Assessing Trauma, Abuse and Loss via Guided Imagery and Music

by Amy Clements-Cortés, Ph.D., MusM, MTA, Mt-BC, FAMI

Abstract

Holocaust survivors often face many psychological and emotional issues such as fear, and intrusive thoughts and images as a result of the traumatic experiences they endured. Guided Imagery and Music is an evidence-based form of psychotherapy which has proven to be particularly effective for survivors of trauma in addressing such emotional and psychological issues and beginning the healing process. This paper presents the case of Rivka, a child survivor of the Holocaust who experienced numerous losses in her life. As Rivka was approaching her death she chose music therapy to address her current concerns as well as those from her past that she had not resolved. Guided Imagery and Music sessions helped Rivka assess and process her losses and fear and overcome her feelings of guilt and suffering, allowing her to move forward and feel free.

Introduction

This paper presents the case study of Rivka, a child survivor of the Holocaust and her process in Guided Imagery and Music sessions as she was nearing her death. Rivka was receiving home palliative care services when she contacted me. The interdisciplinary team working with Rivka at the time had been encouraging her to seek out therapy to help her assess and process the loss of her husband. Rivka decided to pursue music therapy to help her with those issues. She suffered many losses throughout her life, and the most recent loss of her husband connected her to earlier deaths and traumas from which she had not yet recovered. These traumas were worked though in Guided Imagery and Music sessions facilitated by an accredited music therapist.

Background information on the Bonny Method of Guided Imagery is presented below alongside further description of Rivka’s central issues, including verbal, physical and sexual abuse as well as identity.

Guided Imagery and Music (GIM)

Guided Imagery and Music (GIM) is a therapeutic process using music and a trained facilitator to create an environment to encourage personal insight that provides answers and guidance for significant life issues. The Bonny Method of Guided Imagery and Music (BMGIM) is a music-centered exploration of consciousness which uses specifically sequenced music programs to “…stimulate and sustain a dynamic unfolding of inner experiences” (AMI, 2012). GIM supporters believe that imagery and music are therapeutic agents; transpersonal and psychodynamic aspects are part of therapeutic process; and expanded awareness results in major therapeutic benefits (Burns & Woolrich, 2004).

GIM is based upon humanistic and transpersonal theories that emphasize the attentiveness of the individual and the influence of music on ego development. The classical music programs in the BMGIM provide structure and direction for the experience (Bonny & Pahnke, 1972). Essentially, music is the impetus that releases unconscious material such as feelings, images, and memories for use in therapy. Music is prescribed to enable the imagery process. The creator of the method, Helen Bonny, produced numerous music programs on themes including caring, peak experiences, imagery, grieving, relationships, and the music of Bach (Bonny, 1978).

BMGIM Session Structure

The BMGIM session format commonly unfolds through four different phases (Bonny, 1978).

• Phase  One: Opening conversation. Client and therapist find a therapeutic focus for the session.
• Phase Two: Relaxation induction. The therapist guides the client through a short relaxation experience.
• Phase Three: The music-imagery experience. The therapist plays a specifically designed program of classical music and the client images to the music. During the music listening, the therapist dialogues with the client, supporting and encouraging the client’s spontaneous imaging to the music. This process continues until the music program ends, usually around 30 to 40 minutes.
• Phase Four: Return and post-talk. The therapist helps the client bring closure to the imagery experience and return to an alert state of consciousness.

Introducing Rivka

Rivka, born in 1936 in Poland, was a child survivor of the Holocaust. She had one younger sister. Her earliest memories were of her family living in a ghetto. Her family managed to escape from the ghetto and hid in a Polish forest with others who also escaped. When her sister took ill, Rivka’s mother went to search for medicine and German soldiers found Rivka, her sister and father. Rivka watched as the officers shot her sister and father. The soldiers did not see Rivka as she had hid behind a large tree and she was small. Rivka said she did not really remember much after that except that she somehow went to the town and a couple found her and took her into their care. Rivka never saw her mother, who was also murdered, again. Rivka immigrated to Canada when she was in her twenties and married Levi in the late 1960s. They did not have children as the couple suffered from infertility issues. Rivka lived a lonely life, so to speak, with few friends or family members to support or care for her. Her soul mate and life partner was Levi. She worked as a baker in the business Levi had started prior to their marriage until she was 60.

