From the Aphonic Voice of Autism to the FA-Fonie (FA-Voice) in Music Therapy-Case Study

Music in a therapeutic relationship can affect the inner structure of one’s psyche and lead to a more meaningful self-organization and way of life. Music itself consists of all kinds of norms, structures and laws as well as of creative elements allowing freedom in expression and aesthetic beauty [1]. Music is a form of art, which can function as a living organism, as John Dewey (1859-1952) states about music being a “live creature”. As such, music could resemble the inner structure of the human psyche which, based on psychoanalytic theory, consists of the three orders of the Real, the Imaginary and the Symbolic [2,3]. These three orders are active and interconnected as qualities of the healthy functioning human being. Those analogies between music and the human psyche could offer a further comprehension and interpretation of the way one lives in the world of music. In this paper, ancient Greek mythology, psychoanalytic interpretations (mainly based on Lacan), interactive music therapy and a case study will show evidence of the analogies between music and the inner self. In interactive music therapy the therapist and the client are engaged in a lingual1 relationship through music improvisation, because unlike language, music possesses syntax. “The music is structured as a language. According to Lacan [4] “the unconscious is structured as language”. In psychoanalytic sessions the analysand claims the position of: “I am what I say”, “I speak through my symptom”, as well as “I see myself being seen”. Therefore, “I am also that which I express with my music, that which I play, that which I sing”, “I play and sing through my symptom”, as well as “I hear myself being heard” [5].

Through that lens, the music therapist tries to decipher elements of the client’s inner structure. The cues are provided through both sonic and musical structures, as it can be sensed and/or observed from a client’s expression and playing music. Those cues only have meaning when they are reflected through a deeper analysis of where and when the client communicates with an ultimate other outside of himself/herself, or when the client communicates with himself/herself as part of an internal process characterized as a symptomatic self-fulfilling circle, excluding others in the environment. In other words, the music structures come to reflect an inner self structure which the music therapist is called to observe, understand and act upon. The emphasis will always be placed on accepting, accommodating and allowing any facet that the client brings to the session to be expressed. However, it is also necessary to have a clear understanding of the structural dimensions (autistic, neurotic, psychotic) linked with the client’s being for the music therapist to understand the situation in depth and be able to assist with appropriate interventions. The music therapist, whether he/ she is following humanistic or analytic approaches, is specially trained to focus on the sonic pulse of that which is heard or not heard, and to respond to it musically. On the other hand, the client is offered the space to non-verbally express that “which cannot be said”. In other words, we are dealing with an infinite reservoir of meaningful expression and communication between human beings which presides in art [6,7].The therapist-client lingual relationship is mainly based on vocal expression, which, as music therapist Diane Austin [8] states, the most significant moments of music therapy seem to contain. The Lacanian analysis concerning the “aphonic” and “phonic Voice” [9] substantially contributes to the understanding of this non-verbal but lingual relationship, which is formed between the call of the “Voice” and the response to it. Through music therapy clinical practices, community music therapy performances - as well as stage music performances with psychiatric, special needs, and traumatized populations - clients have demonstrated that their symptoms may be seriously reduced and, in some cases, even completely eradicated. In all those cases the performers state that they feel and sound healthy moving on functioning social bonding [7,10-12] Psaltopoulou, 2016.

The present paper discusses the merits of interactive creative music therapy in the special case of Panos (it is a pseudo name)2, a client with autism, who started with piano lessons, moved to individual music therapy sessions based on clinical improvisation, and finally became involved in community music therapy performances. This is opposed to a recent study which states: “In children with autism spectrum disorder, music therapy did not result in significant improvements in man symptom scores compared with enhanced standard care” (Bieleninik, 2017). This could potentially be due to what dr. Alan Turry explains [13]: “To look at symptom reduction and to use cure matrix as the one would use with depression or anxiety, is inappropriate when looking at how any kind of therapy can help autistic people. Autism is understood by contemporary clinicians and autism advocates as a neurological difference that can manifest in a myriad of ways. What was once understood as symptoms, or disturbed behaviors are now recognized as coping strategies and innovative mechanisms to enhance potential development and engagement. Simply put, the goal of curing, eliminating or reducing symptoms is considered by autism advocates to be an outdated misguided approach to helping autist people live more satisfying lives. Functional gains and improvement in quality of life are more appropriate outcomes in this model. So how does spontaneously creating music in therapy lead to these gains?

The voice, like the gaze, the breast, and the feces, is one of the four driving objects causes of desire, the so-called small a. Thus, the voice, (with small v) is perceived exactly within the organization of drives and in the system of signifiers. It involves our voice, “for those of us who believe that we speak with our own voice”, “as it is heard in a structural aspect, in which it is articulated and comprises a system of signifiers” [9]. The voice “is considered to be the expression of the physical, mental and inner emotional world of the human being” [9,14], a Lacanian psychoanalyst, in response to the question “who is talking?” believes that it isn’t our voice, as we know it, but the Voice (with capital V). This voice (with small v), of ours in essence, couldn’t fundamentally be more than a “cry”, the actual call or invocation, which as a small object a (the object of the drive involved), actually “frees us from the Voice and from the silence” (p. 6). This means that we can hide, conceal, or deny our inner truth (which represents an inner structure) when speaking with our voice (with small v). We can avoid being in touch with our unique Voice (with capital V) and from our inner silence which may cause anxiety. Lemoine [9] poetically names this the “Voice” (with capital V), which begins with the “cry that is heard caught from the silence” (p.12). This is the meaning or understanding which underlies what is been said, expressed, stated, denoted by all signifiers presented by the voice (with small v). The psychoanalyst is concerned with the actual “dichotomy of the Voice in aphonic Voice/phonic Voice, which poses two opposite conditions of equal importance” and she is wondering whether “there is another aphonic Voice apart from that which is silent in the symptom and witnesses, in this way, an unconscious which would silently protest” [9].

