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The Arts in Psychotherapy 36 (2009) 75–83

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The Arts in Psychotherapy

Music, trauma and silence: The state of the art

Julie Sutton, PhD a,∗ , Jos De Backer, PhD b
Centre for Psychotherapy, Belfast HSC Trust, Belfast, N. Ireland BT8 8BH, UK
U.P.C. - K.U. Leuven, Campus Kortenberg, Belgium

a r t i c l e i n f o a b s t r a c t

Keywords: This joint-authored article explores the ways in which music can speak directly to the traumatic, and how
Music music therapy offers a unique means of coming to an understanding of the traumatised patient. We take
Trauma a musical and psychoanalytical theoretical stance. Drawing on case material from work with a young boy
and an adult attending a psychiatric outpatient department, we show how a form of musical listening
and thinking about what is emerging in the clinical room can help us to understand something about the
patient, about the treatment of those traumatised, and also about the art of music itself. Our aim is to
place the music and the therapeutic relationship as the central focus in the work.
© 2009 Elsevier Inc. All rights reserved.

“Where I am, I don’t know, I’ll never know, in the silence you don’t This is music’s intimate dimension and it plays a central role in the
know, you must go on, I can’t go on, I’ll go on.” Samuel Becket fundamental process of symbolisation. Music has something dis-
tinctive to offer through its capacity to develop a space between
Consider the qualities of traumatic material: compacted, repeat-
therapist and patient, within which it is possible for the one to res-
ing, shapeless narrative; collapsed time. Consider the qualities of
onate with the other. Music can also speak to the inner world and
silence: in presence, an open, receptive, reflective space; in absence,
personality of very disturbed patients, imparting a unique qual-
void. Through case material with a child and an adult patient, we
ity not only in the space between, but also within therapist and
will explore the ways in which music therapy can speak directly to
the traumatic, and the impact of silence within such work.
Music therapy is particularly effective with patients who,
because of their specific pathologies (e.g., strong defence mecha-
The state of the art nisms, aphasia, dementia, regressed states, or psychic disturbance),
lack the resources or motivations necessary for most forms of ver-
Within music therapy we find a kind of poetry, and a musical bal psychotherapy. In music therapy, we bear in mind and give form
process we describe as a form-giving exchange between patient and to psychic problems on a musical-symbolic level via a process of
therapist. We note that this is true even when the patient is not able musical improvisation, which is present and held within a thera-
to participate in improvisation; in this case, it is the therapist’s per- peutic relationship in music in conjunction with verbal reflection.
ception (both personally and musically) of the affective resonance Our art of music offers the possibility of coming into resonance
of the patient that provides the starting point for musical impro- with the psychic level itself, a level that is found mostly in a rough
visation. It is the music’s very qualities that enable the potential or almost uncultivated form, but which is necessary for the devel-
for such a direct, affective resonance to be sounded in the therapy opment of the therapy. Therefore, we define music therapy as a
room, via musical sounds and silences. form of pre-verbal psychotherapy, conveyed via a therapist and a
Like speech (language), music is a symbolic system specific to patient in musical improvisation. This is a therapeutic relationship
human beings, but which both underlies and contains more than between one or more patients and one or more therapists with the
a shared language meaning system. Music cannot “mean” in the aim of reducing or solving psychic difficulties, conflicts, or distur-
way that language might “mean”; music goes beyond the kinds of bances.
conceptual meaning that could be captured in words, but which In this article, we explore and develop further these ideas and
may underlie words. Music has a unique quality that enables direct include two clinical examples of work with patients’ traumatic
access to an affective and corporal aspect of the human psyche. material. Within the clinical material, we reflect on the thera-
pist’s maintenance of a particular type of human presence that is
personally and musically receptive to what might come from the
∗ Corresponding author. patient. It is in the spaces in which these kinds of presences live
E-mail addresses: (J. Sutton), that the patient and therapist can come closest to the particular (J. De Backer). sense of poetry available in music, in which, there is “a sense of

0197-4556/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
76 J. Sutton, J. De Backer / The Arts in Psychotherapy 36 (2009) 75–83

