CMTJ-Vol 20-2-Web - Canadian Association for Music Therapy

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Canadian Journal of Music Therapy Revue canadienne de musicothérapie Vol 20(2), 2014
Canadian Journal of
Music Therapy
Revue canadienne de
musicothérapie
Numéro spécial du 40e anniversaire
1974 – 2014
40th Anniversary Special Issue
1974 – 2014
Volume 20(2), 2014
Canadian Journal of Music Therapy
The Official Journal of the Canadian Association
for Music Therapy
Revue canadienne de musicothérapie
Revue officielle de l’Association de
musicothérapie du Canada
Volume 20(2), 2014
Editor / rédactrice en chef
French editor / rédactrice (français)
Guest editors / rédactrices invitées
Copy editor / réviseure
Translation / traduction
Jennifer James Nicol, PhD, MTA
Sylvie Ouellet, PhD, MTA
Carolyn Arnason, DA, MTA, FAMI
Amy Clements-Cortés, PhD, MTA,
MT-BC, FAMI, NMT
Michele Satanove, BMus, MTA
Sophie Boisvert, MA, MTA
Felicity Baker, PhD, RMT
Bernadette Boissonnault, BMT, MTA
Sylvie Boisvert, LGSM, MA, MTA
Chrystine Bouchard, MTA
Debbie Carroll, PhD, MTA
Beth Clark, MM, MMT, MTA, MT-BC
Kirsten Davis, AVCM, MTA
Marie-Claude Denis, PhD
Lillian Eyre, PhD, MTA, FAMI, MT-BC
Brian Garner, BA, BMT, MTA
Simon Gilbertson, PhD, RMT
Don Hardy, BMT, MTA
Deborah Hawksley, MMT, MTA
Alicia Howard, MMTA
Ann Johnson, MTA
Petra Kern, PhD, MT-BVM, MT-BC
Jennifer Kong, MMT, MTA
Joel Kroeker, MMT, MTA, MA
Catherine Latendresse, MSc, MTA
Paul Lauzon, MMT, MTA
John Lawrence, MMT, NMT, MTA
Colin Lee, PhD, MTA
Nancy McMaster, MA, MTA
Heather Mohan Van Heerden, PhD, MTA
Nicola Oddy, MA, MTA
Annie Pelletier, MTA
Adrienne Pringle, MMT, MTA
Ruth Roberts, MMT, MTA
Deborah Salmon, MA, MTA, CMT
Stephen Williams, MCAT, MTA
Alpha Woodward, MMT, MTA
Katherine Wright, MA, MTA
Laurel Young, PhD, MTA, FAMI
EDITORIAL REVIEW BOARD / COMITÉ DE RÉVISION DES PUBLICATIONS
© 2014, Canadian Association for Music Therapy
© 2014, Association canadienne de musicothérapie
ISSN 1199-1054
PUBLISHER
Arkay Design & Print, Kitchener, ON
Canadian Journal of Music Therapy ∞ Revue canadienne de musicothérapie, 20(2)
TABLE OF CONTENTS
TABLE DES MATIЀRES
Editorial / Éditorial
Jennifer J. Nicol .....................................................................................................4
Sylvie Ouellet .........................................................................................................7
Carolyn Arnason and Amy Clements-Cortés ...........................................10
What Do Orchestral Instruments Bring to Music Therapy? Developing My
Voice on the Oboe and English Horn as a Music Therapist / Quel est l’apport
des instruments d’orchestre à la musicothérapie? Trouver ma voix au moyen
du hautbois et du cor anglais en tant que musicothérapeute
Aimee Berends .................................................................................... 13
Inter-Active Listening: Re-envisioning Receptive Music Therapy / L’écoute
inter-active : la musicothérapie réceptive fait peau neuve
SarahRose M. Black ...........................................................................32
Safety, Connection, Foundation: Single-Session Individual Music Therapy
With Adolescents / Sécurité, lien, fondation : séance de musicothérapie
individuelle unique auprès d’adolescents
Emily S. Carruthers ........................................................................... 43
An Opportunity for Positive Change and Growth: Music Therapists’
Experiences of Burnout / Une occasion de changement positif et de
développement personnel : l’expérience de l’épuisement professionnel chez
les musicothérapeutes
Kiki Chang ............................................................................................. 64
Emotion Without Words: A Comparison Study of Music and Speech Prosody /
L’émotion sans mots : une étude comparative de la prosodie musicale et de
prosodie de la parole
Sarah Faber and Anna Fiveash ......................................................86
Canadian Journal of Music Therapy ∞ Revue canadienne de musicothérapie, 20(2), 1
Canadian Music Therapists’ Perspectives on the Current State of Music
Therapy as a Profession in Canada / Les perspectives des musicothérapeutes
sur le statut actuel de la musicothérapie en tant que profession au Canada
Erin Gross and Laurel Young.......................................................102
Hermeneutic Inquiry on Musical Gestures in a Music Therapy Context / Recherche herméneutique sur le geste musical dans un contexte
musicothérapeutique
Danielle Jakubiak ............................................................................. 134
Tango Improvisation in Music Therapy / L’improvisation de style tango en
musicothérapie
Damien Kogutek ............................................................................... 166
Jungian Music Therapy: A Method for Exploring the Psyche through Musical
Symbols / Musicothérapie jungienne : une méthode d’exploration de la
psyché à travers les symboles musicaux
Joel Kroeker ........................................................................................ 180
Création d’un programme de musicothérapie pour les proches aidants de
personnes ayant la maladie d’Alzheimer / The Creation of a Music Therapy
Program for Family Caregivers of Persons Suffering from Alzheimer Disease
Christelle Laforme ........................................................................... 205
Le milieu scolaire québécois et les élèves ayant des besoins particuliers;
enseignant de musique ou musicothérapeute? / The Education System of
Quebec and Students with Special Needs: Music Teacher or Music Therapist?
Sylvain Larouche ............................................................................. 237
Guidelines for contributors /
Directives pour les collaborateurs............................................................................... 247
Editorial / Éditorial
Jennifer J. Nicol, PhD, MTA, RDPsych
University of Saskatchewan, Saskatoon, SK, Canada
It is with pleasure that I invite you to enjoy this issue of the Canadian
Journal of Music Therapy, the second volume of 2014. This is an extra publication
offered in celebration of the Canadian Association for Music Therapy’s ruby
anniversary. It was a mammoth undertaking, requiring the cooperation and
efforts of many individuals, all of whom I thank and acknowledge.
This is also my last issue in the role of editor, and I am welcoming
Nadine Cadesky in her new role as incoming editor. Overseeing the journal
has been a rewarding though challenging and labour-intensive endeavour!
So while guest editors Carolyn Arnason and Amy Clements-Cortés take the
opportunity in their editorial to cast a gaze to the future, I would like to
look back and recognize previous editors of the Canadian Journal for Music
Therapy. The journal truly represents a collective effort realized over a long
time horizon, with each successive editor indelibly linked to those preceding.
Following are the photos and names of the music therapists who have been
the visionaries, builders, and stewards of a music therapy research tradition
in Canada. Thank you.
C’est avec grand plaisir que je vous invite à profiter de ce numéro de
la Revue canadienne de musicothérapie, le deuxième numéro de 2014. Cette
édition supplémentaire vous est offerte pour célébrer le jubilé rubis de
l’Association de musicothérapie du Canada. Cette entreprise monumentale a
nécessité la coopération et les efforts de plusieurs personnes et je voudrais
ici reconnaître et remercier chacune d’entre elles.
En fait, ce numéro est aussi le dernier que je produis en tant qu’éditrice
en chef et je voudrais souhaiter la bienvenue à Nadine Cadesky dans ses
nouvelles fonctions d’éditrice en chef. La supervision de la Revue a été
une tâche à la fois gratifiante et difficile et s’est même parfois avérée
laborieuse! Alors, pendant que nos éditrices invitées, Carolyn Arnason et
Amy Clements-Cortés, dans leur éditorial, jettent un regard vers l’avenir, je
voudrais regarder quelque peu vers le passé pour reconnaître les éditeurs
précédents de la Revue canadienne de musicothérapie. La Revue représente
réellement un effort collectif réalisé sur une longue période, chaque éditeur
étant indubitablement relié à ceux qui le précédaient. Vous trouverez dans
les pages suivantes les photos et les noms des musicothérapeutes qui ont
été visionnaires, bâtisseurs et gestionnaires d’une tradition de recherche en
musicothérapie au Canada. Merci.
Editors of the CJMT /Les éditeurs de la RMC
Sophie Boisvert
2003–2004
Marianne Bargiel
2006–2008
Sylvie Boisvert
2008–2011
Connie Isenberg
1977–1980
Johanne Brodeur
1993–1994
Nadine Cadesky
incoming 2014
Carolyn Kenny
1976; 1982; 1999–2002
Editors of the CJMT /Les éditeurs de la RMC
Teresa Lesiuk
1997–1998
Kevin Kirkland
2006–2011
Theresa Merrill
2003–2004
Bill Shugar
1977–1980
Jennifer J. Nicol
2011–2014
Sylvie Ouellet
2010–continuing
Stephen Williams
1995–1996
Éditorial / Editorial
Sylvie Ouellet, PhD, MTA
Université du Québec à Trois-Rivières, Trois-Rivières, PQ, Canada
C’est avec joie que le projet d’une édition spéciale du 40e anniversaire
de l’Association de musicothérapie du Canada a été reçu par l’équipe de la
Revue canadienne de musicothérapie. Cette édition spéciale souhaite donner
toute la place aux nouveaux chercheurs en musicothérapie ainsi qu’aux
musicothérapeutes. Ses buts visent à partager une compréhension renouvelée
des enjeux de cette profession, à poursuivre le travail des pionnières, telles
que Fran Herman, Thérèse Pageau, Josée Préfontaine, pour n’en nommer que
quelques-unes, et à faire rayonner la musicothérapie pour les 40 ans à venir.
Je joins ma voix à Jennifer, Carolyn et Amy pour remercier sincèrement
toutes les personnes qui ont mis leur temps, leur énergie et leur cœur dans
les articles aussi captivants les uns que les autres. Nous profiterons de ces
connaissances et de cette expertise pour parfaire notre propre formation
continue en tant que musicothérapeutes.
En conclusion, je veux souligner qu’à travers les différentes perspectives
de cette nouvelle génération de musicothérapeutes qui unissent leurs
thématiques dans cette édition, la musicothérapie bouge, évolue, se
transforme, s’approfondit et reste toujours vivante dans l’environnement
des services d’aide à la personne vulnérable. Pour cette occasion,
nous souhaitons mettre en lumière le Crédo de Fran Herman, grande
musicothérapeute, membre fondatrice de l’AMC, reconnue au Canada et sur
la scène internationale, en vous laissant sur la musique de ses mots!
« La musicothérapie est une profession qui prend soin de d’autrui...
et, c’est là que réside le défi. Notre espoir est de voir chaque personne
s’apprécier et valoriser sa propre participation lorsqu’elle s’adonne
à des expériences créatives. Ce crédo peut nous aider à garder à
l’esprit les quatre « C » associés à la musicothérapie… Concern (se
préoccuper), Caring (prendre soin), Connection (établir un lien) et
Commitment (s’engager)! » ~ Fran
Crédo
Je crois que :
l’accès à l’expression artistique est un droit fondamental de l’être humain;
les arts sont des voies de communication, d’éducation et de libération,
servant à répondre à la nécessité d’exprimer des valeurs, des préoccupations
et des expériences;
par le partage et le développement de l’activité artistique, les individus qui, en raison de leur handicap sont considérés comme des récepteurs et des
consommateurs - peuvent devenir des contributeurs et des participants à part
entière
l’art devrait être considéré comme un investissement dans le bien-être et le
bonheur de l’être humain plutôt que comme une activité « frivole »;
le rôle de la guérison par l’art ne doit pas être négligé, oublié ou exclu parce
qu’il ne s’inscrit pas dans un mode formel de médecine, de réadaptation et
d’éducation.