Clearly inspired by Lemoine & Psaltopoulou [5] is concerned with the dichotomy of the cry in phonic or aphonic. She believes that the trained ear of the music therapist, can focus on and understand beyond the voice, the pulse, the force of what cannot be said, to a silent cry, a “phonic cry or aphonic cry,” which when mirrored by the “aphonic”. There is, however, the aphonic Voice, which if it were possible to confirm, would be autism, because the aphonic Voice is not heard and therefore cannot be responded to. Hence, the “entry into language is not possible” [9]. Psaltopoulou [5] believes that when the therapist in music improvisation reflects the aphonic cry of a person with autism and engages in a primal form of a nonverbal dialogue, the person feels motivated to communicate. Therefore, the aphonic cry turns phonic. Ontogenetic considerations in the development of the voice [15] commences with the first vocal expression of the newborn baby: the first cry [5]. At that proto stage it is an aphonic cry since it is not addressed to anyone. We do not really know the birth of a musical vocal expression seen like a “live creature.” But if we tap into the rich tradition of mythology, we could say that both life and music begin with a cry. As in Greek mythology, where music is born from Medusa’s cry [16] when she is decapitated by Perseus, Chryssaoras and Pegasus are born from her decapitated head. Chryssaoras is represented by the golden sword, which symbolizes law, norms, and boundaries. Pegasus, the winged horse, is a symbol which exemplifies freedom, creativity, art, and represents the “potentially unlimited” [5]. Life as well as music without the combination of norms (Chryssaoras) and creativity (Pegasus) would be chaos. A law without creativity would be unjust. Creativity without norms would be anarchy. We need to know the rules in order to break them and innovate new rules. Experimental works are only successful because they are playing with and against known rules. According to this myth, Medusa, before her decapitation by King Perseus, was a hideous, omnipotent, and destructive monster that threatened the world. At this previous stage, Medusa was, according to the psychoanalytic interpretation of psyche’s structure, at a phallic (capital F, Φ) state, meaning that she would not obey any laws. She acted as if she were a god herself, who was above the law. This is exactly the case of the psychotic/autistic structure of the psyche, where the other person does not exist as a subject. Lacan [17] uses the capital A to represent this other person in one’s life. This other person contains the sense of the structures, limits and laws, conveyed by a sense of a ‘father’ (“the name of the father,” Dor [3,18,19], which every individual needs to respect and follow to function well in society. Children and adults in the autistic spectrum or in psychosis have difficulty to follow external laws or rules and they seem to lack a sense of common structures other than the ones that represent their own psyche. Usually, they act like they are gods themselves and act as if they are the ones who make the laws and the rules. This is happening because in autism the structure of the psyche remains in the symbiotic relationship with a “mother”, meaning that autistics live mainly in the Imaginary order and sometimes in the Real order, while not being able to enter in the Symbolic order. The separation process from the symbiotic relationship with the “mother” usually starts when the child is at the age of six or seven months. It is followed by numerous attempts to assist the child to accept the laws and norms of life within the family and society. The process is experienced as a symbolic “castration” which allows a passage into language and eventually neurosis (which is a state represented by Lacan by -f or -φ). When the symbolic order is in place through the inscription of capital A (as “the name of the father”) one understands and uses symbols to express oneself through common signs, signifiers, and signified shared by society. A child is thus able to express how he or she feels by addressing others. In autism and psychosis this process of “castration” was “excluded” [4]. The musical expression of an individual with autism may seem to lack any structure as we know it, with beginningmiddle- end. The music seems like the endless movement of sea waves, reminding the sense of being lost in the womb, without any sense of boundaries.