an essence” that as Ogden noted, “is not already there. . .waiting of thoughts and feelings becomes an act of staying with the primary
to be illuminated; it is newly created each time” (Ogden, 2001, p. process that is unfolding in the patient in the room. This process is
177). one that is fundamentally musical.
With traumatic material, the content reverts to a form of pri-
Trauma and repetition mary process thinking (Sutton & McDougall, in press; Williams,
2007). However, instead of the experience of musical listening,
Etymologically the word “trauma” refers to a wound, created time and space appear to collapse, leaving fragments of experience
through damage from an event or from different events (Garland, where past, present, and future appear simultaneously, alongside
1998). As Caruth noted, “trauma is always the story of a wound that the unbearable trauma that these connect with. Such fragments pop
cries out, that addresses us in the attempt to tell us of a reality that up, repeating endlessly in any one moment, where the one cannot
is not otherwise available” (Caruth, 1996, p. 4). Something compels be differentiated from the other. There is no bodily (embodied, or
the person to tell his or her story and to repeat it, creating a tension body-mind) connection with the movement of time as narrative
in the repetition that is in itself a compulsion to heal. Traumatic unfolding into the future.
events always repeat in order to try to form a story and a coher- Traumatic repetition results from the patient’s unsuccessful
ent narrative with which to shape what cannot be assimilated or attempts to annul the impact of traumatic events. Traumata have
understood. two aspects that Freud (1920) notes in the process of Nachträg-
Trauma is not a single entity, but involves an inner process ligkeit, in which initial experiences, impressions, and memories are
that can be compared to the concept of Fremdkörper,1 something afterwards experienced again. This re-experiencing takes place in
embedded in the psyche that is connected with other, undigested a further, developing phase wherein these experiences, impres-
traumatic events. The trauma is not only an external event. It is sions, and memories are reactivated, and out of which emerges
a linking of an external danger with a perceived internal threat new meaning. Stroeken (2000) explains it as a re-interpretation
(including its real link with the past), creating connections between of earlier experiences on the basis of new knowledge. This concept
anxiety about physical death and psychic death (Bertrand & Dory, involves a form of repetition that can also be linked technically to
1989). With internalisation of an external trauma there is a gap the analytic third space, which is in itself a creative act between
between the event and the response to it, within which exists the patient and therapist, but which must reside first in the therapist
traumatic experience. This is an experience that is new, sudden and (Ogden, 1997/1999). We hypothesise that in music we have many
overwhelming, and which from this point is then repeated end- possibilities for this creative process to open up, through the very
lessly. The repetition is described by Caruth as the original event act of improvisation, at the fundamental (primary) level accessible
“not assimilated or experienced fully at the time, but only belatedly, through the art of music. Music therapy follows a process in which
in its repeated possession of the one who experiences it” (Caruth, passive victim moves towards active player, as the traumatic event
1995, p. 4). is repeated in a play (improvisation).
External trauma can come into someone’s inner world in a In a music therapeutic context, we often experience the same
shocking and alarming way, where it remains unknown until the kind of music in post-traumatic play, which we define as a sensorial
point at which psychic pain is experienced, even when there may play (De Backer, 2006). Sensorial play describes the character-
be no conscious experience of this pain (as with dissociation). As a istic playing of patients who, while producing sounds, are not
result of the inner impact of an external trauma, a normal way of able to connect with or experience these sounds as coming from
living is disrupted. As one patient described, “When the external themselves. The patient’s music is characterised by repetitiveness
trauma happened, it felt like my jigsaw (a metaphor for her life and and/or fragmentation. The improvisation cannot really be begun
her being) was hit very hard from underneath, and all the pieces nor ended, and there is no clear melodic, rhythmic, or harmonic
went into the air. Therapy was like watching the pieces falling, and development, no variation, and no recapitulation. The patient is
seeing where they landed. You [the therapist] helped to make the perceptually and emotionally detached from his own musical pro-
edges of the new jigsaw, and helped me to see the shapes, old duction. Improvising, therefore, is not a real “experience” for the
and new, that were made when the pieces landed.” These words patient, who is neither inspired nor affected by the music and is
described the therapeutic process, which continued until a new jig- instead disconnected from his or her sounds and the playing of
saw was created by the patient, who simultaneously experienced these sounds. There is an absence of shared playing and intersub-
and noticed this process unfolding. jectivity with the therapist, in the sense that patients do not engage
in the joint music, and their sounds remain outside of and discon-
Music, repetition, time and trauma nected from them. “The music therapist experiences the patient as
isolated, becomes completely caught up in the patient’s music (i.e.
“Time becomes real to us primarily through movement” Roger Ses- the musical behaviour) and is not free to introduce his or her own
sions musical images; because of this, no interaction is possible, and it is
impossible to engage in a shared timbre in the ‘co-play”’ (De Backer,
Music can be described as an embodied flow in time of our sense 2006, p. 268).
of being. When listening to music, we have available the possibility We suggest that in clinical work the repetitiveness of traumatic
of experiencing ourselves as both familiar and changed. We lose play can be described as coming from a psyche that exists as a
a momentary sense of time, space, and personal identity, while packed, compacted mass. Through the traumatic event, the psyche
also retaining an overall sense of being and feeling. When we con- is so compressed and filled up that thinking becomes impossible.
nect with a process of receiving internally a music from outside It could be said that this compact and compressed psychic space
ourselves, the past and the present sit together in relationship, in can only spin around its own axis, where time has collapsed. The
and through time, as the music moves along with its and our past, music therapeutic process we have observed in patients, who move
newly experienced in the present, in motion towards a future that is towards an inner image or a musical form, suggests that in this
experienced as it is being shaped (Sabbadini, 1996). The therapist’s compact mass, a small opening can emerge. This becomes possi-
openness to staying with the unexpected in the ongoing movement ble when the therapist can be at the same level as the affect of
the patient, waiting for a moment to arise in which his or her
musical play can come into resonance with the different layers
“foreign body.” of the trauma. A part of the patient’s compact psychic space can
J. Sutton, J. De Backer / The Arts in Psychotherapy 36 (2009) 75–83 77

