ARTICLES

Nordic Journal of Music Therapy, 11(2), pp. 165-179.

Restitutional Factors in
Receptive Group Music
Therapy Inspired by GIM
-The Relationship Between Self-Objects,Psychological Defence
Maneouvres and Restitutional Factors: Towards a Theory.
Torben Moe
Abstract
This article is based on a study concerning music psychotherapy based on a Group Music and
Imagery method. The model used is based on patients listening experiences during selected,
primarily classical music, specially designed for an inpatient setting. The patients report their
experiences to the group after the music intervention and the material is used as a part of the
therapy process. The music listening is supported by verbal guiding from the therapist, to help the
patients to focus.
Nine psychiatric patients diagnosed as schizophrenic or with schizotypical disorders participated in
a therapy group during a six-month period, and the study focuses on restitutional factors in the
therapeutic process and the patients evaluation of their therapy.
The methodology is primarily qualitative and the investigation is in two parts. Part one concerns
the patients evaluation of the therapy based on interviews, the GAF rating scale, and a qualitative
questionnaire including a mood test and aspects of the patients overall view of the therapy. The
results of this part of the study were published in this journal. (Moe, Raben & Roesen, 2000.)
The present article is based on part two. The experiences of four patients are analyzed, focusing on
their imagery during the music listening period. The role of the music and the images is discussed.
Data from the therapists log are categorized. The categories include restitutional factors in the
therapy process.
Based on these findings a theory about the relationship between self-objects, psychological
defensive manoeuvres and restitutional factors is outlined and discussed.
Keywords:

Introduction
During the last few years, I have conducted a slowopen music therapy group for patients suffering from
schizophrenia and schizotypical disorders. The

music therapy method used is a music and imagery

technique originating from the tradition of Guided
Imagery and Music - a receptive music therapy
method developed by music therapist Helen Bonny,
where patients report their experiences while
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TORBEN MOE
listening to classical music (Bonny 1978a +b, 2002).
This article focuses on a modification of the GIM
method, namely theoretical considerations based on
my PhD: Receptive Music Therapy with
Psychiatric Patients Based on a Modification of
Guided Imagery and Music (GIM) (Moe, 2001).
Summer (2002, p. 297) suggests the term Group
Music and Imagery (GMIT), which I have decided
to follow in order to separate the model used from
the individual treatment of The Bonny Method of
GIM. The Bonny Method of GIM (BMGIM) is
defined as an individual therapy, a music-centered,
transformational therapy based on specific premises
(Clark, 2002, p. 22). 1
My Ph.D. is an exploratory study of a new field
within music therapy, and there is no existing theory
in this area that can give a detailed description of
cause and effect in Group Music and Imagery
Therapy with schizotypical and schizophrenic
patients. During this study I decided that an
inductive, empirically governed theory generating
strategy of investigation would be preferable in order
to examine the data. I therefore chose a model
inspired by the qualitative research method of
Grounded Theory (GT) (Glaser & Strauss; 1967).
Inspired by GT, I divided the text, consisting of
the comments of 9 patients about their experiences
during music listening, into small units. This was
done in order to obtain a broader view enabling me
to find active themes and coherences in the history
of the patients. GT requires that there is a
construction of the categories. Serving as a
conceptual support the method led to a general view
and the forming of core categories, making up the
TORBEN MOE is a music therapist, MA, Ph.D.
stud. Head of the MUsic Therapy Dept. at Sct Hans
Hospital in Denmark. He is also GIM therapist and
chairman of the GIM association in Denmark.
Addr.: Department of Music Therapy, Kurhuset
SHH, Roskilde DK. Phone (+45) 46 33 47 45. Fax:
(+45)
46
33
43
52.
E-mail:
torben.moe@shh.hosp.dk
1

first steps in a theory, the foundation of the theory.

However, in this study a new theory did not emerge,
but the results have led me to further examine the
positive results in a field between GT, Object
Relation Theory (ORT) and narrative theory (Bonde,
2000). Expressed in simple terms, the basis of ORT
is that interpersonal relations are transformed into
internalized representations as described by
Fairbairn (1952), Ogden (1979) and Winnicott
(1951). In my view the GT basis points towards a
new understanding of ORT and towards a theory
on the meaning of narratives. This may serve as the
foundation of a theory on the relationship between
restitutional factors in GIM and self-objects, in
particular focusing on the conceptualising of
defensive manoeuvres, and why music listening can
have a personality promoting effect. While it is
broadly accepted that individual BMGIM therapy
in its classical form is too challenging for the
schizophrenic patient, the suggested group music
and imagery method seems to be a useful and safe
therapeutic tool for these patients. This expands the
possibilities of using GIM related techniques in the
field of therapy.