When the king Perseus decapitates Medusa, this castration takes place. Therefore, one can see the movement from the phallic state (F, Φ) to the minus phallic state (-f, -φ), which corresponds to a healthy structure of the inner self, functioning in all three orders-real, imaginary and symbolic- interconnected. It is exactly at this stage where the human being can enter the symbolic order and be able to express himself/herself verbally through speech with meaning. Therefore “this myth could comprise a recreation of man’s symbolic castration in the Oedipal stage” [5]. During the same period (from six to seven months onwards), infants begin to recognize the mother’s voice. The face, which responds and answers these sounds, transforms the cry to a call, which could address the mother or any person who is mothering the child, like a career, a foster or biological mother. In this way, a first form of language, a language of sounds, is formed between a child and a mother. Every answer-response of the mother is automatically an interpretation. The quality of this first lingual relationship is of crucial significance, as it substantially contributes to the future psychosomatic development and growth of the human being. For instance, according to psychoanalytic theory [20], when the child experiences pleasure in this mother-infant lingual relationship the child is encouraged to develop a desire for life, whereas when the child experiences dissatisfaction in this mother-infant lingual relationship it is possible that this child will develop a desire for death [20]. The music therapist is specially trained to observe the human being’s audio dimensions through visual observations, singling out the vocal expression from the meaning of the words. The audio dimensions, according to Moses [15], are mainly categorized into five types of vocal phenomena: breathing, range of voice, placement of voice, resonance, and rhythm. The other audio dimensions, such as melody, pitch, speed, accent, and volume, and the emphasis on vocal phenomena and other significant characteristics, like passion, mannerism, melisma, accuracy, and pauses among the words, can be singled out and objectively observed by a trained listener, such as the music therapist. Once the music therapist has interpreted the psychological condition of the client, the therapist will respond appropriately within the lingual relationship established during the sessions. “A key aspect to the work that we do is to approach someone in a holistic way” [13].

Meeting with Panos’ mother and his child psychiatrist

According to the mother’s and child-psychiatrist’s reports, Panos was diagnosed with autism in early childhood. Both parents were medical doctors. His father, narcissistically wounded by the diagnosis, fell into a depressive state. Therefore, the mother took on full responsibility and tried to provide the child with the best care. Panos attended a conventional elementary school, where he managed to pass the classes by memorizing the subjects of study with a lot of assistance from his mother. His speech was echolalic and stereotyped, with a rich vocabulary. He liked to speak about irrelevant things with limited eye contact and stereotyped movements, such as rocking. It was hard for him to follow class rules, but despite this, teachers treated him with good care. Since both his mother and psychiatrist recognized his enthusiasm for music, Panos began taking piano lessons at the age of ten. Both reported that Panos developed music skills of discriminating sounds and memorizing music patterns. Also, his gross and fine motor, as well as eye-hand coordination, improved. He could read music notation and play first-grade level pieces with one hand, later with the other, and, after a lot of effort, with both hands together. He was practicing piano for hours in solitude detached from the outer world. He always played in the same powerful forte dynamic level without using any pedal. When he found it difficult to coordinate his two hands, he would get stuck on the same note, repeating it ad- infinitum. Panos also had a perfect pitch. He could play wellknown melodies by ear, only with the right hand. He sang numerous popular songs, always in pitch, yet his singing voice sounded mechanical without any emotional expression. Usually, he would choose to sing and play songs in the order he would listen to them on CDs in an echolalic and stereotyped way. Both his mother and psychiatrist reported that Panos, at age sixteen, was not growing further as a piano student, as he seemed to repeat over and over what he had already learned playing the piano. Both thought that since the piano teacher had no special training in working with students with autism, she could no further help him. Therefore, they started looking for a music therapist to continue the piano lessons, so that Panos would improve musically.

Discussion with the music therapist

Being the only music therapist in town at that time, I had to clarify that that my work was not to teach piano but rather to use music for such non-musical goals as enhancing self-expression, communication and socialization skills. They both said my comments were “absurd” and insisted I teach him piano in the classical conservatory style. The child psychiatrist especially laughed at my idea of helping Panos through clinical improvisation, to get in touch with his emotions, to connect with his Voice, to express himself, to communicate with others, and to reach a place where he could play and share music with others in meaningful ways. In consideration, I emphasized the fact that a change of piano teacher would probably upset Panos, as it usually happens in autism cases when faced with changes. Therefore, I asked permission to communicate with his piano teacher to further investigate the situation. She spoke very positively about continuing piano lessons with Panos, but she had sensed that the mother had different plans and she did not want to be in conflict with her. Both his mother and child psychiatrist tried hard to persuade me to start working with and teaching Panos piano. The psychiatrist said that she was conducting verbal therapy with Panos. I accepted the challenge on the condition of having three meetings with Panos to investigate his potential of moving on as a piano student according to their request.

Piano lessons with panos

When Panos first came to my office, I could observe his piano playing and singing as a “visual” piano playing and a “visual” way of singing. Meaning, I missed his own heart feelings. It was as if I were listening to a photocopy or sound copy device, without any emotional involvement with the music, or at least a copy of emotions. His music performance sounded at all times mechanical and flat, like a playing “typewriter,” lacking meaningful expression. It was an echolalic-stereotyped, thus “autistic” way of playing; an aphonic Voice, which, in my perception, could only give him some kind of a simple kinesthetic pleasure. One can look at it as if Panos were playing the piano at a “lalling” stage of the infant. His face and his look to the music remained flat and expressionless in whatever he did. In addition to observing his piano playing, I observed and made queries into Panos’ overall way of living. He neither had friends, nor was he engaged in social interaction. His speech was repetitive and made up of exhaustive disconnected narrations and descriptions of agricultural machinery that he recollected he had seen at an earlier age. Thus, his speech could not be defined as a speech that makes sense but as a “visual” speech: his speech was full of words disconnected from feelings and contained scattered phrases that were usually inappropriate to the present situation. Panos lived in the world of music the same way he lived in the world of autism. He was attached to a reality of sequential notes and sounds without being able to make symbolic associations. Thus, he experienced and made music with the same autistic traits that he exhibited in his life: he lived in the Real and Imaginary order while excluding the Symbolic. Music lessons neither helped him to move on to experience life with meaning nor enter the Symbolic order. Hence, I conclude that the piano lessons did not provide him with a way out of autistic silence or introduce him to either music’s inherent emotional quality or elicit emotion in him the way music often does for others. Rather, the piano lessons formed an autistic musical spectrum in the already existing mental autism. One can interpret those features as a harmonious displacement of the mental autism to a “musical” autism. I believe this is due to the fact that sometimes music education involves conditioned learning that remains with children on the spectrum and eventually reinforces autistic attitudes and behaviors. After our three meetings we had another meeting with the mother and the child psychiatrist where I explained Panos’s musical situation - his playing lacked direction, meaning and connection to emotions. It was a stereotypical playing. Through observing him during the piano lessons I could sense his potential for a more meaningful way of living. From my perspective it would eventually be reached through interactive creative music therapy sessions that use music improvisation for non-musical goals. Finally, we all agreed on the necessity to move on to music therapy sessions.