Fran Herman et James C. Smith, Accentuate the Positive
It was with pleasure that the Canadian Journal of Music Therapy
team undertook a special edition for the 40th anniversary of the Canadian
Association for Music Therapy. This special edition makes way for
new researchers in music therapy. The goals were to share a renewed
understanding of the issues of this profession; to continue the work of
pioneers such as Fran Herman, Theresa Pageau, and Josée Prefontaine; and
to promote music therapy for another 40 years.
I join Jennifer, Carolyn, and Amy in sincerely thanking all those who put
their time, energy, and heart into articles each as compelling as the other. We
can use this knowledge and expertise to hone our own continuing education
as music therapists.
Finally, I would like to emphasize that through the different
perspectives of this new generation of music therapists who have come
together in this edition, music therapy is moving, evolving, transforming
itself, deepening, and above all staying alive in the context of providing
services to vulnerable individuals. For this occasion, it is fitting to
highlight the credo of Fran Herman—founding member of the Canadian
Association for Music Therapy and a great music therapist recognized in
Canada and internationally—leaving you with the music of her words!
“Music therapy is a nurturing profession . . . and therein lies the
challenge. Our hope is to see each and every person value and
appreciate themselves better as they are exposed to creative
opportunities. A credo mounted where it can be perceived can then
help us keep in mind the four Cs: Concern. . . Caring. . . Connection. .
. Commitment!” ~ Fran
Credo
We believe
•
that access to artistic expression is a basic human right.
•
that the arts are a means of communication, education and liberation,
answering the need to express common values, concerns and
experience.
•
that through the sharing and development of artistic activity, people—
who because of their disabilities are seen as receivers and consumers—
can become contributors and sharers.
•
that the arts should be looked upon as sound investment in human
welfare and happiness rather than as “frill” activities.
•
that the healing role of the arts should not be overlooked, forgotten, or
excluded because it does not always fit neatly within a formal medical/
rehabilitation/educational structure.
Fran Herman and James C. Smith, Accentuate the Positive
Reference
Herman, F., & Smith, J. C. (1988). Accentuate the positive!: Expressive arts for
children with disabilities. St. Louis, MO: MMB Music.
Guest Editorial / Éditrices Invitées
Wilfrid Laurier University, Waterloo, ON, Canada
Amy Clements-Cortés, PhD, MTA, MT-BC, FAMI
University of Toronto (Music and Health Research Collaboratory)/Baycrest
Centre, Toronto, ON, Canada
As educators at the University of Windsor (Amy) and Wilfrid Laurier
University (Carolyn, Amy), we applaud the amazing and often groundbreaking
research conducted by graduate students. Furthermore, we believe that to
create strong research communities, we need to support young professionals
and guide them throughout the rigorous publication process. Thus when the
call for co-editors came out for a 40th anniversary edition of the Canadian
Journal of Music Therapy featuring the work of new researchers, it seemed
like a natural fit that we become involved as publication mentors.
This special issue is a wonderful way to celebrate our Canadian music
therapy heritage by highlighting the new voices of recent music therapy
graduates. The positive response by recent graduates to the call for papers
indicates a desire to step out, not only by conducting research but also by
sharing research discoveries. This forum is ideal for promoting upcoming
music therapy researchers, making their work better known in North
America and internationally while also advancing music therapy research
and practice with original work by a new generation.
Here you will find a collection of studies that embrace diverse topics.
The use of orchestral instruments in music therapy has not received much
attention in the literature, and Aimee Berend’s article raises awareness of
this important area while providing motivation for music therapists to use
their primary instruments in therapy. SaraRose Black provides a reflective
look at the role of receptive music therapy techniques, proposed in a new
framework that she terms inter-active listening. In articles about singlesession music therapy with adolescents (Emily Carruthers), music therapists’
experience of burnout (Kiki Chang), and music and speech prosody (Sarah
Faber and Anna Fiveash), the authors investigate topics that have meaningful
implications for music therapists with respect to the clinical, personal, and
emotional aspects of music-making in health care settings. Erin Gross and
Laurel Young contribute a timely piece on perspectives on the current state of
Canadian music therapy as the CAMT is celebrating its 40th anniversary. The
use in music therapy of musical gestures (Danielle Jakubiak), tango (Demian
Kogutek), and Jungian theory (Joel Kroeker) exemplify the diversity of
music therapy approaches and research in Canada. From Quebec, Christelle
Laforme describes a music therapy program for family caregivers of persons
with Alzheimer’s disease, highlighting the need for music therapy services
to include caregivers, and Sylvain Larouche investigates the commonalities
and differences between music therapists and music teachers, expressing the
need for collaboration among professional bodies to ensure a match between
the needs of special needs students in the Quebec education system and the
skills of the people who are guiding them.
We trust you will enjoy reading this special issue of the journal and
celebrating 40 years of music therapy in Canada.
En tant qu’éducatrices à l’université de Windsor (Amy) et à l’université
de Wilfrid Laurier (Carolyn, Amy), nous nous réjouissons de la recherche
extraordinaire et souvent révolutionnaire menée par les étudiants de
cycles supérieurs. En outre, nous croyons que pour créer des milieux de
recherches solides, nous devons soutenir et guider les jeunes professionnels
à travers le processus rigoureux de l’édition. Donc, quand la recherche de
corédacteurs pour le 40e anniversaire de l’édition de la Revue canadienne de
musicothérapie a été lancée, il nous a semblé tout naturel de nous impliquer
en tant que mentor de publication.
Cette édition spéciale nous offre l’occasion idéale pour célébrer notre
héritage canadien en musicothérapie en mettant en valeur les contributions
de chercheurs canadiens et plus spécifiquement, les voix de récents diplômés.
La réponse positive des jeunes professionnels et des récents diplômés à cet
appel d’articles nous montre leur désir d’aller de l’avant, non seulement en
menant des recherches, mais aussi nous en partageant les résultats. Ceci est
une plateforme extraordinaire pour promouvoir les futurs chercheurs en
musicothérapie au Canada et mieux divulguer leur recherche en Amérique
du Nord et au niveau international; ces travaux originaux entrepris par
une nouvelle génération font ainsi progresser la recherche et la pratique en
musicothérapie.
Dans ce numéro, vous trouverez un ensemble de travaux diversifié qui
englobe divers sujets. L’usage d’instruments d’orchestre en musicothérapie
n’a pas souvent été documenté dans la littérature et, l’article d’Aimee
Berend nous fait connaître cette facette importante de la pratique tout en
motivant les musicothérapeutes à utiliser leurs instruments principaux
en musicothérapie. Quant à elle, SaraRose Black nous offre une perspective
réflective sur le rôle des techniques de musicothérapie réflective. Ce faisant,
elle nous propose un nouveau cadre qu’elle définit comme l’écoute inter-active
. Dans les articles traitant de session individuelle unique (Emily Carruthers),
de l’expérience de l’épuisement professionnel (Kiki Chang), de musique et de
prosodie de la parole (Sarah Faber et Anna Fiveash), les auteures examinent
des sujets qui ont des implications significatives pour les musicothérapeutes
en respect avec le travail clinique ainsi que les aspects personnel et affectif
du jeu de la musique dans un contexte de centre de soin de la santé. De leur
côté, Erin Gross et Laurel Young, contribuent à un article sur les perspectives
du statut de la musicothérapie canadienne qui tombe à point puisque
l’AMC célèbre son 40e anniversaire. L’utilisation de la gestuelle musicale en
musicothérapie (Danielle Jakubiac), de la musique de style tango (Demian
Kogutek) et de la musicothérapie d’approche jungienne (Joel Kroeger)
illustrent bien la diversité des approches musicothérapeutiques et de la
recherche au Canada. Du Québec, Christelle Laforme décrit un programme
de musicothérapie pour les proches aidants naturels qui s’occupent de
personnes atteintes de la maladie d’Alzheimer, soulignant ainsi le besoin
de services de musicothérapie pour ceux-ci tandis que de son côté Sylvain
Larouche examine l’importance d’apprendre à travailler en collaboration
avec les autres professionnels œuvrant auprès d’élèves avec des besoins
spéciaux dans le système éducatif du Québec, tout en clarifiant les aspects
uniques de la musicothérapie.
Nous sommes certaines que vous aurez beaucoup de plaisir à lire
cette édition spéciale de la Revue pour ainsi célébrer, avec nous, 40 ans de
musicothérapie au Canada.
What Do Orchestral Instruments Bring to Music Therapy?
Developing My Voice on the Oboe and English Horn as a
Music Therapist
Quel est l’apport des instruments d’orchestre à la
musicothérapie? Trouver ma voix au moyen du hautbois et
du cor anglais en tant que musicothérapeute
Aimee Berends, BMus, MMT, MT-BC
Music Therapist (Grand River Hospital) / Principal Oboe (Guelph Symphony
Orchestra), Kitchener, ON, Canada
Abstract
This qualitative case study explored the experiences of both client and music
therapist when the oboe and English horn were used as the therapist’s
instruments. The therapeutic experiences of an adolescent client and the
music therapist unfolded within the setting of an outpatient mental health
facility. The inclusion of the oboe and English horn in sessions developed
the music therapist’s approach with the client and enhanced the musical
collaboration with intention and form. Techniques were developed for
using a narrative style on a single-lined instrument in music therapy, and
suggestions are made for music therapists who wish to bring their principal
instruments to music therapy. This article is an abbreviated account of the
writer’s major research paper, written in partial fulfillment of a Master of
Music Therapy degree.
Keywords: music therapy, oboe, English horn, mental health,
adolescent, music-centered
Résumé
Cette recherche qualitative explore à la fois les expériences du client et de la
musicothérapeute lors de l’utilisation du hautbois et du cor anglais en tant
qu’instruments de la musicothérapeute. Les expériences thérapeutiques d’un
client adolescent et de la musicothérapeute se déroulent dans le contexte de
services ambulatoires en santé mentale. L’intégration du hautbois et du cor
anglais à l’intérieur des séances a amené la musicothérapeute à développer
son approche avec le client ainsi qu’à renforcer la collaboration musicale au
niveau de l’intention et la forme. Des techniques ont été développées pour
l’utilisation d’un style narratif au moyen d’un instrument mélodique en
musicothérapie, et des suggestions ont été proposées aux musicothérapeutes
qui désirent apporter leurs instruments principaux en musicothérapie. Cet
article est un compte rendu sous forme abrégée du projet de recherche de
l’auteure, dans le cadre d’un programme de maîtrise en musicothérapie.
Mots-clés : musicothérapie, hautbois, cor anglais, santé mentale,
adolescent, centré sur la musique
Because music therapy is primarily relational, an in-depth investigation
of the means by which client and therapist relate is essential. As Lee (1996)
wrote in a case study, “I saw the opportunity for a description of music
therapy in which the verbal and musical voices of client and therapist
combine to express the essence of the process” (p. 2). Similarly, the search
for this “essence” was a motivating force behind the research presented here.