therefore be appropriated because of such a moment opening up, Example 1: A deathly sleep—work with a traumatised adult
after which mentalisation2 can occur, a process possible specifi-
cally through the appearance of a musical theme or of rhythms “Absolute silence leads to sadness. It is the image of death.” Jean
or a melody from patient and therapist working together. This Jacques Rousseau
indicates the first presence of a small space that could allow an
initial step towards symbolisation. In this first opening in the Vicky was born three decades ago, and arrived at her third foster
compact mass one can see brief moments of attunement happen- family at the age of 6 months. She was then adopted by this family,
ing. who recall that she had significant problems feeding and that her
Music can be called an art in which material can repeat ad short life up to this point had been full of disruption and confusion.
infinitum, but always with the possibility of endless variety, as for Vicky developed through childhood as impulsive and emotional.
example the music of Bach attests. This is repetition that takes place Her medical notes reveal a dramatic adolescence, full of conflict
in and through time, and offers patients the potential for an embod- and suffering, marked by an eating disorder, risk-taking behaviour,
ied experience of themselves, as their music (and they themselves) cutting, and overdoses. In her twenties, she was raped during a trip
become newly created from moment to moment, at the same to another country. The impact of this event and its aftermath, along
level at which trauma is experienced. We can see from work with with what she had experienced from her early years onward, led to
traumatised patients that there is a clear musical psychopathol- a serious overdose and further psychiatric treatment. Vicky later
ogy (sensorial play), but with a recurring theme of moments of mothered two children but the relationship with the father broke
being something other than this (moments of synchronicity3 ) that down.
coalesce towards more of a new musical embodied self (musical After a series of stressful events within the past year, she had
form). Moving through this process (both backwards and forwards) another major overdose and attempted to hang herself. She was
enables the patient to re-experience him- or herself as an active resuscitated but, due to hypoxia, she now uses a wheelchair and
participant, rather than a passive victim trapped in an endless has laboured and sometimes unclear speech, as well as confused
cycle. When the patient can find release from the confines of his memory and thought processes. Her neuropsychiatrist referred
or her traumatic prison, and discover a means of giving the trauma her for psychotherapy in order to ascertain how much of her dis-
a form of expression through musical improvisation, it can only ability was a result of traumatic brain injury and how much was
happen through a creative process in potential space (Leibovici, caused by the traumatic nature of her early life experiences. A
2007). music psychotherapy assessment was undertaken in order to meet
We explore further the ideas outlined above in two clinical Vicky’s traumatised inner world via the primary processing avail-
vignettes: the first depicting part of an early session with an adult able through clinical musical improvisation. Vicky attended an
patient at the limit of what can be treated dynamically; the second initial meeting and agreed to come to music therapy for 6 months,
describing an unexpected moment in further developed work with after which a further decision might be made about open-ended,
a traumatised child. Both examples can be understood in relation to long-term therapy. She is currently halfway through this 6-month
one another, showing subsequent aspects of the process of working process.
with sensorial play. The first vignette demonstrates how silence can On first meeting, Vicky entered the therapy room with an
be not only a defence, but also a protective shield through which ambivalent, distant, vague interest in the instruments and the ther-
nothing should penetrate. The therapist’s attitude towards, and lis- apist. She was compliant, with a tendency to mirror nuances of the
tening to, this silence is critical for the further development of the therapist’s facial expression and speech. She seemed to be merely
therapy. The second vignette describes how such a listening later a reflection of a person, psychically absent and responding in a way
enables a new space to emerge, within which intersubjectivity is that suggested she was mechanically producing what she felt was
possible. needed by the therapist. Yet, for brief periods something appeared
in the room that had a stronger and clearer affect, which felt to
the therapist as though Vicky was more present and alive. She was
wary of playing, but managed to explore the bongo drums and the
piano for a few minutes at a time, choosing to share the instru-
Not to be confused with the term “mentalisation” described by Bateman and ments with the therapist but abruptly closing off the music by
Fonagy (2004), we use it here to indicate a phenomenon of a process in which the
patient can digest mentally or musically his traumatic affect. In the musical space,
saying, “That’s enough.” She had no reflections about the music.
which is developed in the musical improvisation, the patient can play and think. “In While quiet and slow-moving, the music had been tense, with small,
the appearance of the musical form the traumatic affect and verbalisation will no fragmented silences during which Vicky disappeared. During and
longer be disconnected from one another and from now on, the traumatized patient after the session, the therapist experienced a deep, projected sad-
can speak for himself” (De Backer, 2006, p. 296).
ness and anxious confusion about recalling what had happened.
Synchronicity is a term that describes a point in time in which there is a shared
inner experience of the patient and the therapist, in which they feel free and The image of sitting with a two-dimensional reflection of a per-
autonomous in their play during a musical improvisation. This shared experience son remained throughout the week. At her next session, Vicky
appears unexpectedly and unintentionally, and is characterised phenomenologically arrived appearing more emotionally mixed-up than she did the
by attunement between the musical parameters of the patient and the therapist. previous visit. She stated she had no memory of being in the room
Both patient and therapist have the feeling that they are able to come into a gen-
uine shared play for the first time with an intertwining of two musical lines into
before, but recognised the piano and the drums. This made sense,
one entity, or one whole; for example, where both share the same pulse with shared because she had been barely present in the first session, yet did
accents in the meter. Underpinning this moment is the paradoxical experience of engage with more affect during musical play and on other brief
each individual’s freedom and autonomy. The mutual dependency in the creation occasions.
of a shared musical object leads to a liberating feeling of being able to make music
The following example is of a short piano duet from this second
in a completely independent way. The patient and therapist are free in relation to
one another and can play, think, exist, and develop his or her own musical thoughts. session, with Vicky seated at the treble register of the piano and the
This paradox involves emerging autonomy in the patient and therapist while, at the therapist at the bass register. She and her therapist exchange sin-
same time, there exists acceptance and recognition of mutual dependency. Amid gle notes. There is no sense of forward movement in Vicky’s music
this paradox, brief moments occur in which the timbre of both players intertwines. and she appropriates the post-resonance of the therapist’s first sin-
These moments of synchronicity can be brief, unexpected and infrequent, acting
gle note. Brief silences appear and fall into a void, with an almost
as possible precursors for the development of the musical form. Moments of syn-
chronicity usually appear at a specific or “right moment” in a shared experience (De tangible shock. Vicky’s notes do not resonate; they die away. During
Backer, 2006, p. 276). the play, the therapist is caught in an intense concentration focused
78 J. Sutton, J. De Backer / The Arts in Psychotherapy 36 (2009) 75–83

Fig. 1. Example 1 Vicky.