Individual music therapy sessions with panos

We started with individual hourly music therapy sessions once a week for three years. My approach as a music therapist is humanistic and music centered. The fact that I use psychoanalytic theory to explain the relation between music and inner psyche’s structures provides a new approach, which I call a “synthesis” of humanisticmusic- centered practice and psychoanalytic understanding.

First year of music therapy sessions

In the beginning of the music therapy sessions, it was evident that Panos had established a conditioned relationship with the piano: the mechanical way he approached the piano, placed his hands on the keyboard, positioned the music score and played seemed a clear product of conservatory generated piano lessons. By ear, he played a “photocopy” reproduction of melodies of wellknown songs. In both cases, he played with a great deal of anxiety and intensity. By ear, he played a “photocopy” reproduction of scores or melodies of well-known songs. In both cases, he played with a great deal of intensity and anxiety. It seemed it was impossible for him to free himself of his conditioned routine and to experience the piano playing as a means of emotional expression and interaction. Furthermore, his single-minded focus on the task of playing the correct notes on the piano left no room for simultaneous interaction with the therapist. This lack of freedom indicated a negative consequence of conditioned piano learning. The only time I sensed a “mute cry,” like an aphonic cry, which I felt it as a call for help-of course not addressed to anyone and without Panos, as a subject, knowing it-was when he was getting stuck on something unpredictable in performing the musical piece or song. He would repeat continually a note at different meters of the piece he was playing for no obvious reason, without being able to continue. As I saw it, it was not due to lack of practice or technical ability. Also, he did not accept my suggestions to correct it and move on to playing the rest of the piece but would instead continue repeating the note. In doing so, Panos seemed that he was not addressing anyone and did not even realize he was crying out. I felt it as an inner call for help and interpreted it as an existential cry of despair, rather than an appeal for correction of mistakes. This was a kind of a call for help without Panos knowing it. I would consider this cry an aphonic cry, inspired by Lemoine’s term on phonic and aphonic Voice [9]. At that point, I decided to encourage him to improvise on other instruments-such as percussion, strings, and woodwinds – since he did not have any conditioned reflective connection to them. I also encouraged him to experiment with his voice. I presented to him the instruments I had in the room and invited him to musically improvise together, creating a first form of a lingual relationship. Just as in his relationships with people, Panos’s musical interactions initially presented the following characteristics.

a) Compulsive stereotyped rhythmic response: playing in a mechanical, dull manner without liveliness, flexibility, or variety, and with a lack of speeding up and slowing down to express a musical idea.
b) Unstable rhythmic freedom: remaining rigid and inflexible in a specific mood despite his acute musical perception.
c) Lack of intention or creative expression: trying in vain to lead the sounds he was playing somewhere.
d) Lack of boundaries and structure: no clear sense of beginning, middle, and end.
e) Disturbed rhythmic response: improvise impulsively when he was coming to the session upset, due to unpredictable changes in his life routine outside the music therapy sessions. At times he would play aggressively with gradual loss of energy, culminating in exhaustion.
f) Identification with rhythm, syllable playing demonstrating an inability to play the basic beat on the percussion, while improvising with his voice. Even when singing a well-known song, without ever being out of tune, he would beat on the drum at each syllable. He failed to accompany his own vocal expression by playing the basic, steady beat on the percussion he used.
g) Fragmented dynamics: Disconnected levels of dynamics (e.g., forte, mezzo-forte, piano) without any obvious meaning. Total lack of affection. He could neither express himself by gradually playing musical phrases louder or softer, nor reach a peak or a resolution.
h) Eye contact: in some of our musical interactions, there was an increased frequency in meaningful eye contact. At those moments his improvisation seemed more creative with a flow in dynamics, in pitch range, and in short melodic phrases that he invented and repeated with meaning. His inner desire for more freedom was motivated and revealed.