Assessment

When I met with Rivka to conduct the music therapy assessment, it became clear that she desired to explore the loss of her husband, and to delve deep into her own subconscious to assess her fears of death and process the deaths of her father, mother and sister. Rivka had heard me speak about music therapy a few years earlier at a Holocaust Education Week event and she explained this to the interdisciplinary in-home palliative care team who provided her with my contact information. When I met her, she asked me about my experience working with survivors. My background in work with Holocaust survivors appeared to put Rivka at ease and she was willing to engage in therapy with me. “I don’t really believe in this whole therapy thing. I never did like talking about what I am feeling,” Rivka told me. “But I saw what you talked about and how you helped that other survivor and I think I can trust you.”

Together we explored the potential goals of our sessions and I introduced the concept of the BMGIM. I had not at that time done GIM sessions with a Holocaust survivor, but my experiences of working with survivors of abuse, trauma and loss guided me in suggesting this type of therapy to Rivka. I chose GIM over typical music therapy sessions as I thought this method would help Rivka access her subconscious and work deeply in a short amount of time; which was imperative as her prognosis was  under six months.

I explained the BMGIM to Rivka and described what sessions would entail. Together we listened to a few music examples and I asked her to draw and speak about the images that arose from that listening. This was done in order to prepare Rivka for the sessions which began at our next meeting.

Initial goals for Rivka in GIM sessions included:

1)      Working through her feelings about her husband’s death.
2)      Exploring her fears of death.
3)      Looking back on previous losses and coming to some resolution.

Sessions

Sessions 2-3: “Opening the Wounds of Death”

The first two sessions centered on Rivka’s exploration of the loss of Levi and early losses from childhood. Levi had been a strong, constant and loving husband to Rivka. She had never experienced such love until she met him in the 1960s. His loss was not only significant in her life as he was her husband, it was significant because he was, as Rivka said, “All I had in this world.” Rivka and Levi were unable to have children and she greatly missed him. She described that in some ways she was ready to die as he was no longer with her. “Sometimes I don’t know why I am holding on… for what?” she asked. Valent (1994) notes child survivors are particularly concerned with issues of identity, memory, and existential meanings. Rivka’s expressions suggest she questioned the lack of meaning in her life, her identity and/or purpose.

In session 2 Rivka’s imagery centered on her viewing corpses piled up, naked and rotting. She saw Levi amongst the dead and she was sitting by his side and weeping. There was no one else around who was alive. She was alone with thousands of dead bodies. She began assembling the bodies and burying them one by one but she grew weary and decided to lie beside Levi. She found an old coat from a German soldier that was ripped and dirty but she placed it on Levi now “to keep his spirit warm,” she said. Rivka covered her head with a shawl and began to pray.

Some of the direct words she spoke during the music program included:
“I smell the stench of burning bodies.”
“It is real, I can’t escape it.”
“Why did I survive?”
“Why is this happening again?”
“Once again I am alone.”

Kellermann (2001) states that child survivors of the Holocaust often have an inherent feeling of abandonment and existential loneliness, contributing to isolation and abandonment issues. Rivka felt very alone now that her life partner had died, and as she neared her own death her feelings of loneliness increased. Wiseman (2008) confirms that survivors of trauma often experience acute feelings of loneliness both in the midst of the trauma and in the aftermath of the traumatic experience.

In session 3, Rivka returned to the ghetto from which she had escaped. She visioned her parents and sister and clung to her mother weeping and stroking her hair. The soldiers started beating her mother and Rivka hid in a barrel she found. She heard people screaming but could not help them. She was small, weak and terrified. She wanted to help but decided to stay in the barrel. She was cold and hungry. It began to rain and the barrel was filling up and forced Rivka to get out. When she surfaced the rain began eating away at her. The rain was actually acid and it was burning her skin. She was alone and naked as the acid had eaten away all her clothing.

Hirsch (2001) recounts photographs and stories of Holocaust victims, which confirm that during the Holocaust, victims were often stripped naked and exposed, to be abused, killed, or humiliated. Further, Eitinger (1993) describes that in concentration camps, thousands of naked corpses would be found in various stages of decomposition. Rivka experienced horrific accounts of dehumanization during the war and witnessed images of nakedness and exposure. These images were still very vivid in her memory, thoughts and her imagery session today.