J. Sutton, J. De Backer / The Arts in Psychotherapy 36 (2009) 75–83 79

on staying present. At times, Vicky joins the therapist’s note’s res- apist will be of utmost significance. A primary musical listening
onance as if it breathes her alive for a fleeting moment. The impact to the material that cannot and must not be sounded is essential,
of this connectedness followed by a falling into a deathly silence for it is only in experiencing the therapist’s commitment to being
is terrifying for Vicky. She dissociates from this terror, but returns present at this level that the patient may first feel seen, heard and
for her next session in a distressed state. She begins emphatically, acknowledged.
“I want to tell you something important,” and tumbles out a story The strength of Vicky’s survival instinct is paradoxically in its
about a music teacher from her past who had a terrible accident, dissociated quality (autistic and/or autistic-contiguous position;
and who she wants to know that she is thinking of her but has Ogden, 1989). While it registers strongly in the transference, it
no way of contacting her. A feeling of intense pain and tragedy feels passive in another way. For Vicky, it is a desire for a death-
accompanies this story, which is relayed with the urgency of a trau- like existence and not a fight against it. She makes herself dead
matic narrative, with past and present intermingled. The therapist (not alive) so that the fear and the unbearable pain cannot touch
experiences Vicky in a disturbed psychotic state Fig. 1 Example 1: her. With this patient, it is the silence itself that is silenced;
Vicky. rather than destroy the silence with sound (as in the second case
The score shows how Vicky joins the musical play by attach- example), silence is not allowed to exist externally because of the
ing her own notes to the post-resonance of the therapist’s notes, presence of a different, dissociated, cut-off internal silence. This
in the same way that she mimicked the facial expression and ver- example reveals how unbearable silence is for the traumatised
bal utterances of the therapist earlier in the session. One can note patient. No open, alive, relational silence is possible, because the
that there is no possible forward movement, as the sense of time is patient must keep at bay the terrible pain of separation following
interrupted, and Vicky plays as if sucked into the therapist’s previ- a connection with the therapist, a connection that is wanted but
ous note (as at: ‘52). She does this in an attempt not to exist but to dreaded.
survive, remaining in her encapsulated state. At other points in the
play, two types of traumatic silence can be observed: first, where Mentalisation after the session
Vicky loses a sense of continuity in the music and herself, with her
sounds falling into nothingness (i.e. ‘27–‘28 and ‘31–‘33); second, Holding and working through the traumatic play of a patient is
where she breaks the potential for connection (as at: ‘49), by letting sometimes unbearable for the therapist. However, the music ther-
any hint of musical momentum subside. apist has, unlike the patient, the possibility of making it tolerable
Between ‘56 and ‘59, there is a single example of the beginnings and digestible by improvising in a reverie style after the session (De
of a live connection between Vicky and her therapist in which, Backer, 2008). Following session with this patient, the therapist
for the first time, a fragile pulse almost emerges. A melodic frag- improvised warm, gentle, holding music that was full of tender-
ment (c#-d#-a#) develops out of Vicky’s placing of the note d#, ness. A picture of Vicky as a small baby came immediately to mind:
in relation to the therapist’s preceding c# and following a#. How- a completely vulnerable infant who needed to be held with care
ever, rather than complete the melody, which would result in Vicky and gentleness. Through this (mentalisation) play, the therapist
appropriating the therapist’s first note of the group and maintaining could create in musical form everything that had affected her dur-
the momentum and forward direction (in full: c#-d#-a#-c#-g#), ing the session. Mentalising via these musical improvisations made
she loses connection with the music, preventing the melody from it possible for the therapist to back out of the mire of a traumatic
breathing further. At this point, the image of suffocating the music play. The therapist could then integrate the emptiness or compact-
came to the therapist in somatic transference. ness of the affect within an inner imagination (impression) and
The music continues much as before, with Vicky’s sounds let a hope and desire exist in order to continue the therapeutic
attaching to or avoiding the therapist’s resonant notes. A final post- process.
resonance of the therapist’s last note is accompanied by another We could describe Vicky’s music as an attempt to maintain a sta-
deadly silence, but this time with a quality of affect that is painful. tus in which nothing can intrude nor touch because nothing exists
Vicky looks at the piano notes, desolate and alone. A further intense to receive it. It is a position in which one remains impenetrable
silence then follows, similar to those experienced in the first ses- to what is outside, safe within a lonely fortress. Through the ther-
sion. Vicky says, “I find it hard to play, can’t play like I used to and apist’s willingness to sit beside this compact, deadly silence, and
that’s hard, do you know what I mean?” The therapist answers, “It through musical reverie after sessions, another silence could exist
hurts to play because you remember.” Vicky replies, “Yes, I could, within the therapist’s mind. Only when this internal silence can
you understand.” also exist in the room can a traumatised patient like Vicky sense the
One can sense how this work with Vicky exists in the silences presence of something alive in a less terrifying way. This emerged
before a note could be imagined, which is far away from the idea in a later session when Vicky asked the therapist to share a gaze
of a note being sounded. Rosenfeld (1987) has observed how some with her. Vicky repeatedly sought out, maintained, and then broke
patient’s earliest difficult experiences colour emotional connected- a shared gaze. This occurred in lengthy, intense silences, the quali-
ness at a fundamental level. These experiences leave them in a state ties of which changed. This was a new kind of silence, and one from
of terror during which they must guard against external intrusion which movement emerged, as Vicky experienced herself as con-
from the mother, blocking her out to avoid the pain of such con- nected to a reliable, stable other. During one prolonged silence the
tact. The confusion of different families in Vicky’s first 6 months therapist noticed, with surprise, that an auditory image appeared,
of life and her reported early refusal to take food from her foster in a silent, gentle lullaby. The space for this to be sounded was not
mother fits Rosenfeld’s picture of a baby turning away from con- yet available, but the anticipation of it was present.
tact. Work with such patients should proceed extremely carefully Another illustration of this process can be seen in the second
and gradually, focused on containment and the patient’s primary case, of Tony, who left an intense, full emptiness behind in the
need to feel safely held and accepted. Rosenfeld notes that these first sessions. However, unlike the patient, the therapist had the
children’s experiences “are also much more related to the inside of possibility of making the vibrating affect in his body bearable and
the mother than to the breast; and analysts who tend to interpret digestible through a musical improvisation. By improvising, a ther-
the positive and negative feelings only towards the nipple and the apeutic silence was allowed, something that was essential for the
breast rather than to the inside of the mother may find difficulty in mentalisation of the compact sessions, as via the play the therapist
reaching children of this kind” (Rosenfeld, 1987, p. 278). In musical gave form to the trauma that had to this point remained exter-
terms, we can note how the silent, embodied presence of the ther- nal.
80 J. Sutton, J. De Backer / The Arts in Psychotherapy 36 (2009) 75–83