In my ways of musical interaction with Panos, inspired by the psychoanalytical understanding of the psyche’s structure, I used the expressive elements of music (dynamics, tempo, articulation) in such ways as to provide the father, mother, and creative child sense. I view music as a core family [5], providing very carefully (i) the mother’s qualities of a musical placenta that matched Panos’s state of being, (ii) the father’s qualities of a clear musical structure, as well as (iii) the child’s qualities of freedom in expression. The laws in life are usually hard to make for any human being. When there is a warm and loving hug from a mother, then the process of accepting and following society’s norms is facilitated. Both qualities can be manipulated and combined in a music improvisation so that the creative child will grow safe and sound.

The following are exemplary clinical interventions I used in the clinical improvisations.
I. Mirroring, holding, containing, supporting: The main goal was to establish a trusting relationship in which Panos could feel heard, accepted in his choices, safe, and with some sense of control over his environment. I matched his mood in my playing with his mood, so that the music we improvised together would feel as one. That seemed to be a safe place for him, since it reflected the feeling of a symbiotic relationship with a mother. At that point, the music sounded endless and without any specific direction matching his way of playing. Panos seemed relaxed and happy, as, in those moments, I saw his cheeks flush and his eyes sparkle. As if he experienced some kind of familiar pleasure. When I felt that a sense of trust was established in this music therapy—lingual relationship, I contributed my playing of the father’s qualities of music – clear form, clear melodic phrases with specific direction, and structure accompanied with the appropriate chordal harmonization and dynamics. In those moments, Panos seemed awakened and more interested in the improvisation as he stopped his stereotyped back and forth rocking movements, and tried slightly different ways to beat the drum, and different ways to vocalize. When he heard his choice of a fragmented stereotypical musical expression being contained in the structured and boundary-defined mirroring that the music I was playing provided, he seemed surprised and deeply fulfilled. He used to say, “That’s it. That’s music. That’s our music.”
II. Encouragement: For the client to achieve the feeling of moving towards something new with confidence, I enforced mild rhythmic interventions (e.g., playing gradually faster or slower, syncopated rhythmic patterns, counterpoints), interesting dynamics (e.g., playing gradually louder or softer), harmonization in different styles and modes, and using dissonances to motivate or surprise him. In those moments, the music reflected the family’s discussions. The mother elements of music were holding Panos gently within the state he was in, providing him with a sense of a big embrace so that he could easier accept the laws, limits, and structures of the father’s elements of music. Gradually, Panos was able to improvise vocally or through beating the drum in a more meaningful way.
III. Humor and playfulness: I used humor and playfulness in my music tension-relaxation techniques with moments of musical spontaneity and creativity. Panos laughed loudly at those moments of the creative child’s musical elements and was engaged for some time in a symbolic play. His responses were immediate without the usual autistic delays, and his whole body was alive and flexible.

Those interventions led Panos to (i) a significant decrease in his stereotypical expression, (ii) an emergence of spontaneity, (iii) being more and more present in the here and now, (iv) experiences of pleasure in the interpersonal relationship, (v) an immediate connection to appropriate emotion in the music and in verbal communications, (vi) meaningful and timely speech, (vii) the enrichment of his means of expression: eye contact, enlivened body language, richer vocabulary, and meaningful, appropriate facial expressions, and finally (viii) substantial communication. Through the clinical improvisation of a live-dynamic musical form of interactive lingual relationship, which was continually recreated according to Panos’ present needs as determined through the client-therapist dialogic relationship, his communication skills were enhanced. His connection between speech and appropriate emotions thrived and became meaningful; his self-expression was enriched. Additionally, his sense of boundaries developed. At the last session of his first year of music therapy, he shared that he missed his father, who, as Panos said, was working hard to provide him with everything he needed. He wanted to spend more time with his father and to play music together. While sharing that comment, Panos’s body posture suggested that he was in pain, and his facial expressions exposed that he was close to tears. He mainly focused his desperate eyes on the floor, but at one moment he looked right into my eyes hoping for my help. His tone of voice became softer, and he appeared ready to cry. I interpreted that as a soft phonic cry expressing his inner tears. I held a meeting with his mother and his child psychiatrist to discuss the possibilities of his father taking a more active role with Panos. Summer vacation could hopefully offer a chance for them to work on their relationship, as they would be living all together at their summer home while schools, therapy, and work would be closed.

