Psychotherapeutic Facilitation of Musical Creativity P E T E R F. O S T W A L D , M . D . * Musical creativity can be observed in the work of performers as well as composers. This article discusses biological determinants of musicmaking, developmental factors leading to the choice of music as a career, and assessment of talents or handicaps among musical patients. Three treatment modalities, called life-style management, crisis resolution, and character building, are especially useful in helping these patients, and illustrative clinical vignettes are given. Music rests on two foundations: the art of composition and the art of performance. The first of these, musical composition, refers to an inner process o f making sounds i n fantasy, and transcribing these imaginary events onto notepaper, or electronic tape. I t is a process that relies on auditory thinking, requires knowledge of basic musical structure (tones, rhythms, melodies, and combinations, called harmony and counterpoint), and resembles certain aspects of creative writing, painting, and mathematics. Musical performance, by contrast, involves the making of sounds i n a public setting. I t is a social experience, and requires that there be people listening and participating i n communication of the music. I n centuries past, composition and performance of music were usually not separated, and we have historical developments, especially i n Western society, to thank for the dichotomy. The ancient bards invented songs as they sang them; drummers and other instrumental musicians composed new music as i t was being played, a process called improvisation. Some cultures even today combine the inventive and the productive aspects of musicmaking, for example, people i n Bali, and certain African tribes. Improvisation also occurs quite regularly i n so-called "popular music" (i.e., jazz and rock-and-roll), and there have been a few contemporary composers of "art music" who ask performers to engage in moments of improvisational, or aleatory behavior. Notation systems, first in the f o r m of neumes or special marks placed above words to indicate vocal inflections, later as dots and pauses written on lines, have evolved over

*Professor of Psychiatry and Medical Director, Health Program for Performing Artists, University of California, 401 Parnassus Ave., San Francisco, CA 94142. A M E R I C A N J O U R N A L O F P S Y C H O T H E R A P Y , Vol. X L V I , No. 3, July

1992

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centuries to make i t possible for composers to preserve their ideas, and performers to interpret them. M o r e recently, the technology of electroacoustical preservation of music on tapes and discs has added a new dimension to this process. I n this article, I thought i t might be possible to focus on the topic of psychotherapeutic facilitation of musical creativity without artificially separating these two aspects of composing and performing, and by emphasizing the context i n which musicians do their work. Composition is often thought to be the truly creative aspect of musicmaking, because composers are expected to produce new and original music that has never been heard before. The art of performance, however, can also be highly creative, since new conceptions or interpretations of music are being projected, and listeners are stimulated to experience the music i n unexpected ways. W h e n performers succeed i n arousing, pleasing, inspiring, or uplifting their audience, this has all the earmarks of a creative experience. 1

BIOLOGICAL PRECURSORS FOR MUSICAL BEHAVIOR

Before we turn to the psychotherapy of musicians, it is well to point out that musical behavior is intimately tied to certain physiological events, especially to specific muscle movements and neurohumoral happenings that from an evolutionary point of view probably represent human equivalents of animal behavior geared to the expression of primary emotions and the communication of basic needs. Indeed, the question whether, from a phylogenetic perspective, music preceded speech was hotly debated at the time of Darwin; Herbert Spencer among others asserted music to have been an earlier, more primitive form of communication. Many animals, for example, birds, dolphins, whales, cats, and chimpanzees, utilize tonal and rhythmic noises as signals of imminent danger, the proximity of food, readiness for mating, and other vital biosocial conditions. I n human communication, sounds of a musical quality—cries, gurgles, and humming—are audible from birth. Responded to by parents and other important caregiving persons, these infantile vocalizations (as well as riddance-noises like vomiting, coughing, and defecating) acquire emotional significance early i n life, and quickly enter the fabric of attachment behavior, which is vital for survival. F r o m this primitive matrix of nursery sounds emerge the two differentiated forms of acoustical behavior called speech and music. ' 2

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I t has been proposed that the human brain may be programmed, perhaps genetically or even as a result of some intra-uterine exposure to music, for highly selective inclinations to musical experience; the Harvard psychologist H o w a r d Gardner calls this "special intelligence." B u t so far i t has not been 4

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possible to disentangle presumed prenatal determinants from those wellknown environmental factors that serve to shape and develop musical behavior, including songs and dances to which children are exposed, and, most importantly, what the parents, older siblings, relatives, and neighbors do by way of soundmaking and the degree to which the child's attention may be focused on musical activities per se. Thus babies, universally, begin speaking and singing i n their "mother tongue." The integration of sound into progressively more meaningful communications happens so rapidly and so spontaneously as to seem almost miraculous—hence the many myths, and great interest i n oracular infants. What is important to emphasize i n our consideration of psychotherapeutic facilitation of musical creativity, is that all expressive modalities dependent on soundmaking are aligned w i t h instinctual as well as infantile processes, biologically driven and largely unconscious. Therapists working w i t h musicians must always be alert to the primarily affective meaning of music, ranging from the most distressingly melancholic to the most joyfully ludic, elaborated i n highly symbolic forms. 5

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D E V E L O P M E N T A L ASPECTS AND T H E R O L E O F T H E T E A C H E R

The possibilities for environmental shaping of innate potentials for musicmaking have already been alluded to. Parental interest is critical; rattles and other musical instruments are introduced into the nursery; radios and television provide musical stimuli that are unavoidable even when children turn away or close their eyes. Above all there are tonal and rhythmic ingredients of the mother's voice, which provides orientation and information. Similarly, any musical behavior on the father's part, singing, or playing an instrument, becomes an attractive feature of the social milieu. I t has been postulated that the function of music i n preverbal development may be analogous to that of "transitional" or " l i n k i n g " objects—physical things such as dolls, toys, blankets, etc.—that provide security as the child separates from the mother. Music seems to "belong" to the child as well as the parents, linking them i n reality when they are together, and i n fantasy when they are n o t . Many musicians grow up i n environments where music is encouraged by one or both of the parents, or some other member of the family who is prominently audible and visible as a musicmaker. Thus the process of identification w i t h musical activities may take place very early. Other children find their way to this activity more indirectly, or even accidentally, by observing a neighbor singing or playing an instrument, by going to a concert, or watching performances on television. One of my patients, whose father is a musician, recalls being taken to a symphony concert which he enjoyed immensely, and after pointing to the violin section 8