Example 2: From deathly silence to open silence—work with how the tone ‘b-flat’ musically attracts Tony. It is not the sound
a traumatised boy that follows me, but it is I who follows the sound, and I am sur-
prised by something that pops up in the relation with Tony and
“The silence sank like music on my heart.” Samuel Taylor Coleridge react immediately.”
In a peculiar way, Tony experiences the sounds and the rhythm
Tony is a 9-year-old boy who is very short and small. He has a that appear unintentionally with the therapist as something that
chronic metabolism disorder, a disease that caused the death of his is not foreign to him and joins the musical play instantly. In the
younger brother a few years ago. Because his parents felt that Tony post-resonation of the therapist’s falling second tone “a ,” a space
had difficulties in getting over the death of his younger brother, they originates which is not only the psychic space of the therapist, but
contacted a music therapist to explore the possibility of treatment. also that of Tony. In other words, this is a shared psychic and musi-
The parents are both musicians and believed strongly in the poten- cal space that is inhabited by both individuals. This space originates
tial of music to help their son. It soon became apparent that Tony from a kind of “pulsing,” in that it is not one but two notes. The sec-
had an existential fear of death, shown through anxiety of silences ond note (a ) refers to the first (b-flat), connects with it and, through
(which we can describe as an experience of “deathly” silence). In this connection, then creates a pace. The second note creates a
his experiences in therapy, Tony discovered the creation of an inner space, which is the space between the first and the second note, and
silence through music, from which he could come back into contact between these alternated sounds the therapist and Tony could hear
with the traumatic—namely, his experience of loss and death. an inaudible inner sound. Sensing something from Tony and from
Tony always presented himself as a very active, excited boy who, the resonance between them, the therapist intuitively makes the
in the musical play, directly or defensively showed his fear of silence music sing a melancholic “sigh,” at which point the appoggiatura4
or of standing still. We often observe this phenomenon with trau- figure appears. The therapist’s session notes record a poetic image
matised patients. It is reminiscent of the personality of Frits in “De of “a sound of somnolent water, from an awakening wind, the sound
Avonden” (The Nights), a novel by the Dutch writer Reve (2007). Frits of an extinct season sounds of phenomena which are pregnant of
is a young man who tries to master a psychic crisis by talking con- an unprecedented meaning.” The second note colours the space not
tinuously in order to not be confronted with silence, because he only melodically but also harmonically.
is afraid that out of this silence his constant fear would surface. Tony then creates a silence by taking over the therapist’s pace
Musically, this can be related to, for example, repetitive, hypnotic that had emerged directly out of the resonance with his patient.
“house” music, or systemic music—that is, music that enables a dis- Tony plays with the pulse, and it can be observed that once there
sociated, altered state. It could be that Frits’ talking serves not only is the (musical) space, Tony can create his own perception of what
as a defensive act of negating the possibility of silence, but also as a occurs. Through this perception, he can seek out a specific rhythm
distraction (dissociation) and the manufacture of an altered state, or form for himself. This melodic movement is a falling minor sec-
whereby contact with the terror of deathly silence is kept at bay ond (from b -flat to a ), during which the dissonance is apparent in
and he can become lost in the sounds. a stretched form. This dissonance can be interpreted as the appear-
In a similar way, Tony does not allow a pause or a silence during ance of the traumatic material, which is now being carried by the
the first 12 sessions; rest and silence cannot and may not be present. therapist Fig. 2 Example 2: Tony.
The sessions are full of energy and sound, and Tony fluctuates from The specific feature of this improvisation is the appearance of
one play situation or improvisation to the other. Sometimes, out of pace—of forward movement and direction in the music. The ther-
the transference he beats the gong very hard and unexpectedly, apist offered the pace and, in a slowing down and stretching out
to assure himself that whatever silence could originate is being of time, an inner silence originated. This extended silence (a sup-
destroyed. Even though there is a certain rhythm in the sessions, ported resonance of sounds and melody) was the silence of the
he cannot allow a pause or a phrasing in his music. The therapist trauma, of the loss and the pain of this loss. For the first time, the
can feel the projected fear in Tony’s music. Tony has to continuously therapist experienced a seriousness in Tony, something that had
escape his inner conflicts, rejecting or destroying each overture the not previously been present. The post-resonance of the dissonance
therapist makes that attempts to offer the possibility of a phrase (b -flat to a ) made it possible for the traumatic to be present and
or a silence that would enable an access to his inner world via a contained. During this improvisation, Tony was finally able to make
musical form. a first step towards experiencing his sadness and began a process of
The therapist became fascinated by these musical improvisa- mourning. What first sounded outside, in the music, could suddenly
tions because of their dynamic movements and volume, noting with (thanks to the form of this music) be experienced as something
surprise the strength and determination that this slight boy dis- coming from within himself. After a long and intense silence, the
played. Play involving music and puppetry is central to the sessions, boy said in the reflection that he thought of his little brother and
leading to the session focused on in this vignette, and during which how he said goodbye to him. As we know, the traumatic experience
the therapist musically accompanies the events played out by the is always outside, with a challenge for the music therapist to be in
puppets. In a continuous, tyrannical way, on the musical level, Tony resonance with the patient, to listen to the silence of this trauma
destroys these dolls. The control of his fear and of the confrontation and allow the possibility of being surprised by a musical form that
with death happens through the power he gets over life and death makes it possible that the outside at the same time becomes an
via the dolls. inside.
The next session begins differently, when Tony enters the ther- This example illustrates the significance of silence in the cre-
apy room showing an unusual restraint and he chooses a new music ation of a musical form. We define musical form as everything that
instrument: the small finger cymbals. The beginning of the music the compact, repetitive, endless heaviness of the traumatic senso-
is surprising: Tony sits down quietly beside the therapist at the rial play brings into dynamic motion. This can only be set in motion
piano and a silence appears. The therapist’s session notes state: by penetrating this compact sensorial substance (the traumatic
“Immediately, I come into resonance with Tony’s inner psyche and material). By taking something away from the traumatic material,
myself. During this resonance, I ‘get caught’ by something that I a new space can be created that contains the silence that is taken
did not expect at all—an atmosphere of space that comes over and
inspires me. Not knowing what inspires me, I slow down my pace
spontaneously and discover that I enter into a kind of melancholy 4
An appoggiatura is a decorative addition to the primary theme of a piece of
state. I notice, again with surprise, how time is being stretched and music.
J. Sutton, J. De Backer / The Arts in Psychotherapy 36 (2009) 75–83 81