Second year of music therapy sessions

After three months of vacation, Panos’ mother told me that her husband unfortunately was severely depressed the entire summer and had recently decided to go to therapy himself. She reported that Panos felt deeply rejected by his father. His mother noticed that, despite her son’s feelings of rejection from his father, Panos reached out for the first time in his life to a young boy around the same age as him, who happened to be their neighbor at the summer place. She felt that it was progress for their son and an outcome of the music therapy sessions. At that moment I had the idea of inviting a young male co-therapist, John, into my music- therapy sessions with Panos. I asked Panos before John came into the sessions whether he wanted another person in our sessions, and he liked the idea. With a big smile, he said: “Ah! Yes! We will play music together.” The dynamics of the therapeutic relationship changed. In the beginning, Panos was looking exclusively at me, blocking out of his sight the male co-therapist. However, he acknowledged John and invited him at the end of each session to come again. Gradually, Panos happily accepted this change, and included John in our musical interactions. He addressed John with increased eye contact and meaningful discourse about music and everyday activities. To facilitate the sessions, I mainly reflected on the playful and creative interactions of the co-therapist with Panos on the piano. To maintain a warm and safe atmosphere, I primarily kept the mother vocal qualities of the musical elements, like a vessel, in which to contain their interactions. Panos seemed very happy and eager to come to the music therapy sessions. His eyes were shining, and his cheeks appeared flush. After becoming better acquainted with the co-therapist and building a relationship based on trust, Panos became more assertive. He was able to improvise spontaneously with appropriate emotion in relation to the moment, which was now evident both on his face and in his body movements. He was able to select well-known songs according to what was happening to him at the time, bypassing the order of the songs on the CDs that had previously been his stereotyped way of living. He was able to make his own meaningful choices based on his connection to his inner desires of the moment. That revealed an existing world of personal feelings. He would suggest different instruments for John to play and he would arrange the whole musical setting with him. Almost always, Panos was the singer. In those moments of singing familiar songs, he would at times, unexpectedly sing out of tune. The fact that he was out of tune especially pleased me. At last, the photocopy machine had “broken down” and a Voice had started to emerge, a Voice that refused to copy the contour of the melody and tonality of the song. It indicated the existence of an internal being who processed the tonality of a song instead of merely photocopying it. This new and healthier state of being is “FA-fonie.” The “FA” represents the first syllable of the ancient Greek verb “fasko” which means, “I speak”; “fonie” means “voice.” This is relevant because at this stage of his music-therapy work, Panos began to develop meaningful speech and was engaged in a real discourse without any autistic elements in certain moments of his life. In the lingual relationship which we formed in music therapy, Panos was led from a mute cry-an aphonic Voice-to meaningful, interactive expressions - an expression of his Voice. Additionally, the music therapy worked to foster in Panos a functional coexistence with others, as his mother said. Overall, the music therapy significantly decreased his symptoms of autism. During music-therapy sessions, there were moments when his signs of autism seemed to be absent. His parents told me that outside of the sessions his autistic symptoms were diminished significantly but not totally eliminated.

Third year of music therapy sessions

During the third year of our sessions John had to leave. I kept working with Panos in similar music-therapy modes to the previous year to support and build upon the positive changes that had already been established. Panos was now nineteen years old and able to work at a place of hippotherapy as a trainee without a salary. He was very effective in taking care of the horses, and he communicated well with his boss and the clients. In addition to functioning well in society, he is happy now that he uses his Voice. He became a beautiful human being with a Voice. This new evolution in which Panos’ Voice (capital V) was revealed represented the passage into the Symbolic order for the first time in his life. It seemed that in certain defined moments there were occasions where the Real, the Imaginary, and the Symbolic orders of the psyche came in contact with and interacted in ways that resembled those of a normal-functioning individual. Panos’ aphonic Voice, aphonic cry, and voice occurred together with what I call the FA-fonie. In Panos, the FA-fonie was a Voice that revealed indirectly (e.g. through personal choice of songs related to his state of being during the music therapy sessions and through meaningful communication with other members of his family) his inner truth. The capital F represents the “Fonie” (Voice), the capital A the “afoni” (Aphonic) voice, which is with a capital A because it is no longer the mute cry that the aphonic Voice represents. It became Afonie (Aphonic Voice) with a resonant formed sound that belongs to a structure of signifiers and involves the development of the mute-aphonic cry. The FA-fonie, in other words, is born the minute the music therapist perceives the aphonic cry of the autistic child as a call to some other person and responds to it during the mirroring phase of the interaction. The child finds himself or herself in a healthy dialogue without being conscious of it. The child has entered a new space of communication where the symptoms of autism are absent. During the third year of music therapy, the autistic symptoms Panos used to display significantly decreased. There were moments where his expression was livelier, his complexion looked healthier, and his physical movements and his speech were evidently connected and in harmony with his emotions and with appropriate response time. In the sessions he would express his emotional pain from being rejected by his father, and he would select relevant songs to process it. His mother told me that outside of music therapy Panos communicated with other people and could take part in a discussion about current topics, with excellent eye contact and appropriate gestures. Stereotypical autistic behavior would resume only when he was overwhelmed and confused, which did not happen as often as in the past. Panos was now ready to participate in a group of young people with special needs and move into community music therapy performances.