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and saying " I want t h a t " was given music lessons and an instrument to practice on. Teachers, and the didactic rituals of pedagogy, clearly are very significant in the development of musical behavior, profoundly influencing not only children, who spend years working and identifying w i t h them, but also parents who seek guidance for the child's future education and career. N o t all music teachers are equally competent. Skillful and enthusiastic teachers who are sensitive to the needs of children may be able to sustain their students through the many vicissitudes of training, and serve as an excellent role model, encouraging the development of effective practice habits and a reverence for music. But there are also teachers who manage to turn children off, for various reasons, including a lack of psychological understanding, or by making the music lesson into an ordeal, or because of their inadequate knowledge of anatomical and physiological principles involved i n playing a musical instrument. 9

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Music teaching is a formidable responsibility insofar that the teacher usually enters the lives of children and their families at critical developmental phases when other pressures are being exerted as well. Formal education is about to begin, or has just started. Demands are made for the acquisition of technical skills i n reading, writing, and other classroom subjects; performance is graded; the child receives praise for success, and is punished for failure; there is rivalry w i t h peers. I t is a formidable experience, seldom forgotten by the child who simultaneously must cope w i t h the intrapsychic demands of oedipal adaptations and latency. A n d music teachers are powerful extensions of the social matrix, occupying a privileged position, akin to pediatricians and athletic coaches who have the right to manipulate parts of the child's body. Sit this way at the piano! Curl your fingers around the neck of the violin! Blow into that mouthpiece! Expand your chest and press the diaphragm down! Soon the child's m i n d incorporates the musical instrument, which i n fantasy becomes part of his or her self-image, extends the body boundaries, and has an impact on other people. For example, a small child may relish playing a large instrument like the tuba which makes him seem as big, or bigger than his classmates. Along w i t h music instruction usually goes the student recital, a special occasion when children are put on display by teachers wanting to advertise the results of their expertise. I n children, the experience of being exhibited, and trained to exhibit themselves, can foster pleasurable narcissism which enhances the desire to perform, but i t may also induce disagreeable anxiety, and lead to stagefright, which is one of the most common complaints among performing artists. 11

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O B S T A C L E S , D A N G E R S , AND R E M E D I E S — A F E W H I S T O R I C A L E X A M P L E S

U n t i l fairly recently, boys w i t h beautiful voices were surgically castrated in order to preserve this valuable attribute, so they could sing soprano roles in oratorio or opera. Those who were more (or less?) fortunate, usually had to enter less glamorous careers after puberty. Economic factors produce many conflicts, even today: parental support for music education usually stops at a certain age; scholarships are difficult to obtain; competition is fierce and employment limited. W e l l into the nineteenth century, musicians were treated like lackeys, and ambivalence toward performing artists persists. Society tends to adulate those who achieve stardom, but barely tolerates musicians who must scrounge for a living. The history of music also indicates that there have probably always been certain "specialists" who serve as counselors and therapeutic figures. For Wolfgang Amadeus Mozart (1756-1791) this guiding figure was his father, himself a prominent musician, and someone w i t h considerable practical wisdom and medical sophistication. The elder Mozart, upon w h o m Wolfgang was almost totally dependent until age twenty-five, always carried a medical bag on their travels together, prescribed remedies, sought help from physicians i f necessary, and conscientiously noted every detail of the young musician's illnesses and treatment. I n terms of psychotherapy, Wolfgang knew something of the work of A n t o n Mesmer, and even included a comical scene involving animal magnetism i n one of his operas {Cost fan tutte). More to the point of the subject of this paper is the experience of Robert Schumann (1810-1856), who during adolescence suffered greatly from what today would be called a severe identity crisis, complicated by depression. H e had lost, i n rapid succession, his sister who committed suicide during a psychotic episode, and his father, who had been chronically ill. T o reduce his despair and the fear of going mad, Schumann wrote poetry and drank heavily. H e began having moments of hellish delirium and black-out spells. For a number of years he received counseling and medical advice from D r . Ernst August Cams, a Professor of Medicine i n Leipzig and a musician as well. D r . Cams also introduced Schumann to the young pianist Clara Wieck, who later became his w i f e . Another well-documented case is that of the Russian pianist and composer Sergei Rachmaninoff (1873-1943). A t age twenty-four, after the failure of his first symphony, he fell into a disabling depression, w i t h feelings of self-loathing, and a creative work block lasting nearly three years. Part of that time he was treated by D r . Nikolai D a h l i n Moscow, who used a combination of hypnosis and psychotherapy. They met on a daily basis, and D r . D a h l charged no fee. Gradually, Rachmaninoff was 12

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able to resume composing, and wrote a piano concerto, which he dedicated to this physician. Two additional cases are of historical interest, since they were patients of Sigmund Freud i n Vienna. First the pianist and conductor Bruno Walter, who approached Freud complaining of a paralyzed right hand which had not responded to any of the standard neurological treatments then i n use. The paralysis had occurred after Walter was appointed to a major conducting post; he had also recently become a father. I n his autobiography, he mentions expecting to be asked by Freud about sexual conflicts, but that apparently is not what happened. Freud carefully examined the conductor's hand, found nothing wrong neurologically, and advised him to take a vacation, without his family, in Sicily, there to feast his eyes on the beautiful scenery and wonderful art treasures. One gathers that Freud was trying to distract Bruno Walter from his many musical and domestic responsibilities. This d i d not seem to help; Walter returned to Vienna w i t h his symptoms undiminished. So Freud took a different approach, this time telling Walter to stop worrying about his hand; instead of trying to direct the orchestra with it, he should let his entire body be moved by the music, i n other words, to switch from active assertion to passive enjoyment. I t seems to have worked fairly well. Walter was able to resume his post at the head of the orchestra. H e also developed a tendency, noticeable for many years, to stop using the right hand while conducting, lay down his baton, and lead the orchestra w i t h his left hand instead. The conductor and composer Gustav Mahler also sought Freud's help during a crisis, this one involving an acute agitated depression precipitated by the discovery that Alma, Mahler's attractive young wife, was having an affair w i t h architect Walter Gropius. Freud was on vacation i n H o l l a n d at the time, but Mahler took the train there and spent almost an entire day w i t h h i m . They walked along the beach, did some sightseeing, had coffee, and engaged in a k i n d of ambulatory psychoanalysis. Years later, Freud t o l d his pupil Theodor Reik about this experience, and expressed admiration for Mahler's psychological-mindedness. A childhood memory had been uncovered; Mahler recalled having been distracted from a brutal scene between his parents by hearing the sound of a village band. Freud diagnosed an obsessional neurosis. H e felt that Mahler suffered from an unresolved fixation on his mother, which accounted for the panic over possibly losing his wife. Alma was reacting negatively to his "withdrawal of l i b i d o " from the marriage. 13