The Therapeutic Domain

The model in figure1 is an outline of the active
therapeutic field in the setting applied.
In the therapeutic setting there is a constant
movement between the intrapersonal and the
interpersonal domain. The fixed points in the setting
function as a training framework for the patients,
so that they can practise how to move between an
intrapersonal space, where they will come into
contact with inner object configurations, and an
interpersonal space, where these object
configurations can be divided and worked through.
Thus, there is an ongoing movement between
fantasy, reality- testing and intersubjective
understanding. Also, it is important to note that the
music, the guiding, the image formation and the

Summer (2002, p. 297) writes that the practice of group music psychotherapy, including Group Music and Imagery
(GMIT) requires the education and training of afforded accredited music therapists. Summer presents three levels of Group
Music and Imagery, namely supportive, re-educative, and re-constructive. In my opinion it is also an important advantage,
and in some cases maybe even required, to be a trained, licensed GIM therapist in order to lead this kind of group work,
especially with patients presenting a complex number of symptoms, or clients working with interactive group formats used
at the re-educative and re-constructive level. (Bruscia, 2002 p. 51).

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RESTITUTIONAL FACTORS IN RECEPTIVE GROUP MUSIC THERAPY INSPIRED BY GIM

group, constitute a therapeutically effective whole.
In addition, the therapy takes place in a social
context, which of course has an effect on the progress
of the therapy.

The Importance of the Music

In the setting applied, the patient almost
automatically touches unconscious material. Since
it is common knowledge in the clinical field that
psychotic patients are weak in their distinction
between their internal and their external world,
scepticism has understandably been expressed
towards the use of music and imagery techniques
with psychotic patients. (Wrangsj & Krlin (1995)
states that GIM is contraindicated for the psychotic
patient.)
Nonetheless the analysis of the empirical findings
shows that music therapy supports a psychological
development with the patients. I think there are
several reasons for this. Firstly, the setting, which is
aimed at making access to the unconscious brief and
structured. It could also be due to the fact that the
music is experienced in a space between the external
and the internal world, thereby matching the
schizophrenic patients view or experience of him
or herself in the world. Said in a slightly

commonplace phrase, you meet the patients where

they are, knowing that schizophrenic patients have
weak distinctions between the external and the
internal world.
The feeling of having a self is a core theme and
problem for schizophrenics. Apart from structure,
the music offers affective stimuli, which could be
compared to the affective feelings (real life
feelings) happening in the interaction between
mother and child during the formation of the self
early in life (Stern, 2000).
The most obvious effective factor is the ability
of the music to offer the patients an affective
mirror, which can function as a correlate. Because
the music contains both concrete and abstract
elements, the patients are promoted in their
imaginary treatment of themselves, which makes it
possible for them to experience their lives in a new
way. The music creates a nonverbal narrative
model through which the patients are inspired to
tell stories about themselves and thereby understand
themselves better.
I also believe that the positive result has to do
with the music mainly being experienced as
comfortable, and thereby decreasing the anxiety
level of the patient in the therapeutic situation2 . This
is one of the many potentials of the music, which
has been shown to have great importance for the

Figure 1. Model of the active therapeutic domain in Group Music and Imagery Therapy Projective movements
2

This is confirmed in a mood test questionnaire (Moe 2001 pp. 119), where several patients emphasized the feeling of
peace, safety and harmony as the most prevalent feelings during the music listening.

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TORBEN MOE
client group in question. Perhaps this sounds trivial,
but it is important to consider that to the patient it
could be felt as vitally important to survive the
first sessions.
Clinical observations showed that the patients
were generally more communicative after the music
listening than before, and I have considered the
reasons for this. According to the anamnesis of the
patients analysed by me, they were all characterized
by a lack of self-confidence and low self-esteem.
As the patients learn that they can connect music
and imagery with dynamic forces in themselves, this
creates in them a mastering feeling in the situation,
which builds up their self-esteem and selfconfidence. When the patient succeeds in
transforming stimuli into internal, meaningful
sensations, which are further transformed into
images and feelings (often entering into a correlation
based on the structure of the music), the patients
obtain a sense of self-coherence, inner continuity
and affective attachment. It is these very
foundational self-qualities, which are in varying
degrees dysfunctional in the psychotic state.
A psychosis involves a regression to experiences
of a more malignant character, but a regression can
also serve the self. The most foundational function
of the music in relation to the patient in the clinical
setting is to induce a comfortable feeling as a firm
foundation for their imagery experience.
According to psychodynamic theory, this state
of well-being can be described as a regression to a
state similar to a symbiosis, where the all-good
is, symbolically speaking, the mother feeding the
baby in a state of happiness. Supportive elements in
the music (e.g. soft tones and harmonies, a
predictable structure, and pleasant tempo, as in
Pachelbels Canon in D) are intended to create a
feeling of safety in the patient, decreasing the anxiety
level in the therapeutic situation, and in a wider sense
distancing the patient from the ultimate fear the
all bad - (in Kleinian terms: the punishing absent
breast, which threatens to destroy the child.)
The intended therapeutic role of the music in the
present setting is firstly to compensate for the fear
of extinction, and later to assist in giving the patient
the experience of surviving and thereby integrating
both bright and dark or more dramatic feelings.
The ambiguity of the music contains a possibility

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Nordic Journal of Music Therapy, 2002, 11(2)

of experiencing and tolerating important variations

of feelings.