After three years of individual music therapy, Panos was ready to express his Voice and share meaningful moments with significant others in a communal setting. Therefore, I placed him in a music group that consisted of other members with special needs. He participated with great success in community music performances as a singer. He was now able to select the songs based on how he felt in the moment and the messages he wanted to convey to others about his desires, his thoughts, and his mood as well as about his feelings for others. In addition, he easily cooperated with the members of the orchestra, waited his turn, flexibly dealt with unpredictable occurrences during the performance, changed his routine when needed, and communicated with the audience using meaningful eye contact. In the first performance that he participated in at the music hall, there were almost one thousand people in the audience. Panos sang out of tune continually but communicated and had meaningful eye contact with the members of the orchestra and the audience at appropriate moments. I interpreted that being on stage for the first time in his life must have felt like an intense experience for Panos. Unlike private sessions, he could no longer choose the song. His routine of being in absolute connection with the song he was supposed to sing was severely challenged. Likewise, the large audience made it difficult for Panos to single out people with whom to establish significant interpersonal connections. That had been his usual habit in one-on-one therapy sessions and even in his music group. In front of the large audience, it seemed as if his internal “photocopy machine” were broken. Therefore, he made space within himself for building connections with the members of the orchestra as well as the audience. He allowed himself to acknowledge and connect with the big “Other.” He was interested in communicating with other human beings and was no longer “lost” in his own world or in the music. It was at this first performance that his child psychiatrist was convinced of Panos’ emotional health and creative potential. Panos’ father, who unfortunately did not have any serious progress in his own personal therapy, was deeply moved by his son’s performance. He had an awakening, and said it was the first time he saw his son as being “normal” and felt proud of him. That moment caused him to start his relationship with his son. His depression was superseded by his authentic emotions of fulfillment and genuine tenderness toward his son. After the second performance, Panos stopped singing out of tune but not because of “visual” singing. Rather, he was able to simultaneously focus on his singing as well as be in touch with the audience. In fact, at the end of one performance, he asked to sing a song that was not included in the program (titled: “We Only Have One Life to Enjoy”), in order to share his joy with the audience. He was connected with his inner desire and expressed it clearly, stepping out of the autistic obsession with routine. Thus, as Lacan [18] believes, I would venture to say that the capital A in the term “FA- fonie” could symbolize the big “Other.” On stage, Panos recognized, with meaningful eye contact, the big “Other.” He addressed and communicated with the audience and the other members of the orchestra. There seemed to be a total absence of the stereotypical image of the autistic child. Panos felt safe in the relatively predictable realm of a reality that was constructed on stage, i.e., the performances at a specific hall with specific structures. Through these performances, Panos’ parents claimed that they saw their child as “completely normal.” His speech had acquired coherence and meaning. Panos moved from the aphonic Voice to FA-fonie, which meant that he moved from the autistic state of being to one that resembled that of a non-disabled individual. He behaved in ways that indicated he was mindful of the present. Panos later expressed, to the surprise of his parents, his deep desire to sing at the most famous music hall of the country. They had believed that he did not have the resources to have any dreams or visions in his life. He was able to apply for a job and was hired. Panos became more autonomous, earning his own living, but continued to live with his parents. He communicated meaningfully with significant others and furthermore was in a position to make associative connections and use symbolic language as well. For instance, in our sessions, Panos asked to sing the song “You and I in Love” because he fell in love with a girl at work. When his employer punished him and forbade him to talk to her during working hours, he indicated his emotion by requesting the same song but changing the song title to “You and I Entrapped.” That demonstrated he could distinguish between the emotions of being in love and being entrapped. He was aware he was using a symbolic language since he communicated with me with a sly smile, insight, and substantial speech.

The present paper investigated the three orders-the Real, the Imaginary, and the Symbolic-as a common component of the structure of music as well as of the human psyche. In the case of Panos, it became obvious that the way he lived in the world of music reflected the state of his inner self. Furthermore, the appropriate use of music in a therapeutic relationship affected his inner self-condition to the point that the autistic symptoms became absent resulting in Panos experiencing a healthier self and a wellfunctioning inclusion in society. The clinical use of the voice as a human musical instrument that mirrors the soul was the most direct approach toward the emergence of the Voice. Through the presentation of clinical cases, psychoanalytical thought has been shown to substantially contribute to the understanding and naming of phonic and aphonic Voice phenomena [21]. Panos’ progress in moving from the aphonic Voice to FA-fonie opens up a significant path in music therapy and in psychoanalytic understanding and encourages further research of this phenomenon. Music therapy researchers may analyze the term “FA-fonie” according to the phallic function of capital F (i.e., the symbol for the autistic-psychotic structure of the psyche), where the autistic or the psychotic person is like a god who is not acknowledging any law other than his or her own in its course towards the -f (the symbol in Lacanian thought for the “normal” neurotic condition, wherein a person functions well in society, acknowledging and respecting the laws). At the state of FA-fonie, we see a condition in which the autistic and/or the psychotic person is functioning at the normal neurotic state (-f). In the following figure, we can see that the three orders-the Symbolic (S), the Imaginary (I) and the Real (R) come into a connection with the big Other (A). This illustration represents FA-fonie, the healthy state a person can reach through music therapy (Figure 1). “Much as the laws of DNA provide a plan for the structure of fully functioning physical bodies, aligning our naturally occurring propensities for emotional and cognitive development with the laws of music provides for fully functioning psychological beings” [22].

Figure 1:Sch. 1 FA-fonie (FA-voice). S: Symbolic, I: Imaginary, R: Real, A: Other Psaltopoulou, 2015:65.

It seems that the person with a psychotic structure of the psyche who lives mainly in the Imaginary order and in the Real, as a music therapy client, can enter the Symbolic order, which was excluded in the psychotic psyche. When connecting with the big Other (A), meaning that the aphonic voice can become phonic and address the Other as well as meaningfully interact with the Other, an individual with a developmental or psychological disorder can experience socially functioning moments in life, reaching the state of FA-fonie.