The double reed family of instruments, of which the oboe and the
English horn are members, brings its distinct age-old sounds to orchestral
and chamber music around the world. However, the oboe and English horn
world is small, and the number of music therapists who use these instruments
in therapy is even smaller. Documentation of the therapeutic qualities of
the oboe and English horn are absent from music therapy literature. This
qualitative case study builds a foundation for future study on double reed
instruments in music therapy by providing a preliminary overview of the
themes for inquiry. This study portrays the interactions of an adolescent
client and music therapist over four sessions when the therapist used the
oboe and English horn in sessions.
Music-Centeredness and Stance of Researcher
Music-centeredness (Aigen, 2005; Lee, 2003; Nordoff & Robbins,
1977/2007) is integral to the framework of this study and is essential to my
position as music therapist and researcher. I identify with music-centered
psychotherapy as my approach, combining music-centered values with
psychotherapeutic techniques. Over the course of my music therapy training,
I have been honing my clinical improvisation skills, especially on piano and
on oboe. This study focused on my use of the oboe and English horn in clinical
improvisation.
My relationship with the oboe has taught me various things. For one, it
has given me an appreciation for single-line music-making, or melody. It has
taught me perseverance, especially with the art of reed-making. The oboe
challenges my sense of beauty with the effort it takes to maintain a dark, lush
sound. The oboe also challenges me in clinical settings, to make the doublereed tone warm and welcoming.
Although I do not use the oboe exclusively in sessions with clients, I am
fascinated with its clinical qualities and believe these cannot be separated
from the client’s experience of the instrument. Through this study, I hope that
music therapists will acknowledge the need for further research in orchestral
instrument work, as my own motivation for using the oboe in music therapy
is fueled by substantive evidence of its clinical potential.
Literature Review
The Music Therapist’s Use of His or Her Major Instrument
Music therapists in North America often use piano or guitar to support
clients in music therapy. Usually orchestral instrumentalists will temporarily
or permanently abandon their own instruments in music therapy sessions,
setting aside instruments that have been a major part of their lives. Voyajolu
(2009) surveyed 249 music therapists in the United States to determine how
many had abandoned their major performing instruments for use in music
therapy. The results showed that 62.9% of woodwinds, 57.1% of strings, and
76.9% of brass instrumentalists did not use their main instrument in music
therapy practice within the year prior.
At the 2011 Canadian Association for Music Therapy conference in
Winnipeg, Carolyn Kenny challenged music therapists to pursue ethically
sound practice by encouraging students to use their main instruments:
For education and training, I suggest that we challenge our students
to find their own definitions of beauty. I recommend that we
encourage them to stay committed to their primary instrument of
choice, which is an important expression of soul. (Kenny, 2011, para. 32)
As suggested by Kenny, preparing the student music therapist for music
therapy practice can be achieved by grounding students in the strength of
their relationship with their principal instrument.
There is little in the literature about how to use orchestral instruments
in music therapy. Historically, music therapists who are known to have used
their orchestral instruments in music therapy sessions included the cellist
Juliette Alvin, the violinist Mary Priestley, and the clarinetist Amelia Oldfield
(Lee, in press); however, in their writings these practitioners focused
more on the therapeutic process than on the details of how they used their
instruments in their work.
The History of the Oboe
The oboe is described in the Vienna Symphonic Library (2014) as “clear,
bright, penetrating, acerbic, keen, biting, rasping, reedy, powerful, robust,
full, insistent” (para 1). The oboe’s most recognized ancestor is the shawm,
a double-reed instrument that the oboe succeeded in the 17th Century. The
hautboy, which was first made in Paris in the 17th century, eventually became
a symbol of the pastoral, the feminine, the delicate, and nostalgia for the rural
life (Burgess & Haynes, 2004, p. 7–8). A substantial amount of oboe repertoire
originates from the Baroque era (approximately 1600–1750).
In a 1758 treatise Adlung wrote that the oboe seems “to assert its small
but inexpressibly poignant voice calling, as it seems, from the innermost
secret places” (as cited in Burgess & Haynes, 2004, p. 590). This aspect of
the oboe’s sound, so beautifully articulated by Adlung, is evidence of the
potential for the instrument’s use in music therapy.
The tenor-sized oboe (the modern-day English horn) has undergone
its own major development over the past two centuries. With keys that
correspond to that of the oboe, this instrument sounds a fifth below the oboe
and is often recognized by its bulbed bell. According to Grove Music Online,
Berlioz wrote in his Grand traité d’instrumentation that the English horn
evoked “feelings of absence, of forgetfulness, of sorrowful loneliness” (Page,
Burgess, Haynes, & Finkelman, 2001, “Tenor Oboes,” para. 15). Its application
to numerous operatic scores in the 19th Century made the English horn
a solo fixture in orchestras in the 20th Century, lasting to the present day
symphony orchestra (Page et al., 2001).
Orchestral Instruments in Music Therapy
Part of investigating the phenomenon of exclusion in music therapy
practice also requires identifying when orchestral instruments have been
included. Evidence of orchestral music being used in music therapy exists in
partnerships between professional orchestras and music therapy programs.
For example, the Melbourne Symphony Orchestra and the music therapy team
at the Royal Children’s Hospital (Melbourne) collaborated on adolescent and
neonatal wards, providing live music for patients and their families (Kildea,
2007; Shoemark, 2009).
This community model has also been piloted in Canada by Curtis (2011)
whose Windsor, Ontario, project involved a university music therapy program,
the city’s professional orchestra, and a local hospital’s palliative unit. Results
indicated that two-person music therapy teams (one music therapy student
and one symphony musician) were effective in increasing quality of life for
palliative patients. While this community music framework provides one
way to use orchestral instruments in therapeutic contexts, it is not equivalent
to having the therapist use an orchestral instrument to support their clients
therapeutically.
A growing number of music therapists have written about using their
principal orchestral instruments. Matsumura-McKee (2010) addressed
the use of instrumental techniques in relation to participants’ perceptions;
Schenstead (2009) described her personal relationship with the flute;
and Sun (2012) reflected on possible clinical implications of using the
orchestral marimba based on the pertinent literature and her knowledge as
a performer. While these research studies provide valuable insight into the
use of orchestral instruments in therapeutic work, they do not focus on the
impact of using these instruments on the relationship between the client and
the therapist.
Oldfield (2006) is one of the few music therapists to have written
about how her work on her principal orchestral instrument affects clients.
Oldfield’s description of her clarinet techniques with clients encouraged me
to pursue the therapeutic potential of the oboe.
Despite an exhaustive search of the music therapy literature, nothing
was found about the oboe in music therapy from an oboist/music therapist’s
perspective. Therefore, this study aimed to answer the following two
questions:
•
•
What is the experience for the client and the therapist when the
therapist uses the oboe and English horn in music therapy?
What music therapy techniques can be used with clients when
the therapist is using double-reed instruments?
Method
Research Design
A qualitative case study format was selected to explore the complexity
of emergent themes within the client–therapist relationship when the music
therapist used the oboe and English horn in music therapy. The case study
design strengthened the trustworthiness of the findings since it portrayed
the oboe at work in a real-life music therapy setting. To track the experience
from the researcher’s view, journal logs, thick descriptions (an interweaving
of subjective and objective information), and poetry were generated by the
researcher as additional data sources. The transparency of the researcher’s
experience was especially important given the dual relationship with the
client as researcher and music therapist.
Recruitment Procedures
The clinical research took place at an adolescent outpatient mental health
service. The referral team consisted of four mental health professionals. The
researcher met with Elena (a pseudonym) and her mother prior to beginning
sessions to review the consent form and give them both an opportunity to
ask questions. Consent was obtained both from Elena and her mother. Elena
had not participated in music therapy prior to this study; however, she had
received music lessons as a child and elementary school music instruction
on guitar and cello. Specific details about the Elena’s diagnosis have not been
included for confidentiality and privacy purposes.
Data Collection
Elena was asked to fill out questionnaires at the end of each session
to comment on how the inclusion of the oboe and English horn in therapy
affected her physically, emotionally, and cognitively. Full sessions were audiorecorded using a small hand-held recorder.
The second session with Elena was chosen for in-depth analysis because
of its rich musical connections and its balance of interventions. The session
had three significant musical interventions:
•
•
•
piano four-hands
storytelling with percussion, oboe, and English horn; and
free improvisation with xylophone and English horn.
Session Structure
While the proposed length of treatment was eight to ten sessions, the
therapeutic process was shortened to four sessions due to scheduling issues.
Each of the four sessions with Elena lasted between 45 and 60 minutes.
In each session a similar structure was employed in order to assess
Elena’s behavioural and emotional norms and to help her feel more
comfortable with session organization. Elena and I began each session with
a brief verbal check-in to greet each other and get a sense of her day or
the previous week’s events in her life. Elena often responded with neutral
comments such as “good” that did not describe adequately how she was
feeling. She was not pressed for further description, as at the beginning of
the therapeutic relationship it was more important to allow Elena to sense
safety rather than to explicitly probe into her feelings.
Elena seemed comfortable creating stories in our sessions. She was asked
to create a plot (sometimes asking me to generate ideas) and then together
we put the story to music, as double symbolic distance (Ahonen-Eerikäinen,
2007). Not only was the music offering Elena safety in externalizing her
inner processes in a narrative form, but there was the added protection of
using music to do so. Clinical improvisation was the principal method used
with Elena to invite her into a therapeutic music-centered relationship.
Both referential (i.e., with extrinsic inspiration) and non-referential (i.e.,
without pre-determined inspiration) types of improvisations (Bruscia, 1987)
were included. Recordings that were reviewed for reflection during the
session (e.g., for listening while drawing) were recorded on a laptop using
GarageBand.
During the first two sessions, the musical soundtrack to the story was
improvised with the therapist playing the oboe and English horn and Elena
playing various percussion instruments. Elena chose percussion instruments
to represent the characters in her story.
Elena also participated in non-referential (i.e., free) improvisation with
play rules. Play rules are conditions that can be applied lightheartedly upon
which the improvisation occurs (Wigram, 2004). Elena used a percussion
instrument and the therapist chose either the oboe or the English horn.
While clients often need time to adjust to the concept of free improvisation,
Elena seemed comfortable from the beginning.
Data Analysis
Choosing session two for musical analysis strengthened the sense of
therapeutic process since the frame of reference of session one was already
established. There was more stability, with a clear session structure and clear
data collection procedures. Furthermore, the musical content of session two
was varied, using piano four-hands, storytelling, and free improvisation.
The second session with Elena was first reviewed in a process called
indexing. This Nordoff-Robbins music therapy technique is a form of
documentation that can assist the therapist in acquiring the details of the
clinical sessions and a deeper understanding of the dynamics at play over
time (Nordoff & Robbins, 1977/2007). The session dialogue was transcribed
to paper, and excerpts of the music were deconstructed into segments of
musical notation to reveal further research findings. The transcript of session
two was coded to identify themes.
For analyzing musical improvisations, an adapted version of Arnason’s
(2003) levels of listening approach, which draws on the work of Ferrara
and other analytic methodologies, was used. The verbal components of
the session were analyzed by reviewing the transcript and recordings.
Throughout the analysis, an emphasis was made on the shared experience,
valuing differences and similarities of the meanings that were created for
both the client and the therapist.