Method
The Bonny Method of Guided Imagery and Music
(BMGIM) is based on patients experiences while
listening to selected classical music. In the individual
setting, the patient describes his/her experiences to
the therapist while listening to music in a relaxed
state. These experiences may be understood within
e.g. a psychodynamic or a transpersonal framework
of reference. There is emphasis on the patients own
understanding and insight. In Group Music and
Imagery Therapy sessions, patients can share
experiences in turn, for example with the therapist
as conductor, or they can share experiences after
the music-listening phase is over.
In BMGIM the music listening provides an
ongoing stream of images and associations which
often develop and transform, but because of the more
fragile patient category I worked with, I chose a
more structured session format.
The music-listening phase was limited to only
10 minutes of a 1 hr.30 min session, and each patient
told of his/her experiences after the music-listening
phase. Following this the patients experiences were
seen in the context of psychodynamic theory, based
on Yalom. This method of therapy can be described
as individual therapy in a group setting (Yalom,
1985). Yaloms ideas on Therapeutic Factors in
Group Therapy elaborated in his book Inpatient
Group Psychotherapy (Yalom 1983, p. 39ff), have
been sources of inspiration for my work.
The clinical setting
Sessions were composed in 3 phases: 1) the
preliminary conversation (prelude), 2) the musiclistening phase, and 3) a closing conversation
(postlude).
In the preliminary conversation (prelude), the
patients shared in turn whatever preoccupied them
here and now: for example, how they felt, what they
had experienced during the last week, or thoughts
they had about the previous session, about the future,
or about their relationship with their families or a
partner. This was followed by the music-listening
phase. The patients chose whether to lie on a mattress

RESTITUTIONAL FACTORS IN RECEPTIVE GROUP MUSIC THERAPY INSPIRED BY GIM

on the floor or remain seated in their chair during
the music listening. Before the music started, the
patients were prepared with 2 minutes of relaxation
exercises, focusing on breathing. The musiclistening phase was then initiated through the
therapists guiding. Guiding took place either before
or within the first few minutes of music-listening or
throughout the whole selection of music. Examples
of the therapists guiding could be asking the patient
to imagine a visit to a garden, or to explore a house,
or going on a boat trip. It was important to make the
guiding as simple as possible. Guiding was meant
to help the patient in structuring inner experiences,
but the patients own free associations were also
accepted.
As an important point, the music was not chosen
beforehand - the music therapist decided what music
to play just before the listening period based on
the actual atmosphere in the group after the
preliminary conversation. Examples of music
chosen were Pachelbels Canon in D, and the second
movements of Beethovens Piano Concerto No. 5
and Mozarts Clarinet Concerto in F major.3 The
music-listening was followed by the closing
conversation, which lasted approximately 45
minutes. As in the preliminary conversation, each
patient had a chance to be heard. The patients shared
images, thoughts and feelings experienced during
music-listening. These experiences were related to
their current situation, based on information from
the preliminary conversation and additional
knowledge we had of the patient. (Moe, Roesen &
Raben, 2000).
Data Collection
As outlined in an earlier article (Moe, Rosen &
Raben, 2000) the research method included:
An analysis of the patients experiences during
the music-listening based on Grounded Theory
A GAF test (Global Assessment of Functioning
Scale, DSM IV) which is an assessment of the
patients psychological, social and work-related
function level on a continuous scale of 0-100.
A Questionnaire survey after termination of
therapy. A qualitative questionnaire used for
clarification of issues concerning individual

therapy, e.g.To what degree do you find the

following aspects have contributed significantly
to the positive outcome of your therapy?
A Semi-structured interview including questions
based on cards with written qualities and
additional questions concerning the patients
view of the therapy.
After the end of therapy, the patients were presented
with 10 different cards representing 10 different
emotions and another set of cards representing 10
different written aspects concerning the process of
imagery formation during music-listening. The
patients were asked to place the cards in an order
indicating which emotions and which aspects of
imagery formation were the most prominent for
them. The card model is based on Yaloms
method for follow-up investigation of patients
participating in group psychotherapy, for the purpose
of clarifying and structuring the experiences of the
patient (Yalom, 1985).
Finally, and based on the following questions, the
patients were asked to identify aspects influencing
the course of their therapy:
A: External factors that had a positive influence
on the therapy.
B: Things you have felt were missing from your
psychotherapy.
C: Particular events or experiences in the music
therapy that have made the biggest impression
on you.
D: Particular events or experiences in the music
therapy that you have benefited from most.
E: Additional comments.
Findings
My preliminary theory or hypothesis regarding the
function of the music was that the music because
of its structure, dynamic and non-verbal narrative
character could help the patient create an inner
psychological structure in a divided and often chaotic
universe. The empirical findings seem to confirm
this. The investigation indicates that the music can
have a relaxing effect, which is important when seen
in relation to the sensitivity of schizophrenics to
vulnerability/stress factors. (Moe, 2000 p. 21).