Nevertheless, music therapy does not claim to cure autism or to simply alter behaviors [23-27]. Rather it provides the polyphonic space for the formation of a more functional and healthier structure of the psyche based on the client’s strengths. And “If researchers take a strength-based perspective rather than view treatment solely from a medical model perspective, findings will be more meaningful” [13]. Through the reciprocal communication developed between the music therapist and the child in the autism spectrum, the child is motivated to emotionally attach to and understand another person. “By being attuned to and joined musically the child experiences relatedness in a way that is difficult to do otherwise. These musical interactions are a key factor in developing a therapeutic relationship and music therapists improvise together with the child and guide the child to express themselves musically with increased attention, focus, flexibility and responsiveness. The child has a shared emotionally meaningful experience that motivates the child to continue to communicate and build social skills. These experiences gradually help the child to develop greater awareness, emotional regulation, and overall social reciprocity” [13].

1. Hamilton A (2007) Aesthetics and Music. Continuum, London.
2. Eyre L (2011) From ego disintegration to recovery of self: The contribution of Lacan’s theories in understanding the role of music therapy in the treatment of a woman with psychosis. In: Meadows A (Ed.), Developments in music therapy practice: Case study perspectives, Gilsum, NH: Barcelona Publishers, US, pp. 385-399.
3. Lacan J (1975) Le Seminaire, XXII R S I Ornicar, Paris.
4. Lacan J (1973) Les quatre concepts fondammentaux de la Psychanalyse. Seminaire XI, Seuil, Paris.
5. Psaltopoulou KD (2013) Music therapy improvisation as a core family: the potentially unlimited inspiration leads to self-anamorphosis. CFMAE Interdisciplinary Journal for Music and Art Pedagogy 5(1): 9-20.
6. Georgopoulos N (2010) Retrieving the Primary, 2^nd International Psychoanalytic and Philosophy Conference: The Original, Pulishing of Minutes in progress, Co-organizers FEBE, GRAPPAF, School of Philosophy, University of Aristotle, Greece.
7. Psaltopoulou D (2012) Community music therapy interchange: New paths for personal and environmental changes. Published by ISME Commission on Music in Special Education, Music Therapy and Music Medicine Congress. Thessaloniki, Greece, pp. 217-223.
8. Austin D (2008) The theory and practice of vocal psychotherapy: Songs of the self. Jessica Kingsley Publishers, UK.
9. Lemoine E (1997) The voice, incident, magazine issue, psychoanalytic clinic. Thessaloniki team intergrated in Greek Co-ordination of European Psychoanalytic school in cooperation with the French Institute, Publishers Thessaloniki, Greece.
10. Aigen K (2014) The study of music therapy. Taylor and Francis, New York, US.
11. Jampel P (2011) Performance in music therapy: Experiences in five dimensions. Voices: A World Forum for Music Therapy, North America, 11(1).
12. Nordoff P, Robbins C (2007) Creative music therapy : A guide to fostering clinical musicianship. Barcelona Publishers, US.
13. Turry A (2019) Neurodiversity: Considerations for music therapy practice and research with autistics. Oral presentation in two-day preconference of creative arts interconnection-paideia-therapy (CAIPT): Music and Arts Therapies in Health Care Settings. Aristotle University, School of Music Studies, Thermi-Thessaloniki, Greece, pp. 30-31.
14. Psaltopoulou D (1992) Research on voice techniques in music therapy with adults. 2: 46-48.
15. Moses PJ (1954) The voice of neurosis, New York, US.
16. Tsokani C (2006) The cry of the medusa: From sound to music, Alexandria Press, Greece.
17. Lacan J (1977) The mirror stage as formative of the i as revealed in psyhoanalytic experience, Norton, New York, US.
18. Dor J (1992) Introduction to the Reading of Lacan: 1. the unconscious structured as a language, Paris: Denoel, Theory and Society: Athens, Greece.
19. Lacan J (1991) Le Seminaire, livre XVII: L’ envers de la psychanalyse, Seuil, Paris.
20. Deligiorgi A (2010) I-Other-World: The Primary as Meeting Place, 2^nd International Psychoanalytic and Philosophy Conference: The original, Publishing of Minutes in progress, Co-organisers FEVE, GRAPPAF, The School of Philosophy, University of Aristotle, Greece.
21. Psaltopoulou D (2015) Music therapy: The third way (In Greek). Electronic academic books. Kallipos, Greece.
22. Aigen K, Carpente J (2017) Assessment in music therapy: A music-centered perspective. In: Elliott DJ, McPherson G, Silverman M (Eds.), The Oxford handbook of qualitative and philosophical assessment in music education Oxford University Press, UK.
23. Lacan J (1981) Le Seminaire vol. IV La relation d’objet. Seuil, Paris.
24. Lacan J (1998) Le seminaire livre XX Encore. Seuil, Paris.
25. Psaltopoulou D (1992) Research on voice techniques in music therapy with adults. Mousicotropies 3: 50-54.
26. Psaltopoulou D (2006) Music therapy: disability and psychosomatic anamorfosis. Music therapy and other music approaches for children and young people with disabilities, The University of Ionio, Athens, Publishes Orpheas, Greece, pp. 90-102.
27. Winnicott DW (1965) The maturational process and the facilitating environment. Hogarth Press, London.