W H A T M U S I C I A N S C O M P L A I N O F , AND H O W T H E Y C O M E TO B E PATIENTS

As the above examples suggest, psychotherapy of musicians usually has to be modified i n order to fit the special working conditions of patients whose 388

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habits, schedules, economic circumstances, and character styles often preclude a more orthodox approach. The incidence of psychiatric disorder among this population is not known, and a fairly complicated research design would probably be needed to establish reliable figures. O f 2,212 instrumental musicians who recently responded to questionnaires sent by an organization of symphony orchestras, 39 percent characterized themselves as afflicted w i t h "psychological problems" including stage fright (24.7%), depression (16.6%), sleep disturbances (14.2%), and acute anxiety (13.2%). T o address these needs, along w i t h the many requests from musicians for treatment of their "physical problems," a number of specialized diagnostic and treatment centers have been organized i n major cities throughout the United States, and i n Canada, Australia, and other countries. I t is the work we have done at the San Francisco Health Program for Performing Artists that will serve as a knowledge base for the remainder of this paper. Founded i n 1984, this program, affiliated w i t h the University of California School of Medicine, grew out of the experience I had accumulated over many years as a consultant to the San Francisco Conservatory of Music, where students, as well as faculty members, occasionally needed professional help. Drawing on the resources of our medical center, I recruited thirty experts from various departments, including medicine, orthopedics, neurology, otolaryngology, physiotherapy, dentistry, dermatology, and of course psychiatry, clinical psychology, and clinical social work. A l l of these colleagues are deeply interested i n taking care of performing artists, and many of them have actually worked as musicians, dancers, or actors, either professionally or as amateurs. W e w o r k as a team, refer patients to each other, and hold conferences devoted to clinical and research dimensions of the field recently labelled "Performing Arts M e d i c i n e . " 14

The demographics of our case material have been discussed i n greater detail elsewhere. Approximately one-third of the patients seeking help from our program, an equal number of men and women, are primarily i n need of mental health care. Their ages have ranged from 18 to 72 years, w i t h a mean age of 34. Most of them are professional musicians and students training to be musicians, the majority depending on, or expecting to depend upon the arts as a source of income. I n terms of their presenting symptoms, depression is by far the most common complaint (57%). Anxiety (28%), personality disorders (22%), and somatoform disorders (14%) are also encountered, frequently i n combination w i t h depression. As one would expect from any unselected population, there have been cases of substance abuse (9%), organic brain disease (4%), and schizophrenia (3%). 15

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PSYCHOTHERAPY

A psychotherapeutic attitude is always indicated, even when patients seek help for treatment of what they regard to be primarily physical problems, for example occasional fractures or sprains, the frequent occurrence of muscle pain, "overuse" disorders of the extremities, vocal cord nodules, interference w i t h proper function of part of the body related to playing an instrument, and other so-called "organic" conditions. Inevitably there are fears related to the real possibility of having to stop performing, the loss of income, and the danger of having to change or abandon a set o f habits that have been developed over the course of a lifetime. O f fundamental importance are (1) giving undivided attention to the patient, (2) maintaining strict confidentiality at all times, (3) attempting to ascertain and clarify the unconscious meaning of what is communicated b o t h verbally and nonverbally, (4) offering understanding and support, and (5) integrating mental health care w i t h whatever treatment may be needed for promoting better physiological f u n c t i o n . D u r i n g the process of rehabilitation, i t may be desirable to ask patients to consult w i t h music teachers, voice coaches, and therapists experienced i n using the Alexander method, the Feldenkrais technique, or similar approaches to neuromuscular repatterning. 16

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MODALITIES O F PSYCHOTHERAPY WITH MUSICIANS

A t this point I would like to delineate some of the approaches we have found useful i n facilitating the creativity of musicians. The focus will be on three distinct modalities of psychotherapy, called "life-style management," "crisis resolution," and "character b u i l d i n g . " I prefer to use this terminology because i t avoids the artificial dichotomy between so-called supportive and analytic psychotherapy. B o t h support and analysis are usually needed, and while theoretical distictions between these two approaches can be made, i n practice they cannot be separated. The ideas elaborated i n the following discussion derive not only from working w i t h musicians, but also from treating other artististically inclined patients (dancers, actors, painters, poets, etc.) who are striving to be creative. N o r should i t be assumed that the three modalities exemplified below are mutually exclusive. One or more therapeutic approach may prove to be useful w i t h any particular patient; they can be applied consecutively, or even overlap, depending on the particular circumstances leading to referral, the age of the patient, the amount of time available for treatment, and other individual factors. I n the interest of protecting confidentiality, and avoiding the possibility of identifying either the patients or the therapists, all of the following clinical material has been thoroughly disguised. 390

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L I F E - S T Y L E MANAGEMENT