Analysis of the musical excerpts was triangulated with two peers and a
supervisor to increase the trustworthiness of the findings. This feedback was
requested to verify aspects of the experience due to the subjective nature of
the therapist’s role influencing the role of researcher. Participant checking
was also conducted by reviewing comments with Elena and obtaining
feedback on some recordings. These two techniques were included to uphold
the client’s empowerment in the interpretation of the data and to achieve
a more complete analysis of the data with multiple perspectives on the
therapeutic relationship. Multiple forms of data were used in the research,
and the analysis was reviewed several times. The wealth of findings that
emerged was not possible to include in this study, and several ideas were set
aside for possible future research.
Results: Towards a Style of Music Therapy
The data analysis revealed themes related to research questions as
well as major uncertainties regarding Elena’s experience. Elena’s written
feedback on the questionnaires was especially problematic. When Elena
described her perception of the oboe in the session, she wrote words such
as “happy” and “peaceful.” During the second participant checking session,
Elena compared the oboe and English horn to parts of movies, ones that were
“creepy” or suspenseful. Though these descriptions seemed authentic, the
extent of Elena’s feedback at the time of analysis did not seem like enough
experiential evidence upon which to base an interpretation.
Verbally, Elena seemed to accustom herself slowly to the therapist,
which meant that the therapist found it difficult to interpret meanings from
this written feedback. Furthermore, there were instances where Elena wrote,
as her own questionnaire feedback, insights the therapist shared in previous
discussion. This may have indicated her wish to please the therapist. Was this
feedback her true experience?
Ultimately, the decision was made not to use Elena’s experiential
feedback in the results of the study. From the therapist’s point of view, it
was too early in the clinical relationship for Elena to be able to comment
authentically about her experience. For this reason, the results focus on the
perspective of the music therapist–researcher and highlight the results from
the clinical relationship in the music that was made in session two.
Analysis of the data reveals the development of the therapist’s clinical
musicianship, especially with three core values: intention, form/freedom,
and use of self. Each core value was manifested in the musical and verbal
exchanges between Elena and the therapist in session two.
Intention
Being aware of stylistic approaches to meeting the client in music
refined the intention to explore Elena’s world with her through music.
Wigram (2004) wrote about different techniques for improvisation. He
defined mirroring as when clients can recognize their behaviour in that of
the music therapist (see Figure 1); imitating as when the therapist copies
what the clients play; matching as when the therapist uses the same style and
quality of playing as the client (see Figure 2); reflecting as when the therapist
applies the same mood in the music as the client; and accompanying as when
the therapist establishes a repeating pattern over which the client may create
melodic ideas (Wigram, 2004). By being intentional about each of these
techniques, the therapist could focus on Elena’s responses, thus seeking to
understand her way of relating. Below are two musical examples that display
improvisational techniques used in the musical interaction.
Figure 1. This excerpt from Improvisation #3 in Session 2 is an example of mirroring
(Wigram, 2004). I took Elena’s cues to play, matching articulation (i.e., staccato) and
rhythmic pattern. The English horn intervals (i.e., thirds) went downward to contrast
Elena’s rising thirds.
Figure 2. This excerpt from Improvisation #3 in Session 2 is an example of matching
(Wigram, 2004). Wigram wrote that “to achieve a ‘match’ in musical terms means that the
therapist’s music is not identical to the client’s, but is the same in style and quality” (p. 84).
The therapist’s intentionality with Elena in the music also highlighted
the roles in the relationship. During the sessions, Elena took on the role of
explorer, while the therapist took on the role of encourager. While engaging
in clinical improvisation, Elena often would seek a new instrument or a new
part of the piano to use. As encourager, the therapist used various techniques,
some of which are outlined in the appendix.
Form/Freedom
Form and freedom may be perceived as at odds with each other. However,
these concepts are inextricably linked. Lee (2003) wrote, “Structure is what
makes clinical improvisation an ordered yet free experience” (p. 152). Form
functions in music therapy as a fundamental truth, since musical output
has structure in time. On the other hand, freedom—both musical and nonmusical—is deviation from form, and thus requires form to exist.
When working with Elena, the therapist used different means of
establishing form in the music and tested how much structure to impose
on the musical relationship. The therapist often mediated the form using
harmonic structure, repeated musical motives, stylistic idioms (i.e.,
references), or a change of instrument. Elena also seemed comfortable
creating form and responded with her own formal ideas. Motivic patterns,
repetition of motives, variation of motives, changes of instrument, changes in
dynamics, and changes in articulation of playing often marked Elena’s form.
As Lee (2003) suggested, developing form involves establishing
boundaries within which client and therapist may operate musically and
otherwise. Furthermore, according to Winnicott (as cited in De Backer & Van
Camp, 1999) boundaries function for safety in a therapeutic relationship and
assist in “holding” the client.
Elena seemed to have an overall sense of proportion. For example,
her patterns would often be grouped in sets of four, a common form in
Western music. She played rhythmically, often using dotted figures and
varied denominations of rhythmic values in her playing. Elena initiated new
thematic material consistently and, in so doing, created formal sections of
music. She was sensitive to my playing, consistently allowing space for my
input as her improvisation partner.
Elena and the music therapist co-created form in music. At times, the
music therapist used harmonic underpinnings for a sense of holding in the
music and a clear structure within which Elena could improvise. An example
of this was the use of a pedal dominant tone on the English horn, as shown
in Figure 3. Playing the dominant pedal, while still matching Elena’s style of
playing, communicated to her a suggested structure, which she acknowledged
musically.
Figure 3. At this point in the improvisation, C Major has been established as tonic,
mostly due to the fact that the glockenspiel was tuned in this key. The use of dominantseventh pedal point set up a suspenseful ending for the musical moment.
The therapist’s role as encourager often sounded like variations on
Elena’s playing. Modelling playful deviations from her steady patterns and
musically inviting Elena to move in and out of her comfort zone seemed
important. For example, during storytelling the oboe wove the structural
backdrop for Elena’s characters to exist, as a narrator does orally.
On more than one occasion, Elena and the therapist intuited the sense
of “end” at the same moment. The subjective experiences of each were
connected in the music to create an inter-subjective space. As Pasiali (2012)
found in music therapy with families, “To create music together demanded
intersubjectivity; each person played a role in how the musical experience
evolved and developed” (p. 327). The roles continued to be defined as client
and music therapist, but both selves were interacting in imaginative and
creative spaces.
Use of Self
The use of self is the application of parts of one’s identity in social
interaction with another person or persons. In this case study, it seemed as
though both Elena and the therapist expressed and used their respective
selves as resources for comfort and connection. However, I consider the
oboe an extension of myself as therapist and, therefore, there was distinction
between Elena’s agency in the musical relationship and mine. The oboe and
English horn were very familiar to me, whereas Elena’s chosen instruments
in Session 2 (i.e., percussion) were not as familiar to her. While there is no
conclusion that Elena’s investment in the music was less than mine, deducing
Elena’s use of self in music therapy is outside the scope of this study.
During the story soundtrack intervention, the oboe took on the role of
narrator (as discussed in the previous section). It seemed as though my voice
through the oboe was inviting Elena to trust the therapist, to enter into a
creative, safe space with me and to allow her own imagination to emerge.
Later, in the free improvisation with xylophone and English horn, the
therapist used herself as a more stable presence against which Elena might
experience more freedom. Using patterns, clear harmonic structure (e.g.,
pedal point on dominant), soft dynamics, and a renewed focus on Elena’s
“voice,” the therapist felt able to encourage her more effectively.
Discussion
Throughout the musical and clinical aspects of my therapeutic
relationship with Elena, it was evident that the oboe played an integral role
in our collaboration. The following, drawn from the conceptual framework of
this case study, point to larger discourses for further investigation.
Sound Quality and Intensity
I found when improvising and creating stories with Elena while using
the oboe that it may have been too intense at times, possibly due to its innate
properties. Intensity can be therapeutic; however, there is a time and a place
for it in clinical work. The oboe’s intensity became evident in the volume
imbalance with Elena’s percussion instruments throughout session two.
I sensed a different intensity while using the English horn than when I
used the oboe. The pitch difference is significant (i.e., a fifth below) and may
be a contributing factor. While it is difficult to infer that the English horn is
less intense than the oboe, I sensed my approach with the English horn was
different than my approach with the oboe.
Story and Narrative
A recurring theme in both Elena’s and my experiences of the
oboe and English horn in music therapy was narrative. Does the oboe’s
narrative potential have anything to do with its history? Are there inherent
characteristics about the double-reed sound that catalyze storytelling? While
these questions are musicological in nature, there were some questions that
emerged that would be within the capacity of music therapy research in the
future.
Ideas for Future Research
Though I used both oboe and English horn with Elena, the therapeutic
qualities of each instrument were unique, and in the future it would be
valuable to embark on a comparative research study comparing the two
instruments.
Regarding narrative, there were several questions that arose as seeds
for future research. First, how does story development manifest itself
in the oboe’s music? What harmonic devices, melodic nuances, or other
characteristics contribute? Second, deviation from form (i.e., freedom) was a
major finding connected to this idea of narrative by its nature of manifesting
change over time. As such, can variation in music indicate a narrative
organization of ideas? Third, Elena’s comments regarding the English horn
from different participant-checking instances were contradictory. Does the
English horn hold distinct narrative potential, perhaps more evocative than
the oboe in certain situations? Each of these questions may be explored
in future research to elaborate on this case study’s findings of the oboe’s
narrative potential in music therapy.
Suggestions for Music Therapists with Orchestral Principal Instruments
I wish to encourage other orchestral musicians to use their principal
instruments in music therapy. I have discovered a few helpful hints as I have
increased the use of my oboe in my clinical work:
•
•
•
•
•
Practise. As much as there may seem to be little time for it,
practising pieces for music therapy and for other venues is
important. Even 20 minutes a day will make a difference.
Learn to improvise on your instrument. Improvisation can be
a difficult skill to transfer between instruments but is possible
with practice. Having an improvisation partner is valuable. I
have also found using the voice interchangeably with my oboe
helpful in composing single-line improvisation. A good resource,
especially for developing improvisation skills in pairs, is Lee and
Houde’s (2011) Improvising in Styles.
Play with other musicians not connected with music
therapy. As music therapists, the solidarity in playing with other
musicians can result in developing a voice in improvisation. It
can also be fuel for new narrative material or referential tropes.
Establish clear aims when using your instrument in therapy.
Know why you are using your instrument, and perhaps establish
a role for the instrument that the client will recognize. For
example, the instrument could signify a relaxation intervention.
Try it! Consider a trial period for using your instrument. Bring
issues to supervision, or keep an “instrument journal” of your
findings.
Lee and Houde (2011) suggested that every clinical musician can
develop their clinical musicianship by “thinking like an orchestra” (p. 398).
This will expand not only the music therapist’s listening ear but also her or
his musical potential.
Conclusion
Chong (2007) wrote, “I think finding one’s own musical self is a vital part
of becoming a qualified music therapist” (para. 4). Indeed, my exploration of
the musical and clinical relationship with Elena in adolescent mental health
has illuminated my own understanding of my self as a music therapist and as
a musician.
Through the oboe, I was able to communicate with Elena in a unique
way and manifest a musical presence, like a distinct voice. Lee and Houde
(2011) asserted that “every improvising clinical musician should aspire
to sound unique” (p. 387). The use of the oboe facilitated my musical self
with Elena and developed my musical self. It strengthened the music in its
expressive potential.
Assuming the phenomenon of exclusion affects similar proportions
of music therapists in Canada as in the United States, I agree with Voyajolu
(2009) that more research is important for addressing specific considerations
of each instrument. I would add to Voyajolu’s invitation by encouraging
music therapists to continue playing on their principal instruments on
their own and with others. Let us bring our whole selves, including as much
musicianship as we are able, to our work with clients in music therapy.