3
In the project 95 different pieces of music were used, categorized as: 73 from the area of classical music (of these 53
single pieces from the GIM repertoire), 7 from New age inspired music, 3 jazz pieces, and 1 piece from a movie.

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TORBEN MOE
The active factors
The main results of my investigation are presented
in figure 2 as a catalogue of categories. According
to my analysis, restitutional moments occur at more
psychological levels. Partly a cognitive level, where
the primary focus is on the patients reflection on
themselves and their situation. Partly an emotional
level, at which the patients get in touch with
substantial emotions, and finally, an interpersonal
level, where the patients share their experiences from
the music listening with other patients in the group.
This means that the results can be seen in
consequence of both cognitive, emotional and
intrapersonal and interpersonal activity.
This will show that group music and imagery
therapy is mainly operating with various restitutional
factors, namely:
The music
The image formation
The defense aspect
The Group

Categories of restitutional incidents in the

therapy:
I. Cognitive level
a. Self knowledge
b. Effort to solve problems
c. Improved experience of inner self-coherence
d. Reflections
II. Emotional level
a. Installation of hope
b. Feeling the feelings
c. Ability to contain ambivalent emotions
III. Interpersonal level
a. Interaction with important others
b. Improved management of aggression in
here and now defensive manoeuvres
IV: Images which express core problems
V: Images which give important information
about the background of the patient
VI: Significant metaphorical transformations
Fig. 2: Catalogue of Categories

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Nordic Journal of Music Therapy, 2002, 11(2)

In order to explain theoretically how Group Music

and Imagery Therapy (GMIT) can positively affect
schizophrenic patients, it is necessary to reflect on
the connection between the different elements in the
setting, and the therapeutic process. In the following
model, I have illustrated a possible connection
between the therapeutic interventions and the aim
of the development process.
The aim of the treatment is that the patient
undergoes a development process from a self-view
based on a small and fragile ego in the direction of
a separating ego. This requires:
1) The patient experiences that it is possible to
take part in a relationship
2) The self-view of the patient (which from the
start is characterized by concrete thinking),
moves in the direction of a more cohesive selfview characterized by a symbolic selfrepresentation.
The development from concrete to abstract thinking
is a core theme in the treatment of schizophrenic
patients, as it is a prevalent opinion that
schizophrenic patients are not capable of
symbolizing.
It is a psychodynamic axiom that schizophrenic
patients live inside a chaotic internal universe, and
the aim is therefore that after a psychotic episode
the patient obtains a sense of continuity, self-acting,
physical coherence, sense of affectivity and intersubjectivity. The reason for the often-present
primitive aggressive impulses is continuously
discussed. However, there is a general agreement
that schizophrenic patients are easily influenced by
stress-vulnerability factors. It is therefore also
necessary to emphasize structure-building factors
in the therapy, first and foremost in order to keep
the anxiety level under control. If the anxiety level
is high there is a greater risk of a psychotic relapse,
and the possibility of the development of symbolic
thinking decreases proportionally. Because of the
concrete thinking, the schizophrenic patient often
experiences that he/she contains threatening
impulses, which will destroy both him/her and
others. This general opinion is confirmed to a certain
degree in the empirical material, e.g. when a patient
felt there was a monster within him, or another

RESTITUTIONAL FACTORS IN RECEPTIVE GROUP MUSIC THERAPY INSPIRED BY GIM

patient, who imagined a beautiful garden during the
music listening, but was convinced that her
appearance in the garden would destroy it.
Theoretically I believe that both the music in a
close relationship with the image formation and the
group matrix4 can help the patient dismantle the
aforementioned imagined destructive fantasies (the
megalomaniac fantasies), and thereby reduce the
anxiety level in the patient. This enables a
development process, where the fantasies, perceived
as concrete threatening impulses by the patient, can
be transformed into symbolic images. The aids in
this process are: the music, the image formation and
the group matrix:
The music stimulates the individual experience
of dark, bright and dramatic states in a reassuring
way. These are represented in the image formation
in a way which makes it possible to work through
these psychologically. The group matrix ensures

an interpersonal frame, which can contain the

dramatic fantasies put forward by the patients. These
ideas are illustrated in the model presented in
figure 3.
The analysis of the empirical material shows that
the patients primarily experience the music as a
factor bringing them into contact with their feelings
and their pre-history. The music has a catalytic
function, which initiates an emotional and image
creating engagement in the patient. This causes the
patient to purposefully step into a communicative
space where important experiences and problems
can be shared and worked through in the group. I
believe that the music offers the patients an
opportunity to experience themselves in a spatial
forum, and that via the narrative construction of
the music, the patients are being placed in a time
frame, which assists in creating some structure in
the chaotic inner universe of the patients. The

Fig. 3: The connection between the restitutional factors in Group Music and Imagery Therapy
4
The expression group matrix comes from the psychoanalytic theory concerning groups, which has been described by
Bion.

