feelings can then be given an acceptable form and place in the patient’s experience. The final aim is for this experience to enable the patient to accept his anxieties and learn to live with them; in other words, to understand and accept the containment function.” (p306)
            Jos de Backer (1999) applies this to Music Therapy, saying that the Music Therapist “will stretch a skin over the patient’s experience - an acoustic skin – which binds and shapes the expression of chaos. ……………… Music offers the advantage that the patient need not be alone in his/her chaotic expression and experience. The music therapist has the means of being with the patient without having to exclude him/her. S/he achieves this not only by his/her attitude but by his/her empathic accompaniment. This means that the patient can….feel that someone accepts his/her experience, someone who accompanies him/her without being swept along, who does not become alarmed, someone who gives him/her the feeling that his expression is not “destroying” anyone.” (p19)
            He also refers to Kleinian theory, saying that “In the psychic space created in the therapy the patient will be able to project his/her chaotic and confused feelings and experiences towards the therapist. This will enable him/her to bear these feelings (projective identification). (p19)


Abuse and neglect as causes of learning disability and autism
Stokes and Sinason (1992) write of “the link between sexual abuse and handicap. In several cases, mental handicap seemed to provide a screen against acknowledging the reality of sexual abuse…The “screen” of mental handicap provides a state of not knowing about, as a protection against the terrible feelings of abuse and rejection……..It is well established that learning difficulties…are a regular feature of sexual abuse and physical abuse. This is not surprising. If knowing and seeing involve knowing and seeing terrible things, it is not surprising that not-knowing, becoming stupid, becomes a defence…However, it is a mad defence as it takes away the possibility of communication and gaining help or understanding.”

          For Sinason (1992) “stupid” here is meant in the sense of being “numbed by grief”, rather than as a derogatory term. She has “learned how stupidity could be a defence against the trauma of knowing too much of a painful kind.” (p7)

High levels of stress can be very damaging to a child’s brain development. Gerhardt writes about how stress causes the production of cortisol and the effect of this:
“There is some evidence to suggest that high levels of cortisol might be toxic to the developing brain over time. In particular, too much cortisol can affect the development of the orbito-frontal part of the prefrontal cortex….an area which…is responsible for reading social cues and adapting behaviour to social norms.” (2004:66)
          So it may be that abuse has, to some extent contributed to David’s autistic behaviours, particularly his difficulties in social behaviour. Also, the orbito-frontal cortex is the place where our emotions are processed. This is another area that David had difficulty with. Gerhardt talks about research involving Romanian orphans showing “that those who were cut off from close bonds with an adult by being left in their cots all day, unable to make relationships, had a virtual black hole where their orbitofrontal cortex should be.” (ibid:38) Although David’s situation was different, he also had no one interested in making a healthy relationship with him, where his emotions were acknowledged and processed.
Gerhardt also states that children who experience high levels of cortisol “are most at risk of developing serious psychopathology in adulthood.” And that early abuse and neglect can “affect the volume of the brain in general, particularly the prefrontal cortex which is so vital in controlling and calming the more urgent fear reactions of the amygdala”. Anxiety is a common feature of autism, and this may, in David’s case, have been caused by the effect that abuse had on his brain development. It also suggests that his learning disability may also have its roots in abuse. It would be interesting to do a brain scan on David to see if this part of the brain is damaged, but I am no longer involved with him, and I’m not sure his foster carers would be happy for this to happen. Also, would it actually be useful? We know he has difficulties processing his emotions, and having this confirmed biologically would not change it in the way that a psychotherapeutic intervention might. On the other hand, it would help those who work or live with him to understand him better, and it would offer confirmation of Gerhardt’s theories.
I do not want to suggest that all autism is caused by abuse and neglect, but to suggest that in David’s case, this may have been a contributory factor. We should not be surprised if children that have suffered neglect and abuse develop autistic traits, not just for the physiological reasons given above, but for the simple reason that they have not had the opportunity to develop in the context of a relationship, thus not learning how to interact, or to process their emotions.



Conclusions
In this paper I have presented some case work with a young boy that had been sexually abused. We have seen how the therapy provided a secure base and containment so that he was able to express some of the horror of his experiences, and have them heard and acknowledged. He was able through the therapeutic process , to begin to identify his emotions and to find ways, both non-verbal, and to a limited extent verbal, means to express them. We have also looked at the effects of abuse and neglect on brain development, seeing a possible link with the development of learning disability and autism. Using insights from psychotherapy and neurology, we have gained a more complete picture of the various influences on children and the way that we, as therapists, can help children who have suffered sexual abuse.


Bibliography
Goleman, D. (1995) Emotional Intelligence: Why It Can Matter More Than IQ for Character, Health and Lifelong Achievement.  London: Bantam Press.
Winnicott D.W. (1951) 'Transitional Objects and Transitional Phenomena' International Journal of Psychoanalysis, Vol.34, 1953
Winnicott, D.W. (2005) Playing and Reality. London and New York: Routledge Classics
Bowlby, J. (2003)  A Secure Base, London: Brunner Routledge
Bion, W.R. (1962)  “A theory of thinking.” International Journal of Psychoanalysis 43, 306-310.
De Backer, J. (1999) Specific aspects of the music therapy relationship to psychiatry, Clinical Applications of Music Therapy in Psychiatry.  Ed. Wigram and De Backer. London and Philadelphia: Jessica Kingsley.
Stokes, J. & Sinason, V. (1992). Secondary mental handicap as a defence. In A. Waitman & S. Conboy-Hill (eds) Psychotherapy and Mental Handicap. London: Sage. pp. 46-58.
Sinason, V. (1992) Mental Handicap and the Human Condition. New Approaches from the Tavistock. London: Free Association Books.
Gerhardt, S. (2004) Why Love Matters. How Affection Shapes a Baby’s Brain. Hove, East Sussex and New York: Routledge.
Stern, D. (1985) The Interpersonal World of the Infant: A View from Psychoanalysis and Development. Basic Books, New York
Bunt, L. (1994) Music Therapy: An Art Beyond Words.  Routledge, London.
Watson, T (ed) (2007) Music Therapy with Adults with Learning Disabilities. Routledge, London


[1] His name has been changed to preserve confidentiality
[2] “The good-enough mother....starts off with an almost complete adaptation to her infant’s needs” (Winnicott (1951)
[3]  For a detailed history of this theory, cf Greenberg, J and Mitchell, S (1983) Object relations in psychonalytic theory Harvard University Press

















1 comment:

  1. Henry:
    Great start for your blog.
    I'll be back.
    Wayne

    ReplyDelete