The GIM journey ended with Rivka sitting and weeping beside a pile of bones, some of which were Levi’s. Rivka talked after the imagery portion of our session about the acid. She felt in many ways the acid was representative of all the events, pain and suffering she endured during the Holocaust. The acid had eaten away at her spirit, and contributed to her feelings of hopelessness that she repressed that for many years. Young (2012) states that during the Holocaust, there were massive graves full with bones and skeletons, and that bones represent decay, death, and hopelessness.

Analysis and Reflections

These sessions marked significant steps for Rivka. She needed to go back and truly put some closure to the images and suffering she witnessed at such a young age by first acknowledging what she endured and then trying to express her anger about that time. She was surprised by the words she spoke during the imagery. She said, “These are things I have never spoken about, not even to Levi. … I don’t want them to fill my head anymore. I am going to die soon. I want it all gone.” GIM sessions were providing her with the opportunity to explore the deaths of her significant others, helping her find peace and  resolve traumatic memories, and giving her strength to move forward to confront her own death and her fears. By letting these memories out and finally talking about them, Rivka acknowledged she could be freer and more at ease as she prepared to die.

Sessions 4-6: “Hiding”

In session 4, Rivka began her journey in a basement. Moon (2005) states a basement symbolizes our subconscious, and things that are forgotten or things that make us feel ashamed and guilty. Rivka kept looking for a way out but could not find one. She was alone and scared. She said “I deserve this, I did not help anyone.” She described the basement and it turned out that it was the same basement that she had spent many days and nights in alone when she was taken in by the young couple during the war. Rivka found a doll in the basement, and the doll suddenly became a dove. As an image, doves commonly symbolize the Holy Spirit (McBride, 1975), but can also signify inspiration or uplif, while being universally recognized as a symbol of peace and rest that encompasses all cultures and traditions (Van Riper, 2007). Van Riper (2007) also states that a white dove represents the soul. The dove asked Rivka to get on her back and instantly the basement disappeared and the dove took Rivka high above the ground where she could look down and see what was happening on Earth. Rivka commented, “I can see now that it was not my fault. But why didn’t I die? … I have done nothing great with my life, I wasn’t even a mother.”

The dove turned back into the doll and Rivka began touching the doll’s chest and stroking her breasts. “This is what they did to me,” she said. With the support of the music I encouraged Rivka to say what she wanted to the couple. She began crying and hitting the doll, saying, “Why did you do this to me? I was a child. I didn’t know what to do. I didn’t know what you were doing to me. Why? Why?” Beitchman, Zucker, Hood, DaCosta, Cassavia, and Akman (1992) maintain long-term effects on adult women who were sexually abused are anxiety, fear, suicidal ideas and behavior. While Rivka did not suffer from suicidal ideations she did have overriding anxiety and fear that had accompanied her throughout her life. Further, Browne and Finkelhor (1986) acknowledge long-term effects of childhood abuse include depression and self-destructive behavior, anxiety, feelings of isolation and stigma, poor self-esteem, difficulty in trusting others, a tendency toward re-victimization, substance abuse, and sexual maladjustment. Rivka did suffer from low self-esteem and feelings of isolation and stigma throughout her life. When she met and married Levi she was able to trust him, but she did not have a large circle of friends. She essentially only let a few people close to her throughout her life. This could have been due to the lack of a trusting and supportive relationship in early childhood with a parental figure. Thomas (2005) highlights the importance of attachment and trust as a child, and how survivors of child abuse feel violated by the abusers.

After that session Rivka drew a mandala to help her process the journey and images. The paper was black and she colored half the page in white. When we discussed it she said, “I am starting to see the light. Before this therapy I could only see the dark since Levi died.” Rivka also discussed how much she had wanted to be a mother and she grieved that loss now in therapy. “I guess I never really knew until now how much I kept those feelings inside of how I wanted to be a mother.”