Many musicians are locked into certain routines that cannot be altered, such as daily practicing of an instrument, or vocalizing, or composing. Usually these routines, which on the surface seem almost stereotyped or ritualistic, were trained into them during childhood and adolescence. They provide essential structure for the musician's daily existence. I n terms of the automatic quality, and the discomfort that is generated when a musician has to interrupt these routines, they may resemble obsessive or compulsive behavior. B u t i n reality, constant vigilance, conscious expenditure of energy, and creative imagination are required. This is part of a musician's fundamental devotion to artistic behavior and all the cultural assumptions that go w i t h it. Patients enter treatment w i t h the expectation that their work habits will be respected, but they also recognize that certain changes may have to be made i n their lives, so that symptomatic suffering can be reduced and further distress prevented. Case 1 Miss A . is a successful woodwind player, and the principal oboeist of a major symphony orchestra. H e r father was a professional musician, a pianist, who gave up his career and went into the publishing business. A t age thirty-three, the patient requested treatment because of symptoms that had interfered w i t h her life since age twelve, when her parents separated because of an unhappy marriage. Intense sadness, fearfulness, sleeplessness, loss of appetite, and a prevailing sense of d o o m about her abilities as a musician and her identity as a female surfaced at that time, but she managed to cope w i t h these problems on her own. A t age four, she had started music lessons, playing the piano, which she has continued to do. B u t around puberty, and closely related to the failure of the parents' marriage, which had led to her first illness, she took up a w i n d instrument as well, and began playing w i t h the school band. While this new activity gave her great satisfaction, and reduced some of her emotional distress, i t also aggravated an identity conflict. Most of the other players were boys, and many o f them, as well as her girlfriends, teased her for wearing a uniform, marching at athletic events, and behaving like a " t o m b o y . " After graduating from highschool, she entered a music conservatory, where she felt lonely and isolated, until one of the teachers, an older woman, "adopted her." What this meant is that she received special attention, was given more than her share of instruction from the teacher, and experienced a strong emotional bond, including a desire to be taken care of, pampered, and physically stroked and petted. The homosexuality, which seems to have been mutual, was never discussed, nor d i d it 391

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lead to any genital contact. She dated other students, and just before graduating married a violinist. After six months of living together, they obtained excellent positions, he i n the string quartet of a university on the east coast, she i n California. The separation was painful but endurable, and after several years led to divorce. Since then, the patient has dated men occasionally, but prefers to engage i n clandestine affairs w i t h older women, some of them outspoken Lesbians. What precipitated her current illness was difficult to determine. Over the years, there had been several episodes w i t h similar symptoms, usually associated w i t h severe stress, for example the dissolution of her marriage. But this time, she felt that professional obligations were primarily responsible for her illness. H e r mother, a successful real-estate entrepeneur, had agreed to finance the small chamber-orchestra that Miss A . had been trying to organize for the past year, w i t h herself as conductor and soloist. B u t along w i t h the mother's generosity came considerable bossiness, which the patient has always resented. Besides, her new venture brought the patient into conflict w i t h the director of the symphony orchestra to which she belongs. A coast-to-coast concert tour was being planned, w i t h the patient playing a solo concerto by Mozart i n several major cities. I n addition, she had noted an element of fatigue and exhaustion accompanying the present illness, which seemed more intense than anything she could remember from earlier episodes. Years ago, while a student at the conservatory, she had received a six-week course of psychotherapy, and d i d not feel helped by this, her only experience with treatment before seeking help from us. Because of the possibility that Miss A.'s illness might require medication, she was assigned to a psychiatrist, a woman who herself plays a woodwind instrument and enjoys occasionally performing for friends, rather than a nonmedical psychotherapist. The patient actually insisted that medication be used, because of what she had heard about "chemical imbalances" causing depression, and her skepticism regarding psychotherapy. The first order of business was to clarify her diagnosis, which turned out to be a moderately severe depression i n a narcissistic and avoidant personality. There were unrealistic expectations, perhaps even an element of grandiosity, i n regard to her abilities as a conductor, a role for which she had never been trained, and the few interpersonal relationships she has had generally seemed lacking i n warmth and empathy. The past history contained an episode suggestive of hypomania, during which she had impulsively purchased a motorcycle, raced through the desert, and injured herself. A plan for helping to manage her current illness was outlined. The patient was to arrange regular interviews w i t h her psychiatrist, starting twice a week, for further clarification of her 392

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problems, psychotherapy, and monitoring of her response to antidepressant medication. The immediate response was favorable. The patient readily accommodated her very busy schedule of rehearsals and concerts to the requirements for psychiatric care. Indeed, she seemed to welcome this opportunity for putting her life i n order. M u c h information—about her childhood, her conflicts and dilemmas while growing up, her adult adjustments and maladjustments, and the immediate demands of her career—was revealed to the therapist. A central focus i n the therapy was the patient's awareness of conflict between her intense ambition to succeed as a performer and her personal limitations, as well as her insufficient energy and problems w i t h recurring depression. The therapist offered advice on how best to balance the conflicting demands of reality and fantasy. W h e n the patient's mother and stepfather came for a visit, and wanted to talk about fundraising for the chamber-orchestra she wanted to conduct, they expressed concern about her illness, and requested to see the therapist. After discussing the pros and cons of such a meeting—possibly advantageous i n terms of gaining better understanding of the family dynamics, but potentially disadvantageous from the viewpoint of confidentiality and transference—the therapist decided to invite the parents to participate i n several of the treatment sessions. M u c h anxiety was expressed by the parents about the dosage of antidepressant medication, which all parties recognized might, when pushed to a therapeutic level, produce side-effects like dryness of the mouth, and possibly interfere w i t h competent oboe-playing. However, Miss A. continued to fulfil her obligations. She was pleasantly surprised when her colleagues, and the conductor of the orchestra, said her playing was very beautiful and had even improved lately. This was very reassuring, since questions had been raised, by b o t h the patient and the therapist, about her readiness to travel and to appear as soloist i n the upcoming concert tour. Rehearsals continued to go well, and she received further praise for her outstanding performances, especially a certain glow i n tone-color and maturity of interpretation that had recently become audible. Touring, of course, necessitated a temporary separation from the therapist, who made use of this by discussing the patient's dependency needs, as well as her depressive symptoms, which had not yet abated. She was instructed to keep i n touch w i t h the therapist by telephone. A l l went well until the newspaper critics i n a large city showered the patient w i t h compliments for her solo performances, and the manager of a European chambermusic group asked whether she would consider playing w i t h them on a regular basis. This was a very attractive offer; the patient wanted to accept, 393