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TORBEN MOE
individual notes of the music function not only as
separate units, but are experienced as contexts, which
are recalled. Thereby the patients who are often
caught in the present may experience a
consciousness of the past, the present and the future.
Because the notes are pointing beyond themselves,
and are attracting or repelling each other, patterns
and melodies are created out of this foundation of
tension and relaxation, and these patterns and
melodies can be felt and related to by the patient.
According to the analysis, the music also installs
feelings of hope in the patients (Yalom, 1983) - as
an example, when the music is experienced as
beautiful and optimistic - which assists the patients
in discovering new possibilities in their otherwise
fixed and depressive view on life.

Towards building a theory

The Role of the Music
Seen in relation to the developmental aim, the role
of the music is partly to function as a safety-providing
factor, and thereby a structuring element, and partly
as a projection screen. In other words, when the
music functions as a container for the patients
projections, this also helps (along the way) to
decrease the anxiety level of the patients. I think
that when the patients project their feelings into the
music they have the possibility of displacing the
responsibility for the result. Anyone can say that it
was the music causing the uncomfortable or violent
feelings (if, for example, it was violent or dramatic)
rather than admitting that those feelings were within
themselves. Thereby the music may carry some of
the potential feeling of guilt. This decreases the
anxiety level of the patients, so that they are not
fixed in an unbearable feeling. The patients are
thereby given the possibility of choosing whether
to carry the responsibility for certain feelings
themselves or to place the responsibility on the
music.
The music legitimises and contains. On the other
hand it also becomes legitimate and allowable to
have violent fantasies (which the music contains),
or to become intimate when the music gets persistent
or gentle, or to experience conflict when the music
expresses conflict. This is also the case when

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Nordic Journal of Music Therapy, 2002, 11(2)

experiencing passion, emptiness and loneliness,

feelings which several of the patients came into
contact with during the music listening (Moe,
Roesen & Raben, 2000. pp 36).
The music is metaphoric and stimulating in itself,
and via the collective aim to listen to the same piece
of music in the group, talking about inner
imaginations is legitimised. You can easily imagine
that for most it would be very provocative and
exceed boundaries to talk about their fantasies, but
with a joint starting point in the music, the dialogue
about the fantasies becomes more legitimate. In
addition, it is a commonly known phenomenon that
music supports feelings and images, e.g. in films
and advertisements.
According to the analysis, the music often brings
the patients into contact with important emotional
states. When the patients have the experience of
surviving, e.g. dark and light mood, the general fear
of extinction is eased. The imagery, which is often
generated by the music, thereby indicates that an
important process of symbolising is initiated.
Via the music the patients is provided with a tool
a model for working through their emotions at a
basic level. The patients thereby become able to
handle their anxiety pressure in a more useful way,
which involves a strengthening of the self. A
therapeutic development spiral is thereby initiated,
where the patients little by little experience and
internalise more models, which can be used for
processing. So, when the patients discover that they
are able to handle the challenges presented by the
music, they obtain an embodied experience of inner
tension (or fear of the unknown) being neutralized
or transformed into something else an important
psychological competence or coping-skill. Figure 4
is a model showing foundational modes of
experiencing the music
The Importance of the Group
The most important function of the group is to
function as a container in order to test difficult
emotional states, whereby an opening is created for
the patients to begin to reflect common problems.
The group creates an intersubjective foundation, in
which the patients fantasy material meets reality.
As mentioned, the group has a containing function.
The patients are motivated by each others stories,

RESTITUTIONAL FACTORS IN RECEPTIVE GROUP MUSIC THERAPY INSPIRED BY GIM

and this engagement can help breaking the autism, 1971), both between the individual patient and the
which is one of the symptoms most disabling to a music, and between several of the patients in
schizophrenic person. According to the case certain cases the whole group and the music. This
descriptions (Moe, 2001) feelings of isolation are creates feelings of affinity and communion. A
expressed as part of the problem for all the patients, partnership is developed, which is very important
and all the patients have expressed a wish to work as regards the relations in the group.
Views which may be closely connected to a
through this problem.
concrete
way of thinking, may thereby when
Because the patients are presented to a collective
shared
and
contained in the group be transformed
introduction through the opening images, a common
into
a
fantasy
in the inner symbolic representation
ground is created in the group, which reduces the
systems.
As
an
example, a patient explained that
fear level and increases the possibility of both
she
felt
there
was
a monster inside her which could
identification and variation in how the group
destroy
the
whole
group and the patient herself. By
members understand each other. The patients gain
experiencing
that
the
group survived the story
an insight into each others experiences of the music,
they
saw
each
other
the
following week - the patient
which enables an increased understanding and
found
that
the
fantasy
was dismantled and
mirroring on an interpersonal level. Joint experiences
dedramatized.
The
fantasy
thereby
lost its concrete
of the music create twinship experiences (Kohut,
effect. Such experiences in
a group are very
important, as we live in a
society consisting of
groups. It is therefore
important that the patients
have the opportunity of
assimilating
the
experiences from the
therapy group into their
lives.5 When the patients
find that their destructive
fantasies are contained in
the group this increases
their belief in the
possibility of a relation,
which is a premise for
development. (Moe, 2001,
p. 91). The patient finds
that both positive and
negative feelings are
possible and allowed,
which makes a beginning
integration of good and
bad objects/states possible
(Yalom, 1983).

