Lucia Torre
psycologist, musician, music therapist

In this article we describe the treatment of a patient affected with serious epilepsy. We based the music therapy work on strengthening the mother-child interaction, inspired by the psychodynamic theoretical model. It is centred on the "Iso" principle and on the "intermediary object".
The change occurred through: affective "tunings" (Stern); empathic mirroring; sonorous dialogue; sensory stimulation; vocal and instrumental improvisation.
We used the "sound- rhythm- movement" paradigm for going back to the archaic and primitive forms of pre and post-birth communication.
We stimulated and increased the interaction between the patient and his mother within the music therapy relationship.

Case history
Leonardo is a child who, in his short life (he was born on 2/8/1995), already has a serious, "severe" clinical history behind him which is extremely difficult for his family to accept and to endure, especially considering his body weakened by so much suffering.
Second of two children, he was born by Caesarean after 37 weeks of pregnancy. His mother tells me that during the first three months of the pregnancy she suffered a detachment of the placenta, but in the amniocentesis and checkups everything appeared to be within the norm. At the moment of birth, due to clumsy handling by the nurses, he fractured his right collarbone and already in the first hours of life problems of adjustment and adaptation and a slight deformity of both hands, or rather a muscular retraction of the ring fingers, were observed. The child slept for a lot of the time, didn’t suck, didn’t cry, wasn’t reactive and manifested respiratory seizures.
In this dramatic start to his life his relationship with his mother was also seriously damaged. M. (Leonardo’s mother) tells me how, not without an enormous sense of guilt and a huge weight of emotional experiences, in the first few days after the birth she couldn’t take him into her arms, nurse him, look at him or caress him, so great was her refusal of his physical appearance and of all the problems that the child showed.
At 4 months he became ill with chickenpox and at the end of the illness there was a rise in temperature accompanied by a convulsive fit.
Following this episode he was taken into the care of a neuropsychiatrist who put him on an preventative anticonvulsant treatment.
Around the 5th month the boy had another convulsive fit which was this time diagnosed as epilepsy.
From this moment on his life and that of his family (above all his mother) was completely devastated and went into a never interrupted whirlwind of stays in hospital, trips to specialized centres and attempts at treatment with extremely strong medicines which caused innumerable side effects.
At 5 months he is thus admitted to hospital in Pavia and goes into a pre-coma state, with a "condition" that causes 40 fits a day. During this period his mother is always present, his only familiar, reassuring figure. She comforts him, cradles him, talks to him, caresses him, hugs him, sings him a wordless lullaby whose melody is copied from a sponge toy that she puts on his pillow to send him to sleep. After the initial refusal their bond becomes more and more secure, intense and full of kindness and affection (M. has put her own life to one side to be close to her son).
The diagnosis is very severe: Leonardo suffers from a rare and very serious pathology: Partial epilepsy with migrating seizures.
He is hospitalised in Paris, at the Saint-Vincent du Pol hospital where he begins an experimentalt reatment based on a drug (stiripentol, which he still takes today) that causes oesophageal ulcers, chronic constipation, feeding problems with consequent loss of body weight, and muscular hypotonicity.
The illness is characterised by continual multi-focal random seizures (that involve both hemispheres of the brain); resistance to conventional anti-epileptic drugs; lack of demonstrable aetiology; considerable psychomotor delay. The seizures are frequent, they take place in sequence and often they start covertly even when, after previous releases, the patient is improving. Neurological deterioration, due to the block of myelinisation, causes a gradual loss of eye contact (cerebral hypovision), the incapacity to grasp objects and loss of motor and socialization abilities. Between several consecutive seizures patients are floppy, they tend to lose saliva and they often show drowsiness. They can’t eat or drink and when another block of seizures takes over they get worse.
At present the boy shows all of the symptomatology, but the continuity of the treatment has reduced the frequency of the seizures. Also his feeding has slightly increased (although the condition of malnutrition remains) and, thanks to the administration of semi-solid food he is learning the chewing mechanism.
Music therapy observation I had the chance to observe the child for a long time in his family context at various times of the day and throughout the course of the treatment, which started in October 1999 and concluded in November 2001. Using the music therapy evaluation protocols suggested by Boxill (1991), I performed an overall evaluation of his relational and communicational behaviour and of his reactions to the various sonorous, tactile, visual, sensory and motor stimuli.
Leonardo is a gentle and quiet child, but his silence is extremely "noisy", thick with emotional and affective experiences. His body is fragile, delicate, and thin to the very limits of survival. He has a thoracic kyphosis with cervical compensation and protracted shoulders. He spends most of the day laid out in his bed in a supine position, or sitting in an armchair or on a settee.
At a motor level there is a generalized hypotonicity, but he can hold a sitting position with support and with a moderate control of his torso. His head, however, falls forwards or backwards if not held.
Placed in a prone position, he frees his arms with help and makes as if to lift his head. Motor stereotypies are present, particularly in the head and both arms, which move continuously from left to right and viceversa. His lower limbs, however, are slightly more tonic and Leonardo makes small movements in an attempt to lift them, or stretches them out, tensing the muscles.
His manipulation and exploration of objects is much reduced due to his difficulty in grasping, intensified by the muscular retraction of the ring fingers, however, if suitable stimulated he makes as if to explore them and to initiate a type of game, managing to integrate the visual channel with the tactile one. From this point of view the child receives continual stimulation from the innumerable games, psychomotility objects and other objects created for him by his mother that are scattered around the house. The child shows that he is able to stare (for example, he looks at some objects that hang from the walls of the room), to follow an object even if it is not particularly coloured for a short way, up to a distance of about a metre. Beyond this distance he gradually loses visual interest.
He is attracted above all by noises and sounds around him, despite not always being able to differentiate them. When he hears these sounds, he looks towards their source, excluding the visual channel. In the first observation sessions I stimulated the child with various instruments and each time he turned his gaze and stopped to listen for a few minutes. He was particularly attracted: by the tambourine, moving his hands closer to it and lightly scratching its surface; by the maracas with which I caressed his whole body while he responded with a slight smile; by the triangle (the one with the higher frequency) whose sound completely grabbed his attention.
But the instrument that could draw him in completely at a physical (vibro-tactile) and mental (sensations, perceptions, emotions) level was without doubt the piano. The sound of this instrument seemed to be appreciated by the child. When he lay on top of it and listened to my sound-musical playing he responded continuously, showing curiosity and pleasure with tonic and mimicking variations Every so often the child utters sounds (a sort of muttering) or some vocalizations (rarely) and manages to say two words (water and mummy).
Before the seizures he also managed to emit warbles He doesn’t cry (he has never cried) and he doesn’t laugh, rather he emits wailing sounds and smiles.
His communication takes place on a completely non-verbal level, through smiling and some tonic variation, but his face and his gestures are extremely expressive.
The first time I met him I was struck by his eyes, which, at that moment, expressed sadness and "told" his story, but at other times communicate wonde r, serenit y, anger or irritation. Sometimes he closes them, withdrawing into himself into a sleep that appears to be a defensive condition, expressing a lack of trust or a desire not to communicate and to isolate himself. On other occasions he knits his eyebrows or opens them wide, especially when he is in his mother’s arms and is listening to her voice. His preferred communication object is his mother, who for him re p resents life. I observed how rich their relationship is in "affect attunement", small communication signals which make them both happy in a continuous interplay of non-verbal adjustments and attuning. 
Leonardo loves physical contact, kisses, caresses and his mother’s spoken or singsong voice. When his mother turns towards him, or moves around the room, the child brightens up and reactivates his sensorial channels. When she picks him up and cuddles him he livens up and appears visibly happy, more dynamic and more receptive. If his mother moves away he expresses, through facial mimicking, his disappointment and his loneliness and more often than not he takes refuge in motor stereotypy or immobility.
In rare moments of restlessness his mother’s verbal participation and their tonic dialogue immediately reassure and calm him.
Leonardo accepts his mother’s touch in all parts of his body, responding with moderate relaxation and, sometimes, he makes to caress his mother’s face and hands. In my arms, or those of another stranger, he is tenser, he stiffens, but if his mother is nearby and speaks to him, reassuring him, he gains trust, relaxes and accepts the contact, the relationship.
Sometimes his mother asks him questions (for example, "are you hungry?", "where does it hurt?") and the boy answers with gestures, touching a part of his body (his mouth if he is hungry, his nose if he has trouble breathing).
His mother is the person who feeds him (he only accepts food from her), who looks after him, who makes him feel safe and who encourages him to explore his surroundings, whereas the other family members (father, brother and babysitter) are equally as important but more marginal and less "attuned" to his state of mind and his communication system.