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even though it would mean a breach of contract w i t h her home orchestra. Feeling flattered and excited, she noted an uncanny sense of euphoria, and soon began losing control over her behavior. One day she went into a large department store and impulsively bought five pairs of cowboy boots; another day she was stopped by the police for reckless driving and asked to take a sobriety test. A t that point her therapist recommended that she either return to San Francisco, or consult another psychiatrist, i n the next city on her tour. She chose the latter option; her dosage of antidepressants was adjusted, and a lithium trial was recommended. After completing the tour, Miss A. felt considerably improved. Three months later she decided to take a leave of absence from the symphony orchestra, i n order to participate i n concerts and recording sessions w i t h the European chamber-music group. Issues of rivalry w i t h other woodwind players, questions of repertoire, and long-range career goals were discussed. She remained insightful and cooperative. After completion of therapy, she performed splendidly—"better than e v e r " — w i t h the new group, and on returning to San Francisco not only returned to her previous job i n the orchestra, but purchased a home and made plans for marriage to a fellowmusician w h o m she had dated casually for several years. Five years later, i n a follow-up interview, Miss A . explained how terribly painful this episode of illness had been, and showed the therapist a number of original compositions she had recently been working on. They were short pieces of a dance-like character, for an ensemble of woodwinds, and she was planning to perform two of them. She had been studying w i t h a well-known composer, and had started to compose a sonata for oboe and electronic keyboard. She explained that several of the themes symbolized her feelings of despair, still sometimes very much i n consciousness, but not associated w i t h the disabling symptoms which had once brought her close to a breakdown. She said that her life was now i n much better order, and that psychotherapy had helped her not only to go on w i t h her career as a performer and to seek new outlets for her creativity, but had also given her the courage to face a perpetual sense of loneliness. CRISIS RESOLUTION

This modality of treatment, i n contrast with life-style management as discussed above, entails a drastically more time-limited approach. W i t h crisis resolution, the focus is on a precipitating event or series of events that have resulted i n disrupting the musician's career, and there are far fewer psychotherapy sessions. The magnitude and significance of such critical moments i n the lives of musicians cannot be minimized, considering how much time, 394

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energy, and self-commitment they habitually devote to their art. Even temporary derailment from a path that has led to personal and social gratification for many years can signify a major stress. Case 2 M r . B. is a tenor, now i n his mid-fifties, who sings regularly w i t h choral groups, and occasionally gives song-recitals. H e had grown up in a mediumsized midwestern town, neither of his parents was especially musical, and he is the only one of seven children who has entered the performing arts. The human voice has been a passionate, conscious center of attraction for h i m since age fourteen, when his freshman class was taken to a performance of Bizet's Carmen. Totally fascinated by what was happening on the stage, and engrossed i n the glorious sound of the orchestra and singers, he decided to enroll i n the school chorus, and asked his parents for permission to take private voice lessons. As a junior college student, he majored in music and coached w i t h a retired contralto from the Metropolitan Opera, who strongly encouraged h i m to seek roles i n musical comedies and cinema rather than grand opera, for which his voice was not sufficiently powerful. Although he has never had a leading role i n any musical production, M r . B. found employment i n a number of theaters, and for three years toured the U n i t e d States i n a highly successful musical comedy. A good-looking and rather charming man, he met, while touring, the only daughter of a very wealthy manufacturer of clothing. She admired his singing, fell i n love w i t h h i m , and after a brief courtship agreed to marry h i m . Although M r . B. has never felt strongly attracted to his wife, he characterizes their relationship as generally a happy one. Sexual intercourse is infrequent; there have been no pregnancies; they have adopted two children. H e r inherited wealth enables them to live more comfortably and elegantly than would have been possible on his limited income, and w i t h his wife's support he is able to give recitals for invited audiences, attended occasionally by music critics who have written friendly reviews. M r . B. and his wife have also become known as extremely generous contributors to various cultural and artistic organizations. The crisis which led to his referral for psychiatric care came about as follows. To celebrate the opening of a new wing of an art museum, underwritten largely by donations from his wife, M r . B. agreed to participate in a concert featuring himself and a well-known soprano from the Paris Opera. The program, carefully planned and conscientiously rehearsed, was to include a scene from Carmen. O n the afternoon of the concert, during the final dress rehearsal w i t h full orchestra, M r . B. suddenly felt unwell and doubted whether he w o u l d be able to continue. His throat was tightening 395

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up, a sensation he had not experienced since his early years of touring. The family doctor, an internist, examined his throat and thought he detected a " b u l g e " on one side of the patient's mildly inflamed pharynx. H e said this was probably "a cold coming o n , " and prescribed an antihistamine. The concert that evening proceeded without difficulty until intermission, when M r . B. suddenly began trembling and perspiring. H e had difficulty clearing his throat; his heart was racing; he could inhale but had difficulty exhaling; he feared he might be having a heart attack, that he would pass out and might die. H i s wife, terribly worried but wanting the show to go on, said " i t ' s only nerves" and gave h i m a Valium from her own supply. This calmed h i m down, and he decided to go on. After intermission came an overture, which gave M r . B. some time to relax, and to prepare for the Carmen scene by mouthing, but not vocalizing, his aria. H e wanted to "save his voice." W a r m applause greeted h i m and the soprano when they went on stage. H e felt somewhat on edge, thought the spotlight was too bright, and detected a bluish glare to which he was unaccustomed. Inhaling to start his song, he suddenly felt light-headed and again started to tremble. Opening his mouth, his voice emerged, but slightly off-key, and marred by an ugly vibrato. H e felt exasperated and mortified, thought that everyone i n the audience was aware of his distress, feared that the critics would surely pan his performance, and that he might fall into the orchestra pit. N o matter what he d i d , whether he went on or interrupted the performance, it seemed that disaster was inevitable. Yet he continued singing and acting, "as i f on automatic p i l o t . " A t the end of the scene, which was heartily applauded, he broke into tears. During the reception afterwards, M r . B. felt dejected and terribly nervous, and spoke only to his wife. Later that evening he told her that he had decided never again to sing i n public. H e was referred to our program by his family physician, who wanted an opinion from someone experienced i n the care of singers. A second examination by the internist had failed to confirm the "bulge" i n M r . B.'s throat, but he feared that he might have "cancer." I saw h i m , together w i t h his wife, for the initial interview, obtained the above history, made a presumtive diagnosis of psychophysiological voice disorder w i t h panic, and arranged for h i m to be seen immediately by a laryngologist, who, using a throat mirror, found no evidence of organic pathology but recommended direct visualization of the vocal cords by means of laryngoscopy. W h e n this procedure was attempted, the patient "froze," and refused to allow the examining instrument to be inserted into his throat. A t our next meeting, I persuaded h i m to accept a series of counseling sessions w i t h a clinical social worker, herself formerly a 396