Fig. 4: Foundational modes of experiencing the music

The Importance of the

Guiding
The guiding is part of the
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TORBEN MOE
setting and also functions as a structuring and
thereby safety creating factor. Through the guiding,
the patients are offered a joint starting point and a
focal point in their either chaotic or empty inner
world all according to whether they are
characterized by positive or negative symptoms
(expressed in their anamnesis).
Like the music the therapist (the guide) functions
as a projection screen, as the patient can displace
unbearable or unwanted feelings by saying that it
was the therapist who decides the focus image given
in the beginning of the session, and the music chosen.
It is also important to note that the guiding is an
instrument - the instrument heard by the patient
just before and/or during the music the tone of
voice and the way of speaking must be adjusted to
the music.
It appears from the empirical material that the
guiding functions as a structuring factor and is a
support to the patients. Several patients expressed
that the guiding was a support to them in creating
imagery (Moe, 2001, p. 239 ff)
The Importance of the Image Formation
The image formation symbolizes the patients inner
object (con)figurations, and the development of the
patient is reflected in the transformation and
reconfigurations of the images. The patient can
understand certain images and metaphors very
concretely, as the image formation immediately
catches configurations from the subconscious, but
the contact with this space creates a basis for
differentiating. My analysis shows that the fear of
the concrete understanding e.g. a configuration of
a core problem - can be discussed with the therapists
and the group and thereby be better controlled.
Image formation is a form of thinking which
makes possible a further understanding of sensuous
experiences. According to the data, perception,
memories and fantasy are combined and recombined. The patients thereby obtain a new
understanding of sensuously based connections and
the sense of new differentiations and coherences 6 .
The image formation is closely related to sense
5

impressions, and the imagery often evokes feelings.

This means that narration of memories is often
experienced as present and alive the here and
now principle (Yalom, 1983). Another substantial
reason for imagery is the importance of images in
connection with working through traumas. As lexical
representations and visual representations are
organised and stored differently in our
consciousness, it is important to describe both
representational forms in order to work through and
integrate the traumatic experience as completely as
possible.
As an example, a patient relived a train journey
connected with a traumatic core experience, where
he was obsessed by the thought of throwing himself
in front of a train. After the music listening phase
the patient told about his feelings and thoughts in
this connection. The imagined situation thereby
became both present and processed, both lexically
and metaphorically. The patient experienced not
having suicidal thoughts in the imagined relived
situation, and this concrete sign of restitution created
space for working through also the traumatic part
(or illusion) of the experience, which was thereby
liberated from a psychotic basis.
Finally, the images often express an immediate
quality or degree of an emotion. Images are well
suited for describing complex affective levels and
the re-experience of traumatic events, which can be
hard to explain verbally. The imagery caused by
the music and/or the guiding, is the pivotal point
between the patients understanding of him/herself
as a concretely thinking person or as a symbolically
thinking person. The patients self images enable a
discourse about the patients history. Even talking
about and thematizing - the self, creates a
possibility of also reaching more problematic areas
in the prehistory of the patients. Often the image
formation configures object relations, and by
comparing the various sessions, specific problems
within patterns of object relations appear. The image
formation can also illustrate different aspects of the
self-experience of the patient. As an example, in a
session a patient experienced herself as alternately

Further, it was observed with a few patients that they adopted the whole therapy ritual and group idea. After the
conclusion of the therapy period, they established a set time in the week where they met in a less formal setting and
listened to classical music on the ward.
6
Horowitz (1983) states that the connection between fantasy, memory and perception allows a person to review
information for new meanings, to contemplate objects in their absence, and to seek new similarities and differences.

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aggressor and victim. An aggressive part inside her
was throwing stones at a little bird another part of
her. The image can be seen as having a role model
quality, which can be discussed in the group (for
example feelings of guilt or a sense of shame can be
worked through). Because of the passing narrative
movie it is possible to catch alternately conscious
and subconscious self-identifications, which can be
difficult in a normal lexical situation. Another aspect
of the meaning of the imagery is the meta
understanding. According to the identification of the
metaphoric process (Moe, 2001 p. 287 ff; Bonde,
2000), the metaphor is a symbolic representation of
self-states. The differentiation inherent in the
definition (namely that one thing is described
according to another, so that a third thing is created
out of this comparison), involves a possibility of
psychological development seen in relation to the
theory about the patients concrete one-dimensional
thinking. Via the metaphor, the patient (and the
therapist) obtains a possibility of experiencing the
situation from a new angle. Siegelman (1990)
stresses a very important point in relation to the
development of schizophrenic patients, namely that
through the metaphor itself something is developed.
Furthermore the metaphor is connected with the
language of the primary process often
characteristic of the thinking of the schizophrenic
patients. In my view, the language of the primary
process is symbolic (e.g. the language, which we
use when we dream), but the schizophrenic patient
in a psychotic state sees, forms and acts out from
the symbolical language, as if it was concrete. It is
therefore important that the schizophrenic person
can get to understand the language of the primary
process as a metaphoric and non-concrete language.
Further, I would like to stress that I do not view the
physical way of thinking, and the metaphoric way
of thinking, as simply primitive, early versions of
the lexical mode of thinking. Rather I am of the
opinion that all three forms of language are
developed analogously through life. Another way
of describing the aim of the development of the
patients is that they obtain a greater free flow in the
way they move between the two different ways of
thinking, as this freedom has been limited because
of various blockages in the inner representational
system. A possible causation of a blockage could