Acknowledgements
The author expresses sincere gratitude to her research supervisor and
mentor, Dr. Carolyn Arnason, for guidance throughout this project.
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Appendix: Techniques for Collaboration Using Oboe and English Horn
Holding (based on Bruscia, 1987)
Delicate playing. Playing as softly as possible; listening.
Consistent presence (i.e., clinical and musical). Choosing to enter
into the client’s music may not always be necessary. It is important
to consider the state of the reed when entering musically on oboe
and English horn.
Focus. Being aware of cognitive focus on the client, the focused
sound (i.e., tone quality) of the oboe, and the amount of attention
given to reeds while playing in sessions.
Long tones (grounding versus sustaining). Literally, holding long
tones; however, I found that visualizing the concept of grounding (e.g.,
a musical anchor) evinced a different clinical aim than visualizing
the concept of sustaining (e.g., a musical hammock).
Pedal tones. Providing intentional harmonic implications while
creating space for the client’s music.
Resonance. Creating a round sound (i.e., usually including vibrato) for
full therapeutic qualities, including the biological benefits of vibration.
Shaping
Extremes. Being aware of extremes in the client’s playing and
responding to this, either with similar or contrasting use of extreme
(e.g., dynamics, range, and other musical elements).
Intervals and direction. Creating consequent and antecedent
phrases by responding to the client’s music with similar or
contrasting musical lines.
Playfulness. Modelling play, even if it means the instrument squeaks,
may counter the perceived seriousness of orchestral instruments.
Register changes. Changing octaves in order to hear the client’s
music if the oboe or English horn is too loud.
Sine wave (using Bach). Visualizing the sine wave can be helpful
for me as I weave a single-line melody. Practising pieces by J. S. Bach
has been helpful in learning how to arpeggiate multiple voicings in
a wave-like manner.
Forming
Creating macro-form. Creating a large-scale formal structure
assists not only with clarity but also in assessing the music’s function
in the therapeutic context (e.g., with Elena, I discovered a cadenzalike passage in her playing on the glockenspiel).
Creating themes from client’s playing. It is important to use the
client’s music for thematic material as much as possible (Nordoff &
Robbins, 2007; Lee, 2003).
Stylistic Referencing. When storytelling with clients, I have found
the melodic representation of characters or events come from other
musical material. Referencing intentionally may be used to signal
to the client a particular sentiment, or it may simply give the music
therapist more inspiration for improvisation.
Using accompaniment styles. Wigram (2004) describes an
accompaniment style of improvisation, especially with patterned
playing such as an Alberti bass.
Using counterpoint. The use of counterpoint to respond simply
but in an ongoing manner to the client’s playing; practising Baroque
material is helpful for developing this technique.
Using different modes and scales. With Elena, I often used a
pentatonic scale, as this was an open tonal realm for improvisation.
Developing facility in several modes and scales may add to the
possibilities for single-line instrumental improvisations.
Using harmonic resolution with care. It is important to be wary of
harmonic resolution (e.g., through a dominant progression) as the
clinical context is not one of trite resolution (Lee, 2003).
Using patterns. Recurring patterns, especially from the client’s
playing, are very helpful in structuring improvisations.
Responding
Conversation. Being aware of inflection, grammar, overall tone, and
vocabulary that is inferred in the single-lines of music (influenced by
the teachings of Marcel Tabuteau). This often relates to articulation
styles but also implicates the continuity of the breath.
Signals. Establishing cues for different characters, routines, or roles.
For example, the use of silence. With Elena I found that silence signalled
beginnings and endings and it also denoted humour at times.
Syncopation. To be used with caution as syncopation may destabilize
metric pulse.
Variation. Change of colour (i.e., tone quality), texture, articulation,
rhythm, pulse, volume, emphasis, formal structure and key.
Inter-Active Listening: Re-envisioning Receptive Music
Therapy
L’écoute inter-active : la musicothérapie réceptive fait peau
neuve
SarahRose M. Black, MA, MMT, MTA
Music Therapist, Princess Margaret Cancer Centre and Kensington Health,
Toronto, ON, Canada
Abstract
The interactions and dynamics between client and therapist in receptive
music therapy as defined by Bruscia (1998) are often complex and multilayered. This paper, which is based on a phenomenological narrative inquiry
that investigated the music therapy experiences of four adults diagnosed with
metastatic cancer, challenges and re-envisions current notions of the practice
of receptive music therapy. Inter-active listening (Black, 2013) is discussed as
alternative terminology with which to speak about the interactive processes
that occurred during the interventions. The results of the study are described,
focusing on two participants and the dynamic and dyadic intersubjective
space that was created as a result of the use of this music therapy approach.
Implications for the field of music therapy are discussed.
Keywords: receptive music therapy, inter-active
intersubjectivity, phenomenology, palliative care
listening,
Résumé
Les interactions et les dynamiques entre le client et le thérapeute dans la
musicothérapie réceptive telle que définie par Bruscia (1998) sont souvent
complexes et multidimensionnelles. Cet article, basé sur une recherche
narrative phénoménologique qui examine les expériences en musicothérapie
de quatre adultes avec un diagnostic de cancer métastatique, défit des
notions courantes de l’exercice de la musicothérapie réceptive tout en nous
les faisant réenvisager. L’écoute inter-active (Black, 2013) est discutée en
tant que terminologie alternative laquelle devrait être utilisée afin de parler
des processus interactifs qui subviennent à l’intérieur des interventions. Les
résultats de l’étude sont décrits en se concentrant sur deux participants et
l’espace intersubjectif dynamique et dyadique qui a été créé par le biais de
cette approche musicothérapeutique. Des implications pour le domaine de la
musicothérapie sont discutées.
Mots clés : musicothérapie
intersubjectivité,
réceptive,
écoute
inter-active,
Receptive music therapy is defined as an approach during which clients
in individual music therapy listen to music and respond silently, verbally,
or with another modality (Bruscia, 1998). While receptive music therapy is
used frequently with a wide variety of client populations (Grocke & Wigram,
2007), the complexity of the interactions and dynamics between client and
therapist are not necessarily embodied in the word receptive.
In this paper, which is based on a phenomenological research study
that I conducted on a palliative care unit in a cancer care hospital, I seek
to re-envision and expand the term receptive music therapy in order to
more accurately reflect the dynamic interactions of this approach. I suggest
the term inter-active listening (Black, 2013) as an alternative descriptor
for receptive music therapy, and I give examples of dyadic and interactive
relationships between two research participants and the music therapist
during inter-active listening . I also discuss the concept of an intersubjective
space—defined as the joint consciousness of interacting individuals (Scheff,
1990)—within this music therapy approach.
Questioning the Notion of Receptivity
On an acute palliative care unit where quality of life is critical (Hilliard,
2005) and hope for a good death is important (O’Rourke & Dufour, 2012),
verbal communication is often limited; therefore, receptive music therapy is
a frequently used intervention. Yet the more I engaged in receptive music
therapy, the more the word receptive felt limited. Many clients were verbal
and willing to participate in conversation and musical dialogue, but more
than half of the clients were either actively dying or unable to speak, and in
these instances, extraordinary moments of connection were a regular occurrence.
There was interaction through the music regardless of whether the client was
playing, singing, or even speaking.
This raised questions for me about who was receiving and who was
giving in terms of music therapy. The word receptive describes an act of
receiving, which naturally implies that there is also an act of giving. While
initially this inquiry felt like a battle with semantics, I noted that clients who
were not responding verbally still appeared to be sending a range of cues such
as changes in breathing patterns and eye contact. It is my premise that the
relationship between therapist and client should always be acknowledged
as a dyadic, two-way exchange of information. While the intentions of the
receptive interventions were for the client to “receive” the music, indicators
of awareness and connection from the client were also being received by the
therapist. Can it always be said that a client is receiving music, based purely
on the fact that it is being played or sung in their direction? What about the
concept of reception in terms of the therapist?
The concept of intersubjectivity emerged from the results of a
phenomenological research study I conducted on a 12-bed acute palliative
care unit, which demonstrated that it is essential to acknowledge the impact
of receiving information from and being connected to the client, as the
therapeutic relationship is dyadic, dynamic, and active. Intersubjectivity is
defined both as the joint consciousness of interacting individuals (Scheff,
1990) and as the constitution of psychological systems within which
emotional experience always takes form (Orange, Atwood, & Stolorow,
1997). Understanding these dynamic therapeutic moments within a
framework of an intersubjective space allowed for the contextualization and
deeper understanding of the interactions. In the music therapy literature, the
presence of intersubjective space is highlighted and discussed in the ways
in which a therapist senses aspects of the client and the client senses the
therapist (Kenny, 2006). Kenny suggested that the deep intersubjective space
in which clients and therapists engage is of paramount importance in the
therapeutic relationship and that we must regularly ask ourselves who and
what we represent in that space.
Orange, Atwood and Stolorow (1997) described intersubjectivity
as a metatheory of psychoanalysis in that it examines and connects two
subjectivities in the system they create and from which they emerge. In
music therapy the therapist and client are the two subjectivities and the
session is the system they create. In both the literature on psychoanalysis
and music therapy, the concept of intersubjective space plays a critical role in
understanding the therapeutic relationship. The term inter-active listening
(Black, 2013), which I created as a result of this research study, is supported
by and grounded in the theories of intersubjectivity and was created to
highlight the dyadic and active nature of the interactions experienced
through the study.
Grocke and Wigram (2007) provided clear and detailed descriptions on
how to work receptively with clients, including step-by-step protocols for the
use of visualization and imagery, music for relaxation, song lyric discussion, as
well as vibro-acoustic applications, but they do not address the contributions
from the client that arise out of this receptive work. A review of the music
therapy literature on this topic suggested that little has been written about
the dynamic presence of interaction within receptive music therapy. While
the use of this music therapy approach in palliative care is quite common,
clients who may not be singing, speaking, or even making eye contact during
musical interventions are still sharing a great deal of information, as is the
therapist.
Inspiration for the Phenomenological Research Study
As a music therapy intern on an acute palliative care unit, I was
involved in many intense and engaging interactions that sparked an interest
in the dynamics between client and therapist, particularly during receptive
music therapy. Because of the extent of the use of receptive music therapy
for this client population, I developed a research question based on many
hours spent processing the experiences I was having with clients. The focus
became the clients’ experiences of this style of intervention. As the research
questions evolved, I focused on examining the lived experiences of clients
receiving music therapy on an acute palliative care unit towards the end
of their lives. The primary research question sought to examine the lived
experience of music therapy (specifically inter-active listening between
client and therapist) for a person at the end of life on an acute palliative care
unit. Secondary questions probed what exactly inter-active listening looked
like in music therapy, how it could be defined, and how inter-active listening
might affect the therapeutic space.
Methodological influences for the study were phenomenology, modified
grounded theory, and narrative inquiry, and recruitment was done through
purposive sampling. This study was approved by the University Health
Network and Wilfrid Laurier University research ethics boards. Data
collection took place over a three-week period. Participants were recruited
for this study based on the following criteria: (1) they were inpatients on
the palliative care unit; (2) they had a Palliative Performance Scale (PPS)
rating of 60% or lower; and (3) they were able to consent to participate in
the research process. While this client population was unique in the sense
that they were all admitted to an acute palliative care unit for cancer care, the
techniques used (within the receptive/inter-active listening paradigm) are
highly transferrable to many stages and phases of the experience of palliative
care and disease progression. While some of the participants were able to
interact verbally, others were only able to interact non-verbally. Regardless
of their level of communication, they were able to participate in music
therapy on the unit, which speaks to the adaptability of the techniques. Four
participants (out of six who were approached) consented to be involved in
the study. All sessions took place on the palliative care unit of a Canadian
cancer care hospital.