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professional singer. Visits were scheduled twice a month, and revealed five area$ of psychological difficulty pertinent to the recent crisis. 1. Since childhood, the patient has harbored a feeling of insecurity, related primarily to rivalrous attitudes toward an older brother, now a successful businessman, who used to tease h i m for his "artistic and effeminate" behavior, and even today "makes f u n " of his interest i n music and belittles h i m for not "having a regular j o b . " 2. One of his children is mentally ill, had to be hospitalized the previous year because of a psychotic episode, and needs psychoactive medication on a regular basis. B o t h parents are deeply troubled by this, and regret having gone through w i t h the adoption. The wife is chronically depressed and takes Valium, prescribed by their family physician because of disturbed sleep. H e r generous financial contribution to the new wing of the museum was partly an effort to reduce guilt for presumably having "rejected" their sick child. 3. M r . B.'s father died of esophageal carcinoma. H e had been a chronic alcoholic, and was afflicted w i t h symptoms of choking and dizziness similar to those recently experienced by the patient. 4. Ten years ago, the patient started a clandestine affair w i t h a young singer from the opera company that was deeply satisfying for b o t h , but recently has had to be curtailed because of his fear of A I D S and her unwillingness to use condoms. I t was the therapist's hunch that oral sex was important i n this relationship, but the topic was not explored. 5. H e is beginning to think of himself as "middle-aged" and "over the h i l l " as far as his singing is concerned. H e would like to take steps to reorganize his life, possibly to retire from public performances. I n discussing this patient's treatment, i t should be noted that his presenting symptoms of physical distress abated within the first m o n t h of psychotherapy, and have not recurred. H i s therapist took the position that his illness had been a severe and acute panic, precipitated by the special circumstances and symbolic meaning of his performing a scene from Carmen, an opera at the end of which the tenor kills the soprano. Latent conflicts over display vs. inhibition of rage, and the fear of expressing " w e a k " or " f e m i n i n e " behavior had been activated. The medical finding of something wrong i n the patient's throat had stirred up deep anxieties, linked to an awareness of aging, and associated w i t h the fear of physical decay and death. The history of alcoholism i n his father, and psychosis i n his adopted daughter, as well as his wife's depressiveness and dependence on Valium, had made M r . B. concerned that his own mind might, along w i t h his body, be "going bonkers." Psychotherapy repeatedly emphasized reality testing for the purpose of 397

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putting the recent crisis into perspective, and to establish a practical basis for returning the patient to his previously satisfying career as a singer. During the second month of therapy, he began viewing his illness as "a blessing i n disguise.'' I t had forced h i m to take stock, and represented a turning point i n life that would lead to new projects. Recognizing that his voice and temperament were no longer suitable for anything as ambitious as an operatic performance w i t h full orchestra, he decided from now on to concentrate on learning songs that can be accompanied on the guitar, and performed i n intimate settings at home or i n a cabaret. H e also decided to assume a greater share of responsibility for managing his wife's financial and philanthropic enterprises, and to do more travelling w i t h her. Together they inaugurated a charitable foundation for retired musicians, aiming to help defray their medical expenses. Termination of therapy after three months proceeded smoothly. The patient initiated the separation process by suggesting that from now on he w o u l d be too busy for further appointments. H e said that he had learned a great deal from the discussions w i t h his therapist (who i n supervision w i t h me recognized this to have been primarily a transference cure, w i t h herself symbolically enacting the role of a good mother, thoughtfully caring for a fearful and somewhat spoiled child during a critical developmental crisis.) I t was clear that M r . B. was receiving reliable emotional support from his wife, as well as his healthy adopted son, not to mention his own elderly, widowed mother. Medical help was readily available, i n case of need, from his family physician, and the door w o u l d remain open in the event that he chose to return for treatment i n our Health Program for Performing Artists. Once a year he avails himself of this opportunity, and six years have now passed since his crisis, without recurrence of any disabling symptoms. H e continues to sing, appears i n private recitals from time to time, and also does some teaching. One occasionally sees his name listed, together w i t h his wife, as patron for a fund-raising event. CHARACTER BUILDING

The third approach I w o u l d like to focus on i n this abbreviated discussion of psychotherapeutic principles i n facilitating the creativity of musicians, may include the two modalities already mentioned, but i t integrates these into a far more time-consuming treatment aimed at substantial restructuring of the personality. Character building enters more deliberately into existential and psychoanalytic realms, and tackles fundamental issues involving unconscious motivation, family dynamics, object relations, self-concepts, and sexual identity. 398