be that the processing of stored traumatic

experiences has not been able to take place because
of repressive circumstances earlier in the patients
life. This could result in the suppressed images
appearing as very unpleasant and invading
configurations, as the unprocessed psychological
material always tends to find a way of emerging at
the conscious level. This way of creating space for
new experiences seems plausible seen in relation to
those traumatically coloured images presented by
my patients. To a certain degree this can serve as an
explanatory model for the self-destructive images/
fantasies of several patients. In addition to this, a
too high level of fear will block the patients image
configuration of stored traumatic material. This is a
further reason for focusing on how the stress level
in the group can be kept under control.
A pivotal point for the therapeutic value of the
patients image formation is also the question of
when the patients contact with the fantasies involves
an increased withdrawal into an autistic universe,
and when the fantasy contains the seed of increased
self-realization. According to the empirical material,
the foundation of an increased engagement in reality
often seems to rely on the experience of fantasies
connected with hope. The installation of hope
(Yalom, 1983, 1985) is necessary in the building of
a basic trust, which is naturally connected to the
ability to establish connections and relations.

Self images, Transitional objects, and

Defensive Manoeuvres
One part of the categories of restitutional incidents
I categorize as the defensive manoeuvres of the
patient. In the therapeutic situation it is possible for
the therapist (and the patient) to gain an insight in
the constitution of the defensive manoeuvres, and
thereby the patients aggression management.
Goldberg (1994; 2002) states that defensive
manoeuvres in BMGIM are an adaptive means of
coping with deeply or potentially stressful or
threatening experiences. A defensive manoeuvre is
essential to avoid fragmentation or disintegration
of the ego (Goldberg 2002, p. 364).
From the data of the empirical analysis I get the
impression that the defensive manoeuvres are
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TORBEN MOE
functioning as buffers, to protect the self against
overwhelming stimuli. An example of this can be
seen when the metaphoric configuration simplifies
a complex problem into a single platform.
Hereby an actualisation of the metaphor happens,
underlining certain aspects, but concealing others.
Depending on the context, any metaphor, e.g. a
patients experience of being a chief, can be
understood as the ability of the patient to picture
him/herself in a positive light. The chief could be
a desirable role, but at the same time this could be
interpreted from an opposite point of view asbeing
the patients hidden/unconscious fear of feeling
helpless and powerless. I understand the ambiguity
of the defence based on this context. The patient
being capable of dividing positive and
(subconscious) negative experiences could be
compared to the defence mechanism called
splitting. The therapeutically important potential
is the fact that the configuration can be produced,
whereby positive and possible negative perspectives
can be shown.
I also reach the conclusion that defensive
manoeuvres can be assisting images or assisting
states, which strengthen the ego. These images are
often generated from the dynamic of the music,
thereby having a vitalising effect, which the patient
can absorb as a kind of empowerment which again
strengthens the patients sense of their self. This is
a configuration that gives the patients a feeling of
resistance, which is of primary importance, as this
is exactly what schizophrenic patients are often
lacking. Whether this phenomenon can be
categorized as defence manoeuvres is debatable.
To begin with, an almost magic resistance can
characterize the assisting images. However, as the
self is developed, the images could adopt a more
differentiated character, e.g. a more common belief
that action is worthwhile in certain circumstances.
Therefore, I suggest that the phenomenon
assisting images can be understood as a type of
(inner) transitional object in the Winnicottian sense,
where the patients play with their inner powers.
Assisting images or safe places can also be
understood as a twin phenomenon or an idealized

