Niels Hannibal og Gitta Strehlow (2024). Music Therapy with Patients with Personality Disorder: Advantages and Challenges. Voices, Vol. 24, no. 2.
Personality Disorders
Personality disorders occur in approximately 13 percent of the population and are characterized by a deviation in personality that results in functional problems. The causes of personality disorders can include genetic vulnerability as well as psychological and social factors. These might involve unstable upbringing, neglect, trauma, and a lack of positive adult role models. Individuals with personality disorders may have issues related to identity, life goals and meaning, and the ability to feel empathy and closeness.
Therapeutic Alliance and Common Factors
We know how important the therapeutic alliance is for successful psychotherapy. This is also referred to as a "working alliance" and involves the connection between the patient and therapist, along with mutual understanding of the tasks in therapy. The working alliance is considered one of the "common factors" in therapy, along with empathy, expectations, cultural adaptation, and differences between therapists. These factors appear in all forms of psychotherapy, regardless of the therapist's theoretical approach or model. Such common factors are, of course, also present in music therapy. At the same time, ruptures in the working alliance and potential subsequent repair may be central elements in treatment.
Mentalization-Based Therapy (MBT)
For the authors, psychodynamic theory, and particularly mentalization-based therapy, has been important when working with clients with personality disorders. They also ground their understanding in a process-oriented music therapy where they find that musical improvisation is a meaningful form of interaction that does not rely on language with explicit semantic content. The experiences that emerge through music activities can have aesthetic, interpersonal, and intrapersonal meaning. This meaning is not only cognitive but equally a bodily experience.
Given the pattern of suffering that characterizes people with personality disorders, they may be particularly sensitive to interpersonal dynamics that can remind them of previous experiences. This dynamic occurs without cognitive control. According to mentalization theory, the patient cannot see themselves from the outside or the other person from the inside. This represents a challenge for therapy, and there is a risk that the client may terminate therapy prematurely. The authors write:
“Patients with personality disorder issues are often full of confusion, doubt, anger, low self-esteem, and shame. Their mood is often low, full of thoughts, feelings, and experiences that make being alive a challenge and something full of pain and discomfort. When a person in this state of mind enters a therapeutic setting there is much at risk, and the expectation that change is possible is often not even there. When a person experiences personality disorder issues, their problems are relationship-based. Here, the feeling of who I am, how I feel, what I think, and what I do in general depends on the response from others and the way other patients perceive the person.”
Based on this understanding, we realize that clients often experience painful loneliness, emptiness, and a sense of meaninglessness stemming from an ambivalent and disorganized pattern of attachment attempts. Clients may react to the slightest changes in facial expressions, voice, or questions posed, making the initial encounters with the therapist challenging.
Challenges in Alliance Building
The challenges that the article's authors point out involve doing something that brings the client out of their comfort zone. Given a good working alliance, such challenges are important for progressing in therapy. But before the alliance is established, one enters an unknown and vulnerable terrain. Several themes are linked to the client's experience of music therapy. It may be that the situation is unfamiliar, that improvisation is both uncontrollable and unpredictable.
The client may ask themselves whether playing a drum can really help with their problems, insecurity, and life situation—especially if the person has high expectations of themselves and wants to do things perfectly. Feelings of vulnerability, shame, loss of control, and anxiety can easily arise. Playing a musical instrument can challenge the sense of mastery and thus the possibility of failure, humiliation, shame, anxiety, and other emotional themes, which again evoke old patterns of attachment behavior.
We particularly think that hearing oneself play or sing provides information about how the person feels, their own state of mind. This can, in turn, create an overwhelming sense of frustration and anger. Such challenges are relevant in working with all clients in the mental health field, but are likely especially challenging in work with individuals with personality disorders.
Music therapists will also face challenges in building a working alliance. This might involve how to respond to the way the person plays, for example, if the person plays very loudly or very softly. If the improvisation takes place in a group, this can become extra challenging as there may be different desires among the participants. Another challenge involves countertransference, that is, the strong and uncomfortable feelings that may arise in the therapist. These can include feelings of being entangled in shame, helplessness, tension, fear of failure, distaste, and more. If such feelings are not recognized and understood, this can hinder alliance formation and create mentalization problems for the therapist as well.
Such challenges for both the client and therapist should not be avoided but are considered necessary in the therapeutic process. They must be explained to the client as part of the process that music therapy undergoes. Should a rupture in the alliance occur, it is important to acknowledge this to start a process of repairing and re-establishing the alliance. Understood within this theory, such ruptures occur due to an insecure attachment pattern, negative reactions to transference, defense responses, and dissociations that can happen in the relational dynamics. The authors emphasize that the therapist must be able to recognize their own implicit or automatic responses while beginning to regulate the emotional tension up or down to an appropriate level. At the same time, they suggest ways to do this by paying particular attention to and validating the client's reactions in response to what just happened in the interaction.
Advantages for the Client
There are several advantages to using music and improvisation in this approach. These advantages can be general to music therapy, but also specifically effective for individuals with personality disorders. The authors mention how music is effective in changing a mood, providing a sense of vitality and strength. Playing offers an opportunity to be "childish," allowing oneself to play loudly and aggressively, and to loosen control a bit. Music can also represent a safe space, less challenging and confrontational than using language. The focus shifts more to how it is to be together rather than what we think and talk about. The musical meaning is more open and unspecified, offering a distraction from troublesome thoughts and ruminations. Music provides access to bodily experiences and can open up joy and playfulness.
Most importantly, music creates a framework for relational experiences. Everything we know about improvisation points to its value in establishing contact, creating interactions, and forming a relationship. The methodology of improvisation has provided us with various techniques to create these forms of interaction. We talk about the use of imitation, mirroring, and support to create "attunement" and "entrainment." "The patient can experience a shift from chaos to togetherness. From being alone and isolated, to the subtle experience of attention, empathy, and inclusion, the patient has the power to engage or distance themselves. They may experience being in control," write Hannibal and Strehlow.
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