The study was conducted as a part of a major research project in
fulfillment of the Master of Music Therapy degree, which limited the length
of time for the study and the number of participants. There were 16 music
therapy sessions in total; all sessions were audio-recorded and seven were
video-recorded. The process of data analysis was decided by the researcher,
the primary research supervisor, and an external research advisor based on
a combination of Strauss and Corbin’s (1998) model of coding and Patton’s
(2002) qualitative research evaluative method.
Dynamic Interactions
Data analysis clearly indicated that in each session there were elements
of dynamic interactions between therapist and participant regardless of
whether the participant was speaking, singing, or simply breathing. The
primary themes that emerged, in order of prevalence, were non-verbal
connection, comfort, familiarity, silence, and faith. The participants’
experiences of inter-active listening during the study are described below.
In order to go into more detail and elaborate on their experiences within the
confines of this paper, only two of the four study participants are highlighted.
Pseudonyms have been used in place of the participants’ real names.
Felice
Felice was a 67-year-old female diagnosed with metastatic lung cancer.
She was admitted to the palliative care unit for symptom management and
end-of-life care. Felice’s daughter spent almost every day and night with her
through the course of her stay on the unit. The music therapy sessions began
the day she was admitted, and Felice had a total of seven sessions. Felice died
on the unit approximately two weeks after being admitted.
Felice made clear in the first session that spiritual music was important
to her and requested a number of hymns and spirituals that were significant
in her life. Although improvisation is a significant component of my clinical
practice, there was intentional focus on Felice’s requests for pre-composed
songs, and the primary music therapy intervention was the singing of hymns
and gospel music for her. According to Grocke and Wigram (2007), use of
music that is familiar to the client can be comforting and can aid in anxiety
reduction. The music was often played in collaboration with Felice’s daughter,
who would sing along, and with the accompaniment of a keyboard, which I
played.
The main themes that emerged out of the sessions were comfort, nonverbal connection, and faith. Felice’s daughter often commented that she
sensed Felice was aware of our presence in the room even though she was
sleeping most of the time. The daughter also noted that the music had a
special ability to enhance and strengthen the relationships between all of us.
According to Felice’s daughter, these relationships were comforting to Felice
as she struggled to stay awake and, indeed, she often showed physical signs
of relaxation (e.g., deepened breathing) and asked that the music continue if
it stopped. Felice’s daughter told me that when I left, Felice would often ask
when there would be another therapy session and expressed that she found
the music comforting. Felice’s daughter also said that she herself found the
comfort and non-verbal support beneficial, and the communicative nature
of the interventions allowed for an alternative approach of communication
between Felice and her daughter as Felice became increasingly unable
to speak. The following comments by the daughter (taken from session
transcripts) suggest Felice’s increased comfort through music and nonverbal communication in the sessions:
It’s amazing, the effects that music has even though we might not be
able to see what she’s feeling, but I know she can hear it and it does
something. . . . Whenever she’s upset, if I just sing, she falls asleep,
like nothing happened. It’s hard to explain. It’s different if you just
try to talk to her and calm her down. It helps, but it doesn’t have the
same effect. But if you sing to her, then it’s like everything just melts
away somehow. So I know she can hear you. She knows you’re here.
The reactions of Felice’s daughter confirm my observations that
Felice’s physical reactions reflected a non-verbal musical connection with an
emotional impact. Even though Felice was not able to speak, she appeared
to react in a variety of ways, suggesting that the interventions resulted in
responses that not only were receptive, but highly inter-active. Though I was
unable to know what Felice was thinking, her physical changes and responses
provided evidence that was validated by the observations of Felice’s daughter.
Serena
Serena was a 42-year-old woman with metastatic breast cancer. She
was admitted to the unit for end-of-life care and took part in one music
therapy session. Serena was referred to music therapy as the staff noticed
how much she enjoyed music, and they believed she and her family would
benefit from live music at the bedside. When I was first introduced to Serena,
I observed that her speech was slow and laboured but her eyes were bright
and energetic. Serena told me she was delighted at the idea of live music and
would be grateful for sessions within the next week. Two days later, Serena’s
sister approached the health care team and told them her sister’s condition
had changed rapidly; she was suffering from apnea and unable to respond
verbally. The sister asked if I would be able to spend a little bit of time with
Serena even though it was likely that she would not be waking up or speaking.
I brought a keyboard into Serena’s room and spent over an hour with
her, playing familiar songs that she had requested a few days prior to the
session. The familiar songs were interspersed with longer periods of vocal
and piano improvisation, during which I matched the music to Serena’s
breathing. As Serena breathed in and out, I used melodic vocalizations (e.g.,
“ahh, ooh”) to match the rhythm of Serena’s breath, engaging the iso principle
(Wigram, Nygaard, & Bonde, 2002). Serena’s sister sat at her side, holding
her hand and speaking softly to her.
About five minutes into the session, I began to sing Faith Hill’s “The Way
You Love Me” at a very slow tempo. As I began to sing the words, Serena
opened her eyes, looked up at her sister, then looked at me, and then closed
her eyes again. Her sister beamed at her. “Did you hear that? That’s Faith Hill!
I think you recognize that!” she exclaimed. For the remainder of the session,
Serena’s sister shared many stories about her, and I played improvised music.
Serena died less than an hour after the music therapy session. The moment
when Serena opened her eyes and looked at her sister was the last time they
shared eye contact. That moment—which included me—could be interpreted
as a moment of awareness, possibly of recognition. While it is impossible
to know exactly what Serena might have meant by her gesture, if anything
specific at all, it appeared to bring her sister a lot of comfort, amplified by the
fact that it happened as soon as Serena heard one of her favourite songs. The
fact that Serena looked both at her sister and at me may be an indicator of
the connections that were occurring during the session. Whether Serena was
fully conscious of her eye contact or movement is unclear, but it appeared
that a connection had been made and that there were interactions between
everyone present in the room.
Re-envisioning Receptive
As demonstrated by the examples above, intimate moments of
connection occurred through verbal, non-verbal, musical, and non-musical
moments. It is essential that as music therapists we are constructively
critical and highly aware of the vocabulary we use to discuss the meaningful
moments that so often arise in our work (Amir, 1992). The task of putting a
non-verbal connection into words is an immense challenge, one that many
music therapists often struggle to achieve in daily interactions with allied
health professionals (Kenny, 2006). If the terminology we use to describe
our sessions reflects the nature of our work more accurately, it may become
easier to process, think about, and speak about our experiences. For these
reasons, I felt it essential to re-envision the word receptive. While the
groundwork of the theory of receptive music therapy has been laid (and any
continued theoretical framework building cannot occur without an excellent
foundation), it is important to acknowledge and articulate the complexity of
the interactions we experience as music therapists.
Throughout music therapy training, supervisors often made me aware
of the dynamics of countertransference that were affecting sessions. Priestly’s
(1994) description of empathic countertransference (p. 87) as a plucked
string instrument (the patient) that results in a resonance from a sympathetic
string (the therapist) speaks to the dyadic, interactive dynamics that were
experienced during the research/music therapy sessions. Re-envisioning
a receptive experience as an interactive one allowed for an exploration of
the two-way connection that was felt between the participants and myself.
I have chosen to write this word as inter-active in order to highlight the
experience of being in the midst of or between two or more people (inter)
and the engaging, fluid experience of activity (active). Including the word
listening highlights the unique nature of using music as an intervention. Reenvisioning receptive music therapy as inter-active listening has led me to
consider why there is so much consistent interactivity and has helped frame
and understand experiences in acute palliative care. The data analysis yielded
a more formal description: inter-active listening is an approach that involves
the therapist playing, singing, or providing music in some form while the
client listens but does not necessarily play or sing; the therapist and client
may interact non-verbally or verbally, thus creating an intersubjective space,
and further interventions may be based on potential client response (Black,
2013).
A phenomenological approach allowed themes to emerge as the
sessions unfolded, and the data analysis led to a summary of these. Although
I was already aware of the dynamic interactivity within sessions, using a
phenomenological lens (Creswell, 1998) created an opportunity for themes
to emerge organically within the context of interactivity. These themes (nonverbal relationship, comfort, silence, faith, and familiarity and recognition)
reflect the complexity of the interactions that occurred during music therapy.
The literature suggests that some of these themes are fairly common
in psychosocial palliative care (Breibart, 2004) and with music therapy in
palliative care (Hilliard, 2001). Also apparent in the data was the fact that the
themes all developed as a result of the space (the music, the verbal exchanges,
and the silence) created through inter-active listening. The use of the term
intersubjectivity as a critical component in describing the interactions has
helped contextualize and reframe an understanding of the multiple layers of
connection between therapist and client.
There are frequent moments of connection and communication, largely
because of the intersubjective space co-created by client and therapist;
both parties are sharing a space physically but also participating in music
therapy within the same context (an acute palliative care unit) using music.
As exemplified by the exchanges with Felice’s daughter, it seemed as though
Felice was not only participating actively (even as she was dying) but that
Felice was listening and engaging in the non-verbal communicative cues sent
out by her daughter and me. In a similar way, Serena also appeared to be
connecting with me well as with her sister; what I felt to be her most intense
moment of connection (i.e., the eye contact) happened while I was playing one
of her favourite songs. This may suggest that the use of the music with both
of these participants opened up a space in which the clients could experience
connection and be interactive with me and with their family members.
Conclusion: Moving Forward
The data reflected the complexity of the interactions that take place
during inter-active listening in palliative care. The results also speak to the
strong presence of an intersubjective space that is co-created by a therapist
and client. The intersubjective space must be highlighted in order to gain
a deeper understanding of the impact of music therapy in acute palliative
care. Within this client population, the issues that arise in music therapy are
complex and multifaceted, and a great deal of research has yet to be done.
Further research in this area could involve a greater number of participants
engaging in inter-active listening or a study inquiring specifically about the
effects of inter-active listening on family members of patients on the unit. A
further exploration of the impact and role of silence would greatly support
this current study and would add to the literature on relationships formed
within music therapy.
Limitations of this study include a small sample size (due to the time
restrictions on the study) and a uniform sample population. Future studies
on inter-active listening in other palliative populations, possibly including
participants in long-term care or who are dealing with HIV/AIDS or dementia
may provide additional useful information.
The theoretical groundwork for receptive music therapy is strong;
however, a deeper probing into the results of this kind of music therapy is
necessary. This area of study raises a host of questions about the nature
of communication, interaction, intersubjectivity, and musical relationship.
Through examining the clinical exchanges we encounter in this work, I
believe we can begin to allow layers of meaning to unfold. The vocabulary
and jargon that music therapists use to describe their work directly affects
the understanding of clients and the interactions. How we speak about our
work as music therapists manifests in the clinical actions we take, which is
why attention to terms and meanings is so crucial. In my clinical practice,
inter-active listening has helped further my understanding of the receptive
approach and has challenged me regarding how I approach clients. I
encourage all music therapists to be aware of the ways in which they describe
their practice and to challenge themselves as musicians, therapists, and
researchers.
References
Amir, D. (1992). Awakening and expanding the self: Meaningful moments in
the music therapy process as experienced and described by music
therapists and music therapy clients (Doctoral dissertation).