Intervention method
The treatment took place over the course of two years, with brief periods of interruption, and had a frequency of two 40 minute sessions a week.
The setting consisted of a not very wide semi-soundproof room with soft lighting. The materials I used were some musical instruments (piano, tambourine, maracas, castanets, sleigh bells, triangle, drum, cymbal) and some small coloured objects in fabric or plastic belonging to the child (including a bracelet made of concentric circles, a blue satin scarf and gloves with a sound game at one end).
I used the rhythmic-sound-musical element with a double functionality: both as an "activator", making use of the wide range of timbre qualities, variations of intensity, low-middle-high pitch range, constant rhythmic pulsations modulated in agogic; and as a "container", aiming especially at physical relaxation and at the retrieval of primitive, archaic, reassuring, feeding sounds, creating an atmosphere like a "sound bath" In the light of the observations made in the first phase, I considered the mother’s constant presence to be essential and necessary. She participated actively in the sessions and was the linchpin of a project aimed at strengthening mother-child communication through the integration and attuning of their emotional states with mine, in a constant search for a sound identity. The start of the session was typified by a welcoming and greeting period in which I created an environment favourable to relating by means of a sung and played welcome motif. As Edith Boxill (1991) states, the "contact song" provides a secure base for the person, it is a statement of trust, of being, of becoming, of going beyond".
The melody, played in the middle part of the piano, was very simple and mainly based on third intervals in binary time (both characteristic of most children’s songs), in a descending progression in the key of C major. 
In the bass I harmonised with simple major chords played as arpeggios.
This motif remained unchanged throughout the sessions and it formed a signal of recognition of the activity that the child was about to perform.
His mother’s voice, singing along with me, formed a further positive reinforcement.
Often the child was agitated at the beginning of the session, showing motor stereotypy and tensing his lower limbs, but the contact with his mother who held him in her arms and the sound of the piano, in particular of the welcome song "Ciao Leonardo", made him relax completely, so much so that he stopped to listen with great attention, often turning his head towards me, stretching out his legs and releasing the muscular tension. The child was then laid on the lid of the piano, mainly to receive the vibro-tactile stimulations produced by the instrument. This technique allows us to involve patients at a physical as well as auditory level, especially in pathologies with multiple sensory disabilities or severe motor damage. 
The music therapy approach in Leonardo’s case was based on physical resonance which makes use of the sound waves coming from the body of the piano.
This vibratory effect enabled strong emotions to be evoked in the child, accompanied by strong internal sensations which are also good for stimulating physical exploration. In musical improvisation or in the reproduction of songs, music, sounds characteristic of the Iso of the child’s or of the mother-child pair I took my cue from every movement Leonardo made, his facial expression and the non-verbal (postural, physical, rhythmic, vocal, gesture) and verbal dialogue of the relationship between M. and Leonardo, with the intention of mirroring them with sounds and rhythms, establishing similarity and synchrony between feelings, states of mind, body movements, behaviours and the sound/ musical production. 
During the improvisation I put myself into a condition of maximum empathetic listening (internal and external), respecting the pauses, the response times, the silence, my perception of emotional states and sensations; and thus I also encouraged and stimulated the communication, confirmed, changed and redirected the behaviour, integrating Leonardo’s and his mother’s responses with my musicality.
In a circular game of sound-music (proposal-response), gesture and physical dialogue, Leonardo’s mother stimulated him in various activities which involved his arms and legs, or other parts of his body, mirroring the result of my improvisation and vice versa, I improvised in response to their interaction.
I gradually moved from the lower to the higher register of the instrument, recreating M.’s tactile stimulation which started from Leonardo’s feet and moved up to his head, and vice versa, a quick stroking movement from his head to his feet using a coloured veil in a descending motion that I recreated with glissandos.
His mother also stimulated him with extension and stretching movements of his arms until he touched an instrument positioned a certain distance from his head, on a very soft melody with a calm, relaxed modulation produced by playing the black keys with both hands in an ascending motion, reaching a climax with a chord sustained for a long time (with the same sounds) at the moment of the greatest extension. In the relaxation stage, his mother produced a slight tremolo in his arms that I recreated with right hand trills over a descending pentatonic melody in the left hand. The boy responded to these stimuli by relaxing all of his muscles, relaxing his facial expression and smiling. 
Thus, I used a wide range of pianistic techniques (trills, staccato, small runs, acciaccatura, appoggiatura, legato, scales, chromatic and not, arpeggios), of variations of intensity (heavy, light, soft, energetic touch), of rhythmic pace (slow, fast, andante, allegro), of harmonic and chordal possibilities, of tonal, atonal, modal and pentatonic elements, or unstructured, always attuned to what was happening in the relationship at that moment. At times M. "rocked" Leonardo’s body by twisting his bust and legs from right to left, or from below upwards and my improvisation mirrored all these movements with childlike, rocking melodies, although rhythmically clearly pronounced, with strong intensity, or staccato, "pulsating" note or chords which made the boy "pulsate" (as if on a rocking horse). 
The stimulation and relaxation activities were alternated and there were numerous pauses and silences.
Other than by the gestural expressiveness and by his mother’s touch, the child was also provoked (both on the piano and on the carpet) by other instruments whose use was connected to physical sensations, tactile and auditory stimulation, manipulation and exploration. Starting from Leonardo’s small gestures (such as for example light rubbing of the tambourine, small movements of his feet on the castanets, slight shaking of the maracas or a smile), we proceeded with the recreation of these through song, improvisation, vocalizations and by encouraging their repetition and elaboration, especially through verbal support from his mother and me. For example, Leonardo’s mother beat his feet on the castanets, one at a time or simultaneously, following the rhythm of my improvisation; thus, on a simple binary rhythmic unit (2/4 or 2/8), I created a melody and introduced gradual variations, increasing or decreasing the tempo; the binary rhythm also typified of several songs connected to the sound of certain instruments, whose melody recalled the welcome song. I also introduced postural changes, laying the boy in a prone position or sitting in front of me, supported from behind, to facilitate his movements and change his perception of the environment. These changes didn’t always seem to be appreciated, however, causing Leonardo to express his irritation with wails and by intensifying the loss of saliva.  
I often finished by playing a piece of classical music (Debussy’s First Arabesque), an expression of my sound identity, which was particularly appreciated both by the mother and the child and allowed for a release of the emotional tension.
The piece, characterised by formal vagueness, blurred and indistinct melodies and a calm, rocking rhythm, completely relaxed them both and held them in a symbolic embrace, like the gazes, caresses and embraces of the mother-child interaction.