Fig. 2. Example 2 Tony.

from the sound. This silence enables us to move from the full pres- have ownership of the musical material, and the music produced
ence of the sound, and transforms it, so that it becomes possible remains completely external, foreign, and unfocused.
that all sounds might be given meaning in relation to one another. As we have shown, the phenomenon of silence is an impor-
The introduction of this silence is in this sense a symbolising tant aspect of music therapy and trauma. Sutton’s work (2001,
act. 2002, 2006, 2007) has introduced new thinking about silence in
Silence phenomenologically can appear in various forms. One music and music therapy; for example, illustrating how silence is
of them is what we term the anticipating inner sound (De Backer, significant as an organising principle during musical improvisa-
2006). One can describe the anticipating inner sound as the musi- tion. Within a clinical research focus, De Backer (2007) identified
cal presence of an inaudible sound, in the silence that the music concepts of silence that related to psychopathology and further
therapist experiences and listens within, at the moment they are developed these ideas in a process model of work with psychotic
going to play music with their patient. In the silence before the patients. Silence is the driving force of intersubjective play in
improvisation, the player anticipates the unknown that will come. improvisations during which there are moments of attunement
This “preparation silence” allows one to come into resonance with to musical form. Paradoxically, it is only thanks to moments of
oneself and, in a music therapeutic context, with the other, where silence (which act as a kind of punctuation) that phrasing becomes
an inner space must be created from which each authentic musi- possible, that sounds become structured and that musical form
cal play derives. This anticipating inner sound is not only inaudible, originates with traumatic patients. In musical form, we noted that
but also completely unknown and unpredictable. It is the sound silences added an important dynamic in the structure of the sounds
through which the player lets himself be surprised while listen- and rhythms that were being played.
ing, and which guides the musical improvisation; it is not thought We have shown that in sensorial play one can hear a compact
out, it does not belong to anyone, but is heard by the “third ear” silence, in which no movement or dynamics are possible. In con-
(Reik, 1998) of the music therapist when he displays a receptive trast, we noted the concept of an open silence, which is a silence that
attitude towards the presence of his patient. The player lets himself allows a psychic space and can be seen in parallel with Winnicott’s
be guided by the power that originates from this empty sound. After “potential space” (1971). In the first case example, we see silence
the silence that precedes the improvisation, the first tone sounds as a defence against a connectedness with another, a state into
and from this point one knows how the improvisation will elapse. which no one can be allowed to enter, because of a terrible terror
In music therapy, it is of major importance to have awareness of of being intruded into. Here silence itself is negated, destroyed, or
how patients enter into improvisation; for example, whether or not not allowed to breathe, and what remains is a deadly, empty space
they are able to allow this necessary anticipating inner silence, to where nothing can live. The therapist’s task was to take in and hear
allow themselves to be guided by something that they do not know, this silence and to find meaning in a nothingness. This was pos-
with the alternative being that they might immediately fill up every sible through musical listening, maintaining a space described as
possible silence with sound or noise. the intersubjective analytic third, and making use of mentalisation
post-session in order to open a space within which something as
Final thoughts about silence yet unknown might appear at a later point in the therapy.
If the therapist had instead filled the deadly silent space with
The two previous cases illustrate how traumatic patients have sound, she would have intruded upon and negated the patient’s
the tendency to fill up every emptiness and silence in order to avoid reality. Not to have remained present would have been to destroy
the possibility of creating a psychic space in which perceptions can in turn the potential for two people to exist, with the therapist join-
originate, and in which there might be fantasy or thought. Trau- ing the deadly silence. This process was one of staying with a lack
matic material makes it impossible to anticipate an inner sound not of anticipating inner sound, without a sign that anything different
only before a first improvisation, but also often stretched across a might be possible. It formed a therapeutic sense of hope for the pos-
whole play or throughout an entire session. It is also not possible to sibility of something else to grow. As such, the therapist’s silences
82 J. Sutton, J. De Backer / The Arts in Psychotherapy 36 (2009) 75–83