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Case 3 M r . C , a single man now 41 years old, grew up i n the suburb of a large northeastern city where his Irish-Catholic father, who sings i n a barbershop quartet, had a successful law practice, and his Japanese-born mother—they had met shortly after W o r l d War IT—ran a gift shop. A n older sister is married to an engineer, and they have several children. As far back as the patient can remember, he has felt himself to be overly sensitive, anxious, and isolated. His earliest memory, from age three, is of playing w i t h a toy xylophone, enjoying the sounds i t produced, but fearing that he might strike the instrument too hard, break i t , and be punished by his strict and rather explosive father. W h e n he was four years old, and before going to kindergarten, his mother enrolled h i m i n a Suzuki class where b o t h of them learned to play the violin. W i t h i n a year he was participating i n group concerts, and by the time he entered parochial school he was already playing solos. " I always knew that I wanted to be a musician. I also knew that I was different from the other boys, smarter, more intelligent, but also more vulnerable." But as his expertise w i t h violin playing increased, so d i d his father's disapproval of music as a full-time career, based on the concern that this might lead i n the wrong direction, away from economic security and a "stable" life. While going to high school, M r . C. yielded to his father's wishes for a "more reliable" field of work; he took many science courses, graduated w i t h honors, and entered college as a pre-medical student. During his sophomore year i n college, however, his grades began to drop. H e was feeling " o u t of i t , " had difficulty concentrating, spent a great deal of time alone practicing his violin, or musing about "the meaning of l i f e . " H e experimented w i t h marijuana, took L S D , and enjoyed the " w e i r d fantasies" released during these trips. I n the presence of the few friends he had i n college, mostly students experiencing similar identity problems, he deprecated his parents and the "conservatism" they allegedly espoused, while at the same time he depended upon them for financial support. H e stopped conforming to Catholicism, lost his virginity to a Korean art student w h o m he dropped after a brief involvement, and started to behave and dress like a " h i p p i e . " For several years he drifted around the country, supporting himself by playing the vkblin at street corners, bars, or subway stations. A t age 24, he arrived i n San Francisco, penniless, depressed, malnourished, and physically ill, but still basically attached to his violin which he treasured and wanted to keep on playing. H e had been promiscuous w i t h both men and women, and examination at a public clinic disclosed that he had contracted syphilis. Along w i t h the necessary antibiotic treatment, he was advised to apply for disability, 399

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which led to a psychiatric evaluation, and he was urged to seek psychotherapy i n a clinic, where a compassionate psychiatric resident treated h i m for three months and then referred h i m to our program. Because of his strong musical interests, M r . C. was assigned to a clinical psychologist who is also well known as a classically trained jazz pianist. F r o m the start, therapist and patient adapted well to each other. Meeting once a week, and using a modified psychoanalytic approach, they discussed very frankly the patient's many conflicts around success vs. failure as a musician, the influence of his parents and teachers, his bisexuality, his simultaneous need for dependency and independence, and the use of psychedelic drugs. Although the therapist would occasionally reveal his own passionate involvement w i t h music, and his generally liberal attitudes, he strove to maintain a formal stance, expecting the patient to do most of the talking, and interpreting his silence and persistent symptoms as "resistance." Gradually the patient's depression lifted, but he continued complaining of intense unhappiness, of sexual frustration, and of being unable to find anyone who would listen to h i m play the violin. The therapist asked why he seemed unwilling to apply for a job i n an orchestra, which led to angry sulkiness on the patient's part, and resentful complaints about union fees, competition, and the stress of having to take anonymous auditions. " I ' m an individual; I like to improvise; I don't want to submerge my identity i n a string section, playing all the standard repertoire." Several weeks later, the patient, who had become increasingly silent, mused whether the therapist might be willing to include h i m i n one of his jazz recitals. T o this the therapist responded that it could complicate the transference, and make treatment more difficult. A t the following meeting, the patient repeated his request, only more insistently, and then asked the therapist to play some sonatas w i t h h i m , and shorter pieces, including Sarasate's "Gypsy A i r s . " The therapist demurred; he had too many other commitments; he felt that the patient's inability to find other musicians to play w i t h , and his reluctance to join an orchestra, symbolized the lingering influence of his forbidding father, now unconsciously introjected as a defense against merger w i t h his permissive mother. There seemed to be a split i n the patient's self-representation, w i t h internalized maternal objects (mother, sister, the Suzuki teacher, and the first sexual partner) constantly at war w i t h paternal objects (father, Catholicism, brothers, college professors, and the therapist.) I t was the patient's job to achieve a better inner balance, and to fuse the discrepant part-objects into a more stable, integrated self. The patient stated that he understood these formulations, but that they d i d h i m little good. H e was feeling more lonely and isolated than ever, alienated 400

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from society i n general, feeling more depressed, and having suicidal thoughts. H e wanted to sell his violin and use the money for a trip to India. I f that did not work, he was going to jump off the Golden Gate Bridge. The therapist, duly alarmed, offered to see h i m twice a week, and requested consultation w i t h a psychopharmacologist, to start antidepressant medication. For two weeks the patient complied, but then he stopped coming to his appointments and sent the therapist an apologetic letter, thanking h i m for his efforts and declaring that the treatment had been a "complete f a i l u r e / ' T o this the therapist responded by sending a letter to the patient, summarizing the course of treatment, acknowledging the patient's desire for termination, but insisting that one more meeting be scheduled. This was for the purpose of discussing a bit of "unfinished business," i.e. the patient's request for performing w i t h the therapist's jazz group, and the therapist's response to that request. A meeting was arranged. The therapist mentioned his real concern for M r . C , not only as a patient but also as a musician. H e wanted to propose the following: instead of meeting for therapy, from now on they would get together regularly i n order to "make music." These meetings were to be i n a music studio; the patient was to bring his violin; the therapist would accompany h i m at the piano; they would talk about the music to be rehearsed. While there was to be no formal "psychoanalysis," i t was required that at the end of each session a few minutes were to be devoted to any topic the patient might wish to bring up. H e agreed, and offered the observation that it had been extremely difficult to h i m to fill an entire hour w i t h words. "After ten minutes I seem to have all the answers I need, and the only thing left for me to do is to sit i n silence and think about music." For the next three years, therapist and patient met twice a m o n t h for 90-minute sessions that were devoted primarily to playing music. They rehearsed much of the standard literature, violin-piano sonatas by Bach, Handel, Mozart, Beethoven, Brahms, and other composers, as well as shorter virtuoso pieces. This led the patient to practice regularly, and increased his familiarity w i t h many compositions he had never worked on before. I t also gave the therapist a chance to restudy the classical and romantic literature. The time left for talking was used mostly to discuss technical matters of rhythm, phrasing, balance, ensemble, and other aspects of interpretation. Soon the patient began calling the therapist his "musical shrink." Occasionally he asked for advice about personal problems, specifically some "bad habits" that seemed to interfere w i t h his musicmaking: an irregular life style, frequenting bars to pick up sexual partners, and reliance on marijuana (the patient refused, absolutely, to try any further prescription 401