self object, according to Kohuts theory of a

continuous narcissistic development all through life,
which is based on an ongoing development of
creative elements in the psyche. Kohut states (in
Sand & Levin, 1992, pp.161) that self objects do
not refer to specific persons or caregivers, but rather
they are seen as performing vitalizing, psychological
functions that pertain to the lifelong maintenance,
restitution and transformation of the self experience.
All in all, Kohuts theories on self objects
(reflecting objects, twin objects and the idealised
objects) go well with my empirical findings, and as
an explanatory model they can support the
development tendencies of the patients.7 Via
idealised wishful tales and fairy-tale like stories, the
patients seek to satisfy basic needs and to realize
themselves. (For example, one patients wishful idea
of being the first engineer to sail the seven seas).
When the patient, assisted by the music (which in
itself can be a self object), configures self objects or
self part objects in himself, in the form of wishful
tales, these configurations constitute an important
component in the inner restitution of the patient. As
Stolorow (in Sand & Levin, 1986) points out, the
development of the self is related to integration of
both new and conflict filled affective experiences.
Stolorow suggests that a subjectively experienced
object obtains the function of a self-object, which
pertains fundamentally to the affective dimension
of self-experience. When the psychological
integration of an individual is threatened, the
coherence and the continuity in the self-experience
are diminished, which results in a fragmented self
experience. Stolorow mentions that the
fragmentation is often a consequence of an
inadequate affective responsivity, and that the
restitution of the self is a restitution of a sense of an
affective context. Stolorow writes, it is the subtle
shifting and interplay of these internal self-states that
are the organizing agents for every individual
(Stolorow, in Sand & Levin, 1986). In the process
of (re)establishing the integration between object
and effect, the music plays an important role as an
integrating/connecting agent and bridge builder.

7
Kohut originally described his theory based on the case The tragic Man. It was his view that the patients tried, on the
basis of their core self, to realize ambitions and ideals, and that the degree to which they succeeded in this reflected either
joy or satisfaction versus feelings of despair and loss/rejection.

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RESTITUTIONAL FACTORS IN RECEPTIVE GROUP MUSIC THERAPY INSPIRED BY GIM

The Theory construction seen in a

developmental psychology
perspective
Seen in the context of developmental psychology
Kohut (1971) and Stern (2000) seem to have some
interesting theoretical views, which contribute to our
understanding of why schizophrenic/schizotypical
patients could perhaps benefit from the model of
Group Music and Imagery Therapy.
In several sessions it was observed that the
patients were active at several psychological levels,
as illustrated in the model shown in figure 5 with
an example from the clinical material.
Patient A experienced himself as an ice dancer.
The music induced a whizzing feeling in him8
(kinaesthetic/senso-motoric influence). The
sensation spontaneously caused a configuration of
himself as a skater (a positive self object), dancing
with a skating princess. Everyone was there, and
the king and the queen applauded (the therapists?).
The image is placed in a brief narrative context,
which can be interpreted in the group. A is puzzled

about himself he usually does not daydream, and

he reflects on himself. (Cat. I-d in the category
model).
Integration between several of these levels can
be observed, which can be understood in a
developmental psychology perspective. In figure 6,
I have tried to illustrate such connections according
to the outline of Sterns developmental theory.
On the right side of this model I have indicated
Sterns theories about the developmental levels of
the child. Further I have added Horowitz, as
Horowitz has worked on theories about the image
representation system (Horowitz, 1983).
The more controversial aspect of Sterns theories
is that in contrast to traditional psychoanalytic
theory (i.e. Klein, 1946; Mahler, 1975) the
primary and secondary processes should
ontogenetically be exchanged, as the child only
gradually learns to symbolise, and that the sense of
reality is present already at the time of birth. Stern
also assumes contrary to Mahler that the child
never enters into a symbiosis with the mother, but
that it already at the time of birth has a dawning

Fig. 5: Active Operational Levels

8

Which Stern calls a vitalizing effect (Stern, 2000).

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TORBEN MOE
sense of its self, and experiences attunement and
likeness versus separation at a sensing level.
According to Stern the children experience
themselves as physically limited, and gradually also
emotionally limited, very early on in their
development. After the establishment of the basic
senso-motoric competence the child enters into an
attachment relationship, which can activate inner
images as self-representations. Stern expresses that,
what dominates the consciousness of the child is
that it experiences being the origin of its own actions,
and that it has a will (experiencing the core self).
This is different to Kleins theories, about the split
fantasy universe of the child and the split selfawareness at the same time in the development
(Klein,1946).
According to the empirical material, the patients
image representation system is activated and
functional. In my category system areas are
highlighted where the imaging is activated as well
as examples of image transformation. It also appears
that the patients are capable of structuring and
making emotional connection of certain images,
which thereby become self-objects, and also they
are capable of connecting images in inner object
relation patterns.
How then, is this to be understood in
developmental psychology terms?
From the empirical results it seems to be the case
that, if the ability to symbolise/create inner images
has been established, it is possible to
psychotherapeutically process stranded and

Fig. 6: Ontogenic Model

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Nordic Journal of Music Therapy, 2002, 11(2)

fragmented self images and object relations with

schizophrenic/schizotypical patients in the setting
given.
My theory is and this contradicts Klein, Mahler
and Wilber (1986) that this is due to the patients
having a sense of an inner core self, and that based
on this sense, a contact is created via the music with
the experience of the damaged subjective self, which
then enters a repair process where exactly stranded
objects are identified and picked up.
A sense of hope and trust is thereby generated
in the patients, and in connection with a detoxication
of megalomaniac fantasies in the group; a positive
treatment spiral is activated. In this process, the
patients awareness of their core self grows, and
thereby the patients become more able to produce
and incorporate vitalising self-images, thus
stimulating an increased autonomy and self control.
The development of the patient is to be understood
in the field between the production of self-objects
and psychological defence manoeuvres.

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