during and after session punctuated the patient’s silent void that own images and thoughts, with an intertwining of the timbre of
was present in the sessions. This void was a form of un-felt silence both players.
that the therapist recognised and aimed to feel and understand. The During this process, the sounds that are generated in a musical
process of mentalisation gave meaning to the therapy and would improvisation are guided by something unknown to the subject.
eventually enable the patient to feel accepted. The music resonates with an inner awareness of something that is
In the second case example, an open silence was introduced no longer experienced as external or unrelated. As we have shown,
through phrasing, holding sounds, or delaying and slowing down it is a form of poetry, and it can be discovered in the fundamentally
the tempo. Through this introduction, the pure repetitiveness of musical processes generated in which “potential potential space”
traumatic play could be broken, allowing the first moments of can be found (Williams, 2007), and through which the patient is
attunement to appear. In this vignette, silence created a space able to experience him or herself moving out of the traumatic mate-
in the compact mass of the psyche of the traumatised patient. rial into the shared connection of intersubjectivity. When musically
Through this silence, the full presence of the traumatic sound (in experiencing, listening, digesting and thinking, one is able to under-
terms of repetitiveness in sensorial play) could be transformed stand traumatic material at the level at which it occurs. In musical
into other sounds, which, in turn, gained a certain mutual value. thinking, primary processing is revealed in depth and detail. It
This space made it possible for the endless heaviness of senso- comes closest to what musicians know, that “Music can bring about
rial play to be brought into motion. The musical form originated a ‘different state’. . .it can take one out of time or enfold itself end-
here. The introduction of silence into it was a kind of symbolising lessly, as it were, within time. It can therefore be a process, and
act. simultaneously freeze time” (Brendel, 2001, p. 253).
As the case material has demonstrated, silence can only be truly As therapists we must find ways in which to come to terms with
felt if there is a connection with what previously happened, where the unbearable nature of the life experiences of our patients, in
what has sounded before continues to sound in what we term a order to remain present when traumatic material fills the therapy
linking tension. Such a tension becomes a “time-bridge” that can room. In the gap between the traumatic event and the response to it
carry a continuation of the music into a lived future. Without this exists the actual traumatic experience; but it is within this same gap
time-bridge, the connection between time and space loses its link- that another kind of space can be found to exist: the potential space.
ing character and becomes empty, without meaning or significance. We have argued that in musically perceiving, experiencing, feeling
In considering the space between patient and therapist in terms of and thinking about such spaces, we can be alongside our patients at
this potential for the significance of silence within musical play, we the same level at which traumatic material is experienced. Through
are in contact with an affective primary process, within which there musical listening and improvising, we can discover potential poten-
is a possibility for inner and outer worlds to connect. tial space within traumatic experience. In being alongside the
As Winnicott (1971) noted, the creation of such a space is at the un-sounded silences that contain the patient’s unbearable mate-
edges of both the internal and external, at the very place that we rial, and by finding our own musically resonant silent presence,
mark our being in the world. Potential space also occurs in time, we can offer some meaning to patients who have experienced and
as it bridges past, present, and future, while traumatic experience are caught inside the ever-repeating unthinkable. We believe that
robs us of our sense of this relationship of space and time. Musical this potential can be carried specifically in the state of the art of
improvisation enables the therapist to remain at the affect level, music.
and creates a space in which traumatic events once more can be
experienced, but this time in a safe context. During the patient’s References
musical improvisation with the therapist, while the uncontrolled,
Bateman, A. W., & Fonagy, P. (2004). Psychotherapy for borderline personality disorders:
terrible, dreadful traumatic core remains, there can be created at Mentalization based treatment. Oxford: Oxford University Press.
the same time a manageable, aesthetic distance—a new space. This Bertrand, M., & Dory, B. (1989). Psychanalyse et sciences sociales. Paris: La Découverte.