Retrieved from Dissertation Abstracts International. (4361B)
Black, S. (2013). Inter-Active Listening: A phenomenological study on music
therapy and intersubjective space in acute palliative care (Unpublished
master’s thesis). Wilfrid Laurier University, Waterloo, ON, Canada.
Breibart, W. (2004). Beyond symptom control: Research in psychosocial and
existential issues in palliative care. Palliative and Supportive Care,
2(1), 1–2.
Bruscia, K. (1998). Defining music therapy. Gilsum, NH: Barcelona.
Creswell, J. (1998). Qualitative inquiry and research design: Choosing among
five traditions. Thousand Oaks, CA: Sage.
Grocke, D., & Wigram, T. (2007). Receptive methods in music therapy:
Techniques and clinical applications for music therapy clinicians,
educators, and students. London, England: Jessica Kingsley.
Hilliard, R. E. (2001). The use of music therapy in meeting the multidimensional
needs of hospice patients and families. Journal of Palliative Care, 17,
161–166.
Hilliard, R. E. (2005). Music therapy in hospice and palliative care: A review
of the empirical data. Evidence Based Complementary Alternative
Medicine, 2(2), 173–178.
Kenny, C. (2006). Music and life in the field of play: An anthology. Gilsum, NH:
Barcelona.
O’Callaghan, C. (1990). Music therapy skills used in songwriting within a
palliative care setting. The Australian Journal of Music Therapy, 1,
15–22.
Orange, D., Atwood, G., & Stolorow, R. (1997). Working intersubjectively:
Contextualism in psychoanalytic practice. Hillsdale, NJ: Analytic Press.
O’Rourke, M., & Dufour, E. (2012). Embracing the end of life: Help for those
who accompany the dying. Toronto, ON, Canada: Novalis.
Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.).
London, England: Sage.
Priestly, M. (1994). Essays on analytical music therapy. Gilsum, NH: Barcelona.
Scheff, T. (1990). Microsociology: Discourse, emotion, and social structure.
Chicago, IL: University of Chicago Press.
Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and
procedures for developing grounded theory (2nd ed.). Newbury Park,
CA: Sage.
Wigram, T., Nygaard, I., & Bonde, L. O. (2002). A comprehensive guide to music
therapy: Theory, clinical practice, research and training. London,
England: Jessica Kingsley
Safety, Connection, Foundation: Single-Session Individual
Music Therapy With Adolescents
Sécurité, lien, fondation : Séance de musicothérapie
individuelle unique auprès d’adolescents
Emily Carruthers, MMT, MTA
Private Practice/Music Therapy Placement Coordinator (Wilfrid Laurier
University), Waterloo, Ontario, CANADA
Abstract
Single-session individual music therapy (SSIMT) is an uncommon practice
in mental health settings, especially with adolescent populations. The aim
of this qualitative research study was to explore this unique clinical setting
and to establish a framework for one-off sessions. The study focused on
the experiences of nine adolescent participants in single 45- to 50-minute
individual sessions. Music therapy sessions were conducted as part of mental
health treatment for adolescents admitted to hospital for short-term care.
The research findings demonstrated the effectiveness of establishing a safe
atmosphere, creating a secure connection, and building a foundation to
reduce future emotional anxieties for the client. A clinical framework based
on these concepts was developed. The outcomes of this research can provide
strategies for other music therapists conducting single individual sessions
with adolescents.
Keywords: music therapy, single session, adolescents, mental health,
improvising, songwriting, music listening
Résumé
La séance de musicothérapie individuelle unique (SMTIU) est une pratique
peu courante en milieu psychiatrique, spécialement auprès d’une clientèle
adolescente. Le but de cette recherche qualitative vise à explorer ce contexte
clinique spécifique et d’établir un cadre pour une séance unique. L’étude
se concentre sur les expériences de neuf adolescents participant à des
séances individuelles uniques (SMTIU) de 40 à 50 minutes. Les séances de
musicothérapie sont organisées en tant que partie du plan de traitement pour
adolescents admis à l’hôpital en soins de courte durée. Les résultats de la
recherche démontrent l’efficacité de la création d’une ambiance sécurisante,
de l’établissement d’un lien sûr et de l’élaboration d’une fondation afin de
réduire les anxiétés émotives futures pour le client. Un cadre clinique basé
sur ces concepts a été élaboré. Les résultats de cette recherche peuvent
offrir des stratégies à d’autres musicothérapeutes qui dirigent des séances
individuelles uniques en musicothérapie auprès d’adolescents.
Mots clés : musicothérapie, séance unique, adolescents, santé
mentale, improviser, écriture de chansons, écoute de musique
As a graduate student music therapist, beginning a new clinical
placement can be both exciting and terrifying. One anticipates new challenges
and learning and feels compelled to research the proposed site and client
population in order to prepare. I was eagerly looking forward to starting my
clinical hours at a local hospital in child and adolescent mental health. It was
an area I had yet to experience as a music therapy student and one of which
I knew little. Questions came to mind: What is child and adolescent mental
health? Would I be working with clients who had experienced trauma?
Would music therapy be similar to my previous clinical experiences with an
individual adolescent client or the elderly? I met with my on-site supervisor,
who explained that my time would be divided between the in- and outpatient
units. One of the unique factors of the inpatient setting is that it is designed as
a short-term-stay facility; on average, clients are admitted for three to seven
days. I left the meeting unsure of what I might expect when seeing patients
the following week. How should music therapy be adapted for a singlesession framework?
As I began to prepare, I looked for literature on single-session individual
music therapy (SSIMT) with adolescent clients experiencing mental health
issues. While there was some research describing the single-session
framework and also literature about adolescents and music therapy, I had
difficulty finding resources specific to my search. There was one notable
book—Adolescents, Music and Music Therapy by Katrina McFerran (2010).
Throughout my training, I had read and been taught about how each
client in music therapy was unique. Though clients may come from the same
population, they have their own stories, needs, likes, and dislikes. It was a
fact I had come to know, but did not think about, until I started working in a
clinical environment where I met new patients every week. This observation
was repeated throughout my experience in this clinical setting. When I
thought I had developed some “perfect” strategies for adolescents facing
mental health issues, I would have a new client who was not interested in any
of these interventions. This was both a learning experience and a challenge. I
never quite knew what to anticipate, and it was difficult to develop a refined
repertoire for this client population.
As a student attempting to represent music therapy to the best of my
ability in a new clinical placement, this was a difficult situation. However, it
planted a seed of inspiration for an in-depth look at the techniques required
to facilitate a single individual music therapy session. I decided if there were
insufficient resources, I would develop them through careful study and
exploration in the form of a major research project.
Literature Review
Music Therapy and Mental Health
According to Centre for Addiction and Mental Health statistics (CAMH,
n.d.), the prevalence of mental illness is one in five Canadians. Thus mental
health is common in our society, but it is surrounded by stigma, and recovery
support is crucial. Further, mental illness is an issue in adolescent health.
The CAMH also states that “70% of mental health problems have their onset
during childhood or adolescence” and that “young people aged 15 to 24 are
more likely to experience mental illness and/or substance use disorders than
other age group” (n.d., “Who is Affected?”).
Music therapy is an effective method of treatment for individuals
experiencing mental health issues. It has been shown to reduce anxiety
and help those affected take on more responsibility for their treatment
(Silverman, 2011). The practice of music therapy can meet the unique needs
of each client because its techniques are inherently flexible in nature.
Historically, one of the starting points for the music therapy profession
was working with individuals experiencing mental illness. In the United
States in the early 1950s, Gilman and Paperte (1952) described the value of
music in the treatment of mental illness. Soon after, Mary Priestley, another
pioneer in psychiatric music therapy, developed her analytic music therapy
method in the early 1970s (Wigram, Pedersen, & Bonde, 2001). This method
was created primarily in adult psychiatric hospitals, and it used musical
improvisation to explore clients’ unconscious experiences. More recently,
Rolvsjord (2010) published a guide to resource-oriented music therapy in
mental health care, in which she highlighted the importance of empowering
the client throughout the treatment process.
Aldridge (1993) observed the difficulties of conducting qualitative
research studies in mental health because of the number of variables present
in the diagnosis. Though this type of research is challenging, there have been
several studies published about psychiatric clients (e.g., Silverman, 2009,
2011; Silverman & Marcionetti, 2004;). However, there are fewer articles
about adolescents and mental health.
Gold, Wigram, and Voracek (2004) published a meta-analysis to
determine the effectiveness of music therapy for children and adults
with psychopathology. They completed a thorough literature review and
determined that 11 studies met the inclusion criteria From this intensive
review, Gold et al. (2004) concluded that music therapy had “a highly
significant, medium to large effect on clinically relevant outcomes” (p.1059)
and was “an effective intervention for children and adolescents with
psychopathology” (p.1060).
Adolescents and Music Therapy
Adolescence is an important and difficult time as children make the
transition into adulthood. According to McFerran (2010), the concept of self
is developed during the younger adolescent years, and one of the four key
elements of adolescent health is identity. The other elements she identifies
are resilience, connectedness, and competence. A professional working with
adolescents must take these into consideration when regarding complex
needs unique to the adolescent population. Lefebvre (1991) outlined a list
of strategies for working with this population in a case study on a female
adolescent client, and her observations, recorded over several sessions,
revealed principles that can give insight into working with adolescents in
a music therapy setting. Music is a significant medium through which one
can connect with teenagers (Hendricks, Robinson, Bradley, & Davis, 1999;
McFerran-Skewes, 2005). It is an accessible outlet worldwide and one that
adolescents “take an active interest in” (McFerran, 2010, p. 73). McFerran
also wrote that “music functions as a window through to the internal state
of the teenager that can be used to increase personal understanding” (p. 66).
Clark, Roth, Wilson, and Koebel (2013) surveyed 60 credentialed music
therapists “to identify the current practices of music therapists working
with high-risk youth in Canada and the United States” (p. 70). Their findings
suggested that music therapists working in this field were under 40 years of
age, female, and used a “blended/eclectic” (p. 82) approach to “encourag[e]
high-risk youth to use their strengths and talents to share their stories and
achieve their goals” (p. 83).
The Single Session
The idea of a single-session approach in the helping professions
was developed during World War I and World War II for young men and
women who had experienced trauma on the battlefield (Bisson, 2003).
These debriefings would give a sense of closure while building morale and
developing the next combat strategy. Today, health care is moving towards
an approach where patients receive care in the shortest possible time.
Cassity (2007) observed brief therapy/short-term care to be the number
one ranked theoretical orientation. Those in psychiatric inpatient units are
often hospitalized for a few days (three to ten) and then discharged with
referrals to community support organizations (Black & Winokur, 1988; Wells
& Phelps, 1990; Winston & Winston, 2002). For this reason, appropriate and
effective interventions must be developed to meet the needs of clients in the
moment and to provide them with strategies to be used when returning to
daily life outside the hospital or treatment centre.
Music Therapy and Short-Term Therapy
Music therapy has been used as a short-term intervention to assess
clients, promote socialization, and prevent the occurrence of further health
issues. It may address communication difficulties, promote attachment,
and encourage self-esteem and awareness (Cassity & Cassity, 2006;
Kaenampornpam, 2010; Molyneux, 2005). It can be used during recovery
to minimize pain and manage stress (Kaenampornpam, 2010; Magill, Levin,
& Sodel, 2008). Clients learn how to practise relaxation and become aware
of the connection between the mind and the body (Cassity & Cassity, 2006).