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drugs.) Thus the therapist, by setting an example of stability and abstinence, and by giving constructive advice, was able to influence the patient's overall behavior. H e used examples from the lives of the composers whose music they were playing (e.g. Franz Schubert having to cope w i t h poverty; Charles Ives's dual career as composer and insurance broker) to increase the patient's optimism i n facing some of his own problems. H e also encouraged the patient to develop greater freedom and initiative by engaging i n musical improvisation. Regularly, part of each session was used to play "whatever comes to m i n d , " a way of reducing anxiety related to feelings of uncertainty, and of expressing spontaneous emotion i n the context of a personal relationship. After six months of this unorthodox music-psychotherapy, the patient decided to return to college and obtain a degree. After graduating, he immediately obtained employment i n a Canadian music school, which brought the relationship w i t h his therapist to an end, although he sends an annual Christmas card "newsletter." Over the years the patient has done very well, not only as a classroom teacher but also by giving private violin lessons and conducting the school orchestra. H e has had several satisfying relationships, but never married. Recently, he requested an interview w i t h the therapist, to discuss lingering self-doubts and anxieties related to approaching middle age, as well as a desire to give concerts i n Europe. Arrangements were made for h i m to have further psychotherapy, this time w i t h a psychiatrist associated w i t h a performing artists program i n Canada. CONCLUSION

I t is important to challenge the myth of the creative individual as someone who works like an inspired genius, i n total isolation, and produces only masterworks. Musical creativity especially is an enterprise that involves composing, playing, and improvising, usually w i t h other musicians and an audience. Cultural expectations are very important, and differ considerably from one generation to the next. Music is a living art, done i n practice. This paper attempts to outline some of the biological and developmental aspects of musical activity. I t reviews specific ways for enhancing the functioning, creativity, and health of musicians who seek treatment i n an organized program for performing artists. A basic concern should be to maintain the continuity already established i n the musician's career through life-long practicing and playing. T o be i n therapy w i t h someone experienced w i t h what i t means to be a musician obviously facilitates the treatment. There can be no rigid distinction between supportive and analytic psychotherapy. B o t h are needed, and depending on such factors as the realities of the situation, 402

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the patient's personality structure, the clinical syndrome, and the time available, can be characterized as "life-style management," "crisis resolution," or "character building." SUMMARY

The distinction between musical composition and performing is an historical artifact. B o t h activities have creative components, expressed by composers through the originality of their scores, and by performers through their unique and stirring interpretations. Music represents an artistic refinement of biologically driven activities, serving the need for communication, self-orientation, social contact, and emotional expression through soundmaking. Developmental factors—attachment to a soundmaking object, parental influence, the role of teachers, and supportive environments—have been reviewed i n connection w i t h the choice of music as career or avocation, and in the assessment of talents and handicaps presented by musical patients. Some historical examples serve to show that psychotherapy has traditionally been modified to fit the special needs of musicians. Familiarity w i t h the musical culture and community can be helpful i n treating these patients, and special clinics or health programs for performing artists have been established over the past few years. Three case examples are presented, based on experience w i t h musician-patients i n San Francisco, to illustrate different ways of providing psychotherapy that enhances musical creativity. REFERENCES 1. Roehmann, A. L., & Wilson, F. R., (Eds.). (1988). The biology of music making Proceedings of the 1984 Denver Conference. St. Louis, M O : M M B Music Inc. 2. Ostwald, P. F. (1972). The sounds of infancy. Developmental Medicine and Child Neurology, 1:350-1. 3. Ostwald, P. F. (1973). The semiotics of human sound. The Hague: Mouton. 4. Gardner, H . (1983). Frames of mind, New York: Basic Books. 5. Lomax, A. (1968). Folk song style and culture. Washington, D C : American Association for the Advancement of Science, Publication # 88. 6. Redford, J. (1990). Child prodigies and exceptional early achievers, New York: Free Press. 7. Feder, S., Karmel, R. & Pollock, G. (Eds.). (1990). Psychoanalytic exploration in music. Madison, CT: International Universities Press. 8. Ostwald, P. F. (1989). The healing power of music: Some observations on the semiotic function of transitional objects in musical communication. I n I . Rausch & G. F. Carr (Eds.). The semiotic bridge: Trends from California. Berlin & New York: Mouton de Gruyter, pp. 279-296. 9. Ostwald, P. F. (1968). The music lesson. I n E. T. Gaston (Ed). I n Music in therapy. New York: Macmillan, pp. 217-235. 10. Ostwald, P. F., & Morrison, D . (1988). Music in the organization of childhood experience. I n D. C. Morrison, Ed. Organizing early experience: Imagination and cognition in childhood. Amityville, NY: Baywood Publishing, pp. 54-73. 11. Ben-Tovim, Boyd, A. & Boyd, D . (1985). The right instrument for your child: A practical guide for parents and teachers. London: Gollancz. 12. Ostwald, P. (1985). Schumann: The inner voices of a musical genius. Boston: Northeastern University Press.

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13. Reik, T. (1953). The haunting melody: psychoanalytic experiences in life and music. New York: Farrar, Straus and Young. 14. Sataloff, R. T., Brandfonbrener, A. G., & Lederman, R. J. (Eds.). (1991). Textbook of performing arts medicine. New York: Raven Press. 15. Ostwald, P., & Avery, M . (1991). Psychiatric problems of performing artists. I n Textbook of performing arts medicine, pp. 319-335. 16. Ostwald, P. F. (1987). Psychotherapeutic strategies in the treatment of performing artists. I n Medical problems of performing artists, vol. 2, pp. 131-136. 17. Feldenkrais, M . (1949). Body and mature behavior: A study of anxiety, sex, gravitation & learning. Madison, CT: International Universities Press.

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The distinction between musical composition and performing is an historical artifact. Both activities have creative components, expressed by composers...
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