is a necessary process in order to mentalise the trauma, without Brendel, A. (2001). The veil of order: Conversations with Matrin Meyer (R. Stokes,
Trans.). London: Faber & Faber.
which the patient would remain trapped inside his or her repetition
Caruth, C. (1995). Trauma: Explorations in memory. Baltimore: Johns Hopkins Univer-
of the raw, unprocessed traumatic material. Without a therapeutic sity Press.
consideration of silence in work with the traumatised, the therapist Caruth, C. (1996). Unclaimed experience – Trauma, narrative and history. Baltimore:
The Johns Hopkings University Press.
will be missing the fundamental core of the treatment; for without
De Backer, J. (2006). Music and psychosis. Unpublished doctoral dissertation, Uni-
silence no space can be created. The state of the art of music speaks versity of Aalborg, Denmark.
directly to this process, coming out of and returning into silence. A 2006/phd-backer.htm.
delicate and depth-embodied understanding of traumatic silence De Backer, J. (2007). Die Entwicklung eines psychischen und musikalischen Raumes.
Adrian– eine Einzelfallstudie. In S. Metzner (Hrsg.), Nachhall. Musiktherapeutis-
in the therapist introduces a human presence with which to bear che fallstudien (pp. 45–89). Giessen: Psychosozial Verlag.
witness to the traumatic. De Backer, J. (2008). Music and Psychosis: A research report detailing the transition
In our work, the idea of mentalisation-in-music results in the from sensorial play to musical form by psychotic patients. Nordic Journal of Music
Therapy, 17(2), 89–104.
patient potentially coming to a musical form through the pro- Freud, S. (1920). Herrineren, herhalen en doorwerken. Werken 6. Amsterdam: Boom.,
cess of his improvisation. Musical form in a therapeutic context pp. 165–218
(De Backer, 2006) is a term describing a musical structure that is Garland, C. (Ed.). (1998). Understanding trauma: A psychological approach. London:
created within a symbolising process that develops from the foun- Leibovici, S. (2007). Trauma and creativiteit. Tijdschrift voor Psychoanalyse, 13(2),
dations laid down during moments of synchronicity (e.g., as noted 108–120 [jaargang].
in the second case vignette). Through such moments, which orig- Ogden, T. (1989). On the concept of an autistic-contiguous position. The International
Journal of Psychoanalysis, 70, 127–140.
inate out of traumatic sensorial play, clear rhythmic and melodic
Ogden, T. (1997). Reverie and interpretation: Sensing something human. London:
themes may appear that can be further explored or varied by the Karnac Books.
patient, and by patient and therapist together. Musical figures can Ogden, T. (2001). Conversations at the frontier of dreaming. London: Karnac Books.
Reik, T. H. (1998). Listening with the third ear: The inner experience of a psychoanalyst.
then be characterised by phrasing and pauses, with features of the
New York: Farrar, Straus and Giroux.
musical improvisation typically having a clear beginning and end, Reve, G. (2007). De Avonden. Amsterdam: Uitgeverij De Bezige Bij.
prepared for mentally by patient and therapist. This phenomenon Rosenfeld, H. (1987). Impasse and interpretation: Therapeutic and anti-therapeutic fac-
is always an intersubjective dialogue between patient(s) and ther- tors in the psychoanalytic treatment of psychotic, borderline, and neurotic patients.
London: Tavistock.
apist, in which both experience themselves as equal to the other, Sabbadini, A. (1996, March 16). On sounds, children, identity and a ‘quite unmusical
feeling free and autonomous to play, think, exist, and develop their man.’ Paper presented at a Study Day on Psychoanalysis and Music at the Centre
J. Sutton, J. De Backer / The Arts in Psychotherapy 36 (2009) 75–83 83

for Psychoanalytic Studies, University of Kent, Canterbury. Retrieved April 24, Sutton, J. P. (2007). The air between two hands: Silence, music and communication. In
2008, from N. Losseff & J. Doctor (Eds.), Silence, music, silent music (pp. 169–186). Hampshire:
Stroeken, H. (2000). Nieuw psychoanalytisch woordenboek. Amsterdam: Boom. Ashgate Publishing Ltd.
Sutton, J. P. (2001). The pause that follows. . .Silence, improvised music & music Sutton, J., & McDougall, I. (in press). The roar on the other side of silence: Some
therapy. Nordic Journal of Music Therapy, 11(1), 27–38. thoughts about silence and the traumatic in music therapy. US: Satchnote Press.
Sutton, J. (2002). Music, music therapy and trauma: International perspectives. London: Williams, P. (2007). The worm that flies in the night. British Journal of Psychotherapy,
Jessica Kingsley. 23(3), 343–364.
Sutton, J. P. (2006). Hidden music: An exploration of silence in music and music Winnicott, D. W. (1971). Playing and reality. London: Routledge.
therapy. In I. Deliège & G. A. Wiggins (Eds.), Musical creativity: Multidisciplinary
research in theory and practice (pp. 252–271). East Sussex: Psychology Press.