Investigations of the effectiveness of single-session music therapy with
cancer patients (Krout, 2001; Magill, Levin, & Sodel, 2008) found music
to be beneficial as it promoted pain control, physical comfort, and patient
relaxation; reframed cognitive distortions; and improved emotional wellbeing. Furthermore, Silverman (2009) evaluated the effectiveness of music
therapy in a psychoeducational setting: using rock operas and music games,
he found that the patients responded with positive feedback as to the
effectiveness of these interventions.
While investigating SSIMT with children, Kaenampornpam (2010)
used herself as a single participant in a study. She asked how she, a music
therapy student in a pediatric ward, could provide children with beneficial
single-session music therapy. She conducted four cycles of action-based
research on the burn unit of a pediatric hospital and kept a reflective journal,
using observations of herself as data. Her findings suggested the following
principles to be used to inform music therapy practice:
1) a need for flexibility; 2) keeping the therapist’s and children’s
power of control in balance; 3) sensitivity to children’s responses
and their needs; 4) familiarity with background knowledge; 5)
ability to build rapport in short time; 6) the need for availability
when required; 7) open-mindedness; and 8) ability to reduce
anxiety. (p. 70)
Mind the Gap
Although there is literature on music therapy with adolescents, including
working with them in short-term therapy, to my knowledge there are no
qualitative research studies on single-session individual music therapy with
adolescents experiencing mental health issues. McFerran (2010) has made
a strong impact on the profession with the publication of Adolescents, Music
and Music Therapy, in which she discussed parameters for music therapists
working with this intriguing population. Buchanan (2000) described
strategies for working with a group of adolescents in single-session or shortterm therapy (one to three sessions); her sessions were two to three hours
in length and used both music and art media. However, most research using
SSIMT methodology with individuals in music therapy is based on work with
adults (e.g., Krout, 2001; Magill, Levin, & Sodel, 2008; Silverman, 2009, 2011;
Silverman & Marcionetti, 2004).
There is literature focused on single sessions in other helping
professions (Bisson, 2003; Curtis, Whittaker, Stevens, & Lennon, 2002; Slive,
McElheran, & Lawson, 2008). It has been a treatment model employed in
psychotherapy, psychology, and counselling for a number of years. It was
helpful to read this literature in other fields as learning points can be taken,
especially guidelines for verbal interventions (Bisson, 2003). However, there
are factors unique to music therapy, specifically the integration of music and
the use of instruments, which are not addressed by other disciplines.
Because of limited resources for professional music therapists and
students/interns working in a single-session framework and the increasing
prevalence of music therapy work in this clinical environment, the following
research questions were developed:
•
•
What are common themes or patterns in SSIMT with adolescents?
What clinical framework can be developed through the study of
SSIMT?
Method
Research Design
This study investigated SSIMT using a qualitative research design
informed by Glaser and Strauss (1967) and Amir (2005). In order to create
and develop a framework for conducting single-session music therapy, I
immersed myself as researcher in the data to gain a deeper understanding of
the phenomena. I used Amir’s (2005) six phases—general listening, indexing
and transcribing, open coding, categorizing, synthesis and model technique,
and development—to analyze the data and create the framework. With this
knowledge, I was able to make connections and applications for professionals
in similar settings. It was necessary to be aware of my own bias and to bracket
any pre-existing notions as a music therapist in this clinical environment. To
do this I worked with a clinical supervisor and a research supervisor and had
support from professional staff on the inpatient unit.
Research Setting and Participants
The research took place in a child and adolescent mental health
inpatient unit. This unit is a transitional experience for patients while
treatment is being prescribed or adjusted. The average stay is three to eight
days. Each day, the patients attend group sessions led by a child and youth
worker (CYW), complete an academic period, have free time, and work
individually with a staff member discussing discharge and safety planning.
The adolescents meet daily with their case care team, composed of a child
psychiatrist, social worker, nurse, and if needed, a teacher and CYW. There is
a group music therapy session once per week, and one to three patients are
referred for individual music therapy as well.
Participants selected were 16 to 19 years of age, resided on the
inpatient unit, and were willing to partake in a clinical research session. The
Wilfrid Laurier University research ethics board considers participants less
than 16 years of age to be vulnerable persons; the selection of this age group
ensured that clients had the capacity to make an informed decision about
their involvement in the research. The only exclusion criteria were if staff on
the unit felt a participant was unable to consent to the procedure or was not
physically or emotionally well enough to be a part of the study. As I was not
a staff member at the facility, I could not make contact with the participants
until they had consented to be a part of the study. Therefore, I relied on the
CYW to recruit participants for the research study. To facilitate this process, I
clearly described the study protocol to the CYW and explained the inclusion
and exclusion criteria. For all participants, the CYW and I gained written
confirmation on the informed consent statements.
Ten participants were recruited for the study. Due to an audio recording
technical difficulty, only nine of these individual sessions were transcribed,
analyzed, and used to generate findings. This group of nine adolescents
comprised of five girls and four boys. As this setting was a transition for many
individuals to further treatment, in most cases a mental health diagnosis had
not been reached. I was briefed on each participant’s presenting issues, but
often there was limited information. As it was difficult to create a unique
goal for each individual in a short time period, my therapeutic aim was to
provide a safe environment where participants could express their feelings
and emotions through music while having a positive individual session
experience.
Therapeutic Orientation of Researcher
I strive to create a comfortable, safe, and successful music therapy
experience for my clients. My personal approach is client-centered, as I
believe the session “relies on an equal term relationship between therapist
and client” (Wigram, Pedersen, & Bonde, 2001, p. 66). Each person who
participates in a music therapy session should feel as though they are heard,
both verbally and musically (Lee & Khare, 2001). I endeavor to use music as
the main medium for communication in my clinical work. However, I also
encourage my clients to use movement, art (Ahonen-Eerikäinen, 2007), and
written word to process their feelings. Every participant experiences music
therapy differently, and I believe the musical and creative practice has the
ability to be a catalyst for change.
Instruments Used
The instruments available in the session were a large wooden djembe
(a large, hide-covered hand drum), an electric piano, an alto xylophone, two
tone chimes (G4 and E4), and a singing bowl.
Session Structure
The participants were asked to engage in a single 45- to 50-minute
individual music therapy session. The basic structure of the experience was
the same for each participant; there was flexibility for participants to choose
specific interventions and express responses to the music they created. The
session was in three parts: opening, middle, and end.
The opening consisted of an introduction to music through instrument
exploration. The middle consisted of one to three interventions in any
combination: improvisation, songwriting, and music listening/lyric analysis.
According to Clark et al. (2013), these three interventions, along with
drumming, are the most frequently used by music therapists when working
with adolescents. The participants also had the opportunity to choose the
order of the preferred interventions. The end involved a relaxation exercise.
Participants were active contributors to the experience, and they listened,
sang, or played tone chimes as I vocalized and accompanied myself with the
singing bowl.
Data Analysis
Following Amir’s (2005) phases, I audio recorded, transcribed, and
indexed the sessions. Indexing is “a form of ongoing assessment that
evaluate[s] the complex strands of the therapeutic process from audio and
video recording,” (Lee, 2003, p. 137). This method of analysis organizes all
session events into musical and clinical categories, allowing for subjective
observations. NVivo 10 software was then used for analyzing and categorizing
the verbal data. The transcriptions were entered in the NVivo 10 program,
which allowed me to identify common themes, phrases, and words used
throughout the sessions.
Research Findings
Figure 1. The framework for a single-session individual music therapy.
The Framework
An SSIMT framework was developed that involved a three-part
structure for each single session: the beginning, the middle, and the end. The
framework is summarized in Figure 1 and presented in point form in Table 1.
The Beginning: Establishing Safety
Safety is the most important feature of SSIMT with adolescents. Without
it, neither the participant nor the therapist will feel comfortable engaging
in musical dialogue. To establish a secure atmosphere, key strategies for the
music therapist are to consider the opening dialogue, focus on the client’s
strengths, and get to the music as quickly as possible.
Introduction. The music therapist must be prepared before meeting
the client. A successful session requires arranging a comfortable music space
and practising interventions prior to the introduction of the participant.
Building rapport begins the moment the music therapist interacts with the
client. It is important for the music therapist to have a greeting ritual as it
sets the tone for the session. When meeting the client, it is an asset in the
restricted time frame of the session to ask informative initial questions such
as “How are you feeling?” or “Have you ever played an instrument before?”
The term music therapy can be overwhelming for participants with
no experience of it, so the opening dialogue needs to be understandable
and short. Findings supported the use of a simple introduction that clearly
explains and outlines the SSIMT.
Using empowering language helped to create an atmosphere of
security in a single music therapy session, and to reduce anxiety during the
novel experience. You, can, do, and play were four of the top five words used
most frequently in the introduction. The use of the word you promotes the
empowerment of the client. For example, saying “You choose the instrument
you would like to play” gives power back to the client by offering choice, so
important in a hospital setting. The word can challenge clients to highlight
their skills; encouraging the participants to talk about their skills sets the
tone for the session. For example, I responded with “You can play!” after one
participant said, “I dunno how to play the piano”—and then improvised a
21-minute piece on the instrument. Eliciting contribution through positive
language with do—“Let’s do it together”— highlights the expectation of
active participation and builds a safe atmosphere for the client to explore and
connect to the music and me. Finally, play is central to the initial interaction:
Table 1
Summary of Single Session Individual Music Therapy Framework
PURPOSE
Establishing
Safety
Establishing
Connection
Establishing
Foundation
STRATEGY
Introduction
•
•
Exploratory
Improvisation
•
Improvisation
•
Music Listening
•
Songwriting
•
Relaxation
•
Discussion
•
•
•
•
•
•
•
ACTIONS
Clearly outline what will take
place during the session
Introduce the instruments to the
client
Ask the client to choose an
instrument for themselves and
for the music therapist
Begin playing as soon as possible
Offer both referential and nonreferential improvisation.
Ask the client to choose
instruments for themselves and
the music therapist.
Choose music from genres
appropriate to the population.
Have a clear and concise
understanding of the lyrics and
ask questions to explore the
experience further.
Assist the client to brainstorm
topics and lyrics.
Provide clear choices for musical
accompaniment.
Provide a clear induction to the
intervention
Allow the client to be active in
the music making
Encourage the client to provide
feedback about the session
Dialogue with the client about
musical coping strategies
“Let’s play!” Humour, clarity, and energy were used to engage the client
immediately in the process and inspire them to explore their musical abilities
and emotions. For example, telling the participants that someone once asked
if I ate cereal out of my singing bowl seemed to lighten the mood and reduce
anxiety when I was introducing the instruments at the beginning of the
session.
The value of starting the initial improvisation—getting to the music—
as quickly as possible was one of the most important discoveries of this
research project. In most of the sessions, the music started within the first
two minutes, and this seemed to reduce the anxiety participants experienced.
Establishing a solid musical foundation promotes a positive space in which
to respond, although some adolescents may not feel comfortable enough to
share their thoughts immediately.
These three guidelines—simplify the opening dialogue, use
empowering positive language, and get to the music—create a safe,
comfortable environment for participants to explore themselves and their
feelings through music.
Exploration. After the introduction, the client was asked to choose
an instrument for each of us and then instructed to play. This emphasized
that the client had the power to set the tone for the session. Then I asked
the client to describe the experience and to discuss feelings, images, and
body sensations. Asking the client concrete questions set an unobtrusive
atmosphere for the session and reduced the pressure on the participant to
answer open-ended questions. When asked to choose an