Rivka carried around a great deal of guilt about being the only survivor of her family. Garwood (1996) states that a central and persistent component of survivor syndrome for Holocaust survivors is survivor guilt, with a large contribution of self-blame. Robinson, Rapaport-Bar-Sever, and Rapaport (1994) found that in interviews with child survivors of the Holocaust, they still suffered extreme survivor guilt even 50 years after the war. In addition, Shmotkim and Barilan (2002) maintain that excessive guilt is a common symptom related to self-image and interpersonal behavior in Holocaust survivors. Rivka questioned why she had survived while so many perished and felt guilty that she allowed her sister and father to be shot by the soldiers while she hid. It surfaced that the couple who took in Rivka abused her. They hid her in the basement for days and only gave her one meal a day. They hit her and she also suffered verbal and sexual abuse. Moskovitz and Krell (1990) acknowledge one in six children in hiding were sexually abused, and the younger the survivor, the more pervasive are the potential harmful effects of traumatic experiences (Kestenberg & Brenner, 1986; Keilson, 1992).

Session 5 began with Rivka imaging and holding the doll from the previous session while she was hiding in a small hole in the ground. She said, “I have to hide here like when I was a child in Poland or they will find me.” By “they,” she was referring to the couple who took her in. She began scratching her face and rubbing her eyes (both in her imagery and while in the unconscious state) while saying, “The smell — I can’t take it any longer.” She looked around and began digging the hole deeper and deeper. She created an underground tunnel and she kept pushing to make the tunnel longer. She grew very weary and tired but kept plugging along. The smell was that of rotting bodies. “I smell the rotting bodies. I can’t get the smell out of my nose, my hands, my face, my eyes. I am blind from the smell,” she said. With the support of the music, Rivka was able to see what she had repressed for many years. She had not acknowledged her own suffering and abuse and was now expressing her anger and resentment about that time. “I can be freed from this misery,” she said. “I am letting go.” Mazor, Gampel, Enright, and Orenstein (1990) confirm child survivors cut off their memories of the past, thinking of them as belonging to an irrelevant past. Until now Rivka had repressed her true feelings of anger, resentment and hurt. Through GIM she was able to access those emotions and express them, in order to free them in her progress towards healing.

At the beginning of session 6, Rivka commented that she had thought a lot about our weekly sessions and she said, “You know, I was not sure at first, but I feel good about this now.” She articulated a goal for her session: “I am going to stop hiding.” I encouraged her to embrace that feeling and to use the music to help her accomplish her goal. As the journey began, Rivka was dancing and singing on a stage in New York City. She was floating across the stage and felt as light as air. The audience was commenting on her gracefulness and she was showered with flowers. The flowers were so fragrant. I encouraged Rivka to drink in the beauty of the flowers and to embrace these feelings of acceptance from the audience. Rivka said, “I have never felt so alive.”

In the post-talk that day Rivka said she always wanted to be a dancer, but never had the training to pursue it as a career. She also said she would not have felt comfortable being so exposed on stage until more recently. Levi did not care much for dancing and Rivka never had a chance to live out this dream. Instead of drawing a mandala after the imagery I suggested that Rivka and I dance to some music. I put on a few classical pieces and we each moved to the music in whatever way able. Rivka was somewhat limited due to her illness but could still move her arms in multiple ways and express whatever the music brought forth for her. This movement appeared highly therapeutic for Rivka. “I feel like a bird, I am free, freer now than I have ever been,” Rivka said. “I can let go and die… I want to see Levi again. I want to see Mommela, my Papa and my sister.”

Analysis and Reflection

These three sessions helped put some completion to the years that Rivka spent hiding during the war and also hiding in some ways in her adult life from living out dreams in fear of feeling exposed and vulnerable. She finally acknowledged the abuse she suffered and freed herself by talking about it. She had repressed it all her life and she was not going to bring this with her in her death. She had expressed it now and could move past this. She felt free and was looking forward to being reunited with her parents, sister and Levi. By accomplishing this, our sessions moved into the next phase.

Sessions 7-9: “Healing Water”

For the first time since we began therapy sessions, Rivka talked about her illness. “This cancer, my tumor is bad, but it is not as bad as the things I suffered as a child,” she said. “I was really scared when I found out I had cancer but since Levi died I don’t care as much now about it.” I opened up a discussion about Rivka’s feelings about approaching death, and specifically inquired if she was fearful or afraid so that we could explore and discuss these issues. Rivka explained that when our therapy sessions started she was afraid of death, and she still was to some degree, but not as much as before. “I can’t change that I am going to die, but I am not scared now. For a long time I thought I might see those soldiers who killed my family and I thought I would be abused again and helpless. I was scared because no one knows where we go when we die,” she explained. Through therapy Rivka began to understand that she was not to feel guilty about surviving. She could not have done anything differently and, in fact, she honored the family name by surviving and making a life for herself with Levi. Therapy was validating for her and contributed to her feelings of self-worth.

The imagery portion of session 7 began with Rivka sitting with her feet dangling over a small pond with a large waterfall in front of her. The water was warm and inviting and Rivka immersed herself in it and began washing and cleansing herself. She said, “Water, wash away my tumor, wash away my fear, wash wash me.” Bouguerra (2005) states that in most religions, faiths, and philosophies, water is baptismal, lustral, holy, vital, and purifying. As her therapist and GIM guide, I heightened this experience for her by encouraging her to drink the water and wash away all feelings of fear while accepting the cleansing nature of this water. Rivka stayed in the water for the entire portion of the imagery. She watched as several key people passed by in mirages or images in front of the waterfall, appearing from the mist. Among those were her mother, father, sister, Levi, and two friends who had passed away. They were all telling her it would be OK. She would be OK in death. She did not have to be afraid.

After the imagery portion of the session I encouraged Rivka to draw a mandala and she drew each of the figures she visioned holding hands circling the water. When we talked about the image, she said she felt that the water was helping her feel free and that in death she felt she would be free from the physical pain of the tumor and cancer and also the psychological pain of the abuse of trauma. She knew there were supports for her in death. She felt strongly that she would now see her mother, father, sister and Levi and that she did not have to fear death.

When I arrived for session 8 at Rivka’s home she said she had thought a lot about the last weeks in therapy. She acknowledged that we covered a lot of issues in a relatively short amount of time. She said today she was tired, and physically she was declining rapidly due to the cancer. I encouraged her to use this GIM session to help her recharge her spirit, find sources of energy and repose. I chose the BMGIM “Caring” music program as I thought this music would help awaken Rivka’s senses and open her up to experience a beautiful and aesthetic experience while feeling nurtured and supported by the music. Rivka’s imagery moved from one beautiful picturesque scene to another spanning from fields of vibrantly colored and fragrant flowers to hills and valleys with lush green grass and trees to its completion, where Rivka was immersed in water that she was drinking and said was it refreshing and nurturing.

At the completion of this session, Rivka and I discussed the content and progress of her sessions. Rivka said, “I think I am done here.” Instead of drawing a mandala I encouraged Rivka to list some words, themes, sentences or images that were important to her. I wrote these down for her and then suggested we turn these thoughts into a song. Rivka wrote the lyrics to the song and I assisted with suggesting a melody line to accompany the lyrics. I did not have a piano or keyboard with me this day and instead I sang the suggested melodies. We began to write the song, called “Light,”  whose lyrics are listed below. We decided to meet for one last session to finish the song and have a music therapy session as opposed to GIM session.

Light

There is a light, burning bright
It’s inside my soul tonight
I felt alone but now am free
Free to speak and see and feel and be

Chorus
In death I will be reborn
I no longer have to mourn
I have found new strength
In me I am strong!
I will no longer hide
I am proud to be alive
I have lived my life well
My stories are freed to tell.

When I met Rivka for session 9 it was clear to me that she would most likely die within the next few days.  She was very weak and our session consisted mostly of me providing relaxing music to ease her pain perception and enhance her sense of physical comfort. I sang the song we started to write last week but Rivka was too ill today to continue this project. Rivka died that night.

 Analysis and Reflections

In sessions 7 and 8 Rivka was able to solidify her therapy process and put closure to it via the imagery of the nourishing water. She had finally expressed feelings and memories she had repressed for years and she freed them, making room for the healing water and her ability to move forward from the trauma and abuse. It seemed appropriate that at the end of session 8 I introduced the idea of songwriting to Rivka as a way to express her feelings, emotions, thoughts and the therapy process.

Conclusion/Discussion

Although Holocaust survivors suffer long-term psychological and emotional effects of trauma, there are treatment options available to help survivors address issues and move forward in the healing process. Rivka was one such child survivor who had hidden and suppressed many important and serious issues until the end of her life, when she sought a music therapist to provide end-of-life care. Rivka took part in nine GIM and music therapy sessions which focused on helping her work through feelings of death about the recent passing of her husband, death and trauma suffered as a result of the Holocaust and her own fear of death. GIM was particularly effective at helping Rivka express, free and discuss her memories in order to move forward and bring some healing to her issues in a relatively short period of time. Near the end of life, Rivka needed closure on major issues concerning the Holocaust and other losses in her life, and she was able to achieve this through the Guided Imagery and Music process.