Evaluation of the intervention
On the whole Leonardo responded well to the music therapy treatment which enriched his perceptive, expressive and communicative potential.  
The most significant changes were seen at a motor level with a clear reduction in stereotypy especially while listening to music with a calm, rocking rhythm, and with a slight increase in spontaneous motor activity thanks to the vibro-tactile stimulation and the innumerable stimuli for manipulation, exploration of the instruments.  
After a year the child managed to interact with my stimulations, playing with both hands on a small keyboard, facilitated by his position (he was lying face down on his stomach on my legs or on his mother’s). He also played some small instruments (sleigh bells, maracas, castanets) without help, managing to hold the weight for short periods and to produce sounds of low intensity.
On a few occasions after the end of the session he uttered vocalisations different to those normally emitted. Sometimes he showed reactions of refusal or isolation depending on his physical condition (the frequency of the seizures or other health problems) and on his emotional condition but also with a communicative intent within the relationship with his mother and the music therapy relationship.
With some particularly pleasurable stimulations like the sound of the piano he showed very clear expressive reactions with prolonged smiles, eye movements or sighs, and his listening and concentration ability increased.
I was also able to observe an improvement and an enrichment of the relational exchanges between mother and child in a context (non-verbal) characterised by a calm, pleasant, joyful atmosphere which created in both a condition favourable to interaction. His mother benefited because the time dedicated to the session represented a moment of joy, relaxation and privileged relationship with her child in the course of a day full of demanding commitments. In the end, the entire treatment formed a great help in terms of a mental space in which to overcome negative feelings of anxiety and resignation. More than once his mother found herself at the beginning of the session to be in a state of great physical stress and low spirits or despondency which had repercussions on the child, but at the end of the session both seemed revived, relaxed and revitalized in their communicative exchanges.

