Synthesis Sunday: Dealing with Aggression in the Music Therapy Session

I am a music therapist.

I consider myself to be a music therapist who specializes in treating people with developmental disabilities who also have concurrent psychiatric diagnoses. Almost every single one of my clients has a history of traumatic experiences, and many of those traumatic experiences include sexual and physical abuse. Almost every single one of my clients has learned to remain safe in the world that they know through aggressive behaviors - "I'll hurt you before you can hurt me." This is the reality that I walk into every work day, and is the reality that my clients have.

As someone who has chosen this population and continues to be part of the treatment of my students, I have learned to see behind and beyond the surface of the aggression to some of the possible causes of the responses and reactions. My current study of trauma, trauma-informed care (T-IC), and recommendations for treatment continues to enrich my level of understanding of what happens in the minds of my clients in specific situations and increases my repertoire of responses when crisis and aggression occurs.

As a music therapist who routinely works with people who become aggressive, I've learned several things that I'd like to share with others. 

Aggression is rarely rooted in simple anger. It may be a product of fear, frustration, feeling trapped, or exhaustion, sadness, selfishness - there are many different roots to aggressive behavior.

Aggression is the result of learning. At some point, my clients were able to escape situations that they did not like when they hit or bit someone. Humans learn to do what works for them and then repeat what works in other situations. Aggression is a learned behavior that gets quick results. People leave you alone when you attempt to bite them, and then you don't have to: get that shot - finish that counseling session - apologize to another person - be abused. 

The best thing to do when confronted with an aggressive person is to regulate your own responses. I meet angry, frustrated, scared clients all the time during music therapy sessions, and I've learned how to project a facade of calm. When I become counter-aggressive or confrontational, I serve to escalate the situation for both the client and for myself. When I am able to appear calm, I have the ability to think through what is actually happening in order to start to fix the situation.

How do I do this? Practice and training. I have been trained in physical behavior management for many years, so I know when to use my body to assist someone in remaining safe. Those skills, however, are a last resort. There are many other skills and techniques that are available to me before I get to the point where I have to put my hands on another person to maintain their safety.

For me, the most important part of working with clients who have the potential to be aggressive is remembering my non-physical techniques for defusing crisis. Again, the first is to project that attitude of calm into the situation. When I am faced with an aggressive client, my heart starts to beat, my breathing becomes a bit more labored, and I start into my own crisis response (which is most often a flight or freeze response). I have to remain in the present moment and in command of my thoughts, actions, and words to help us all be safe.

Over my years of working with this population, I've learned to start with my breathing. Before I speak, I take a deep breath and attempt to relax my muscles. I continue to breathe during any and all confrontations, and I keep going until I have the time to give into the adrenaline rush that happens to me. Sometimes I have to keep going for hours in order to keep music therapy treatment going for my other clients.

The second thing that I do is to drop my voice volume and pitch. If I am confronted by someone who is yelling, I get quiet and try to portray calm. I will often repeat one phrase over and over again in an attempt to make an impact on what is happening. Sometimes I even chant or sing my prompts for safety and desired outcomes.

The other thing that I do is constantly monitor our safety - the safety of the client, the safety of others clients, and my own safety. I will casually go around the room, collecting materials that could be harmful. I will do this as I am still running music therapy interventions, focusing on calming techniques and coping skills. If a client becomes aggressive, I can go down several paths, and I choose the path that I want in that moment. Sometimes that means physical management of unsafe behaviors. Most of the time, though, it means removal from the session itself.

Then, as the therapist, it is my job to assist my other clients to use their coping skills and to release their adrenaline in safe manners. The session does not end just because an aggressive person leaves (at least, not in my facility). Everyone is affected by the behavior of others, so everyone needs to process the event and find a way into calming.

In my many years as a therapist for this population of people in our society, I've been hit, bit, scratched, kicked, injured, spat on, called offensive names, and these things will continue. I know this. I've lived with this fact for 25 years now. I've survived in this brand of music therapy because of a couple of things - most aggression is not based in anger, and it is not always personal. I've learned to regulate my own responses to the behavior of others, and I've learned to release my responses in an appropriate manner for me.

I thought that this might be a good way to continue to process my current synthesis subject, that of trauma-informed care. The majority of my clients are affected by trauma, and many of the behaviors that we see during their time with us is also born from traumatic experiences. This filter encourages me to view aggression directed towards me from a different perspective than many who work with my clients. It helps me defuse situations that others escalate. It helps me be safe in the face of clients who may become aggressive, and it keeps me coming back to more music therapy sessions and therapeutic relationships with people who are difficult to interact with.

When I was a younger therapist, I was telling my dad about a session that I had with a client. 
Me: "Dad. Client didn't kick me today!" 
Dad: "MJ, why do you work with clients who kick you? You could work with other people." 
Me: "Because there are days like today when Client didn't kick me. That makes it all worthwhile."
Dad: Silence...

It's hard to explain, but at the root of every situation lies the therapeutic relationship - even when one member of the relationship is aggressive. That relationship is the foundation of interaction in the moment and in the future.