 

References

Association for Music and Imagery [AMI]. (2012). About. Retrieved from http://ami-bonnymethod.org/about/

Beitchman, J.H., Zucker, K.J., Hood, J.E., DaCosta, G.A., Cassavia, E., & Akman, D. (1992). A review of the long-term effects of child sexual abuse. Child Abuse & Neglect, 16 (1), 101-118.

Bonny, H. (1978). Facilitating GIM sessions: Monograph #1. Salina, KS: Bonny Foundation.

Bonny, H., & Pahnke, W. (1972). The use of music in psychedelic (LSD) psychotherapy.Journal of Music Therapy, 9(2), 64-87.

Bouguerra, M. L. (2005). Water: Symbolism and culture. Les Rapports de l’Institu Veolia Environnement, 5, 1-70.

Browne, A., & Finkelhor, D. (1986). Impact of child sexual abuse: A review of the research. Psychological Bulletin, 99(1), 66-77.

Burns, D., & Woolrich, J.W. (2004). The Bonny method of guided imagery and music. In Darrow (ed.). Introduction to approaches in music therapy. Silver Springs: American Music Therapy Association Inc.

Eitinger, L. (1993). The aging Holocaust survivor. Echoes of the Holocaust, 2, 5-12.

Garwood, A. (1996). The Holocaust and the power of powerlessness: Survivor guilt, an unhealed wound. British Journal of Psychotherapy, 13(2), 243-258.

Hirsch, M. (2001). Surviving images: Holocaust photographs and the work of postmemory. The Yale Journal of Criticism, 14(1), 5-37.

Kellermann, N.P.F. (2001). The long-term psychological effects and treatment of Holocaust trauma. Journal of Loss and Trauma, 6, 197–218.

Kestenberg, J.S. & Brenner, I. (1986). Children who survived the Holocaust: The role of rules and routines in the development of the superego. International Journal of Psychoanalysis. 67, 309-316.

Keilson, H. (1992). Sequentielle Traumatisierung bei Kindern. In Gertrud Hardtmann (Ed). Spuren der Verfolgung. Gerlingen (Bleicher Verlag).

Mazor, A., Gampel, Y., Enright, R.D., & Orenstein, R. (1990). Holocaust survivors: Coping with post-traumatic memories in childhood and forty years later. Journal of Traumatic Stress, 3, 1-14.

McBride, A. (1975). The gospel of the Holy Spirit: A commentary on the acts of the apostles. New York: Hawthorn.

Moon, C. (2005). Basement. Retrieved from http://spiritlodge.yuku.com/topic/1183#.UJfrUGtOzzp.

Moskovitz, S. & Krell, R. (1990). Child survivors of the Holocaust: Psychological adaptations to survival. Israeli Journal of Psychiatry and Related Sciences, 27, 81-91.

Robinson, S., Rapaport‐Bar‐Sever, M., & Rapaport, J. (1994). The present state of people who survived the Holocaust as children. Acta Psychiatrica Scandinavica, 89(4), 242-245.

Shmotkin, D., & Barilan, Y.M. (2002). Expressions of Holocaust experience and their relationship to mental symptoms and physical morbidity among Holocaust survivor patients. Journal of Behavioral Medicine, 25(2), 115-134.

Thomas, P.M. (2005). Dissociation and internal models of protection: Psychotherapy with child abuse survivors. Psychotherapy: Theory, Research, Practice, Training, 42(1), 20-36.

Valent, P. (1994). Child survivors: Adults living with childhood trauma. Melbourne: Heinemann.

Van Riper, S. (2007). Wings of white: Poems about white doves, with notes on white dove releases and the symbolism of doves. Tuscon, AZ: Beyond the Sidewalks.

Wiseman, H. (2008). On failed intersubjectivity: Recollections of loneliness experiences in offspring of Holocaust survivors. American Journal of Orthopsychiatry, 78(3), 350-358.

Young, D.G. (2012). The valley of dry bones [Powerpoint slide]. Retrieved from www.focusonjerusalem.com/TheValleyofDryBones.pps.