Conclusions
Beyond the distinctions between music in therapy and music as therapy, and therefore between interventions focussed on the music’s own therapeutic qualities (MUSIC therapy) and those based on the development of the relationship (music THERAPY), the importance that both elements (the sound mediator and the relationship) have in the context of music therapy is indisputable. 
This paper aims above all to offer an opportunity for reflection on the richness and complexity of the mother-child relationship and on the very special communication that is set up between them, even before birth, which is so important throughout the course of the life of every human being.
I believe it is essential for whoever works in a therapeutic area and specifically in the area of music therapy, that is in the fragile field of "relationship specialists", to know the intersubjective world inside out, to inquire and question themselves incessantly on the principles and procedures that govern this basic relationship. More so for music therapists that use the element of sound as a therapeutic mediator, which turns out to be one of the preferred channels of communication of the first relationship and one of the few communication channels of which a trace or a memory remains even in situations of severe physical or mental disability.
Learning about and studying the research and theories on the mother-child relationship in depth helps the music therapist: first to get to know themselves better, to become aware of what characterizes them as human beings and their way of relating to others; to have a point of reference and a model upon which to build the therapeutic relationship; to get to know the client better and to reach very profound levels of emotional and affective attunement together with them; finally, in the case of working with children with serious pathologies, to use their relationship with their mothers with the aim of strengthening the element of sound’s therapeutic mediation and enriching the relationship itself, or identifying and if necessary reducing or eliminating, also preventatively, its disfunctionality.

Leonardo is a child who, in his short life (he was born on 2/8/1995), already has a serious, "severe" clinical history behind him which is extremely difficult to accept and to endure

Leonardo suffers from a rare and very serious pathology:
Partial epilepsy with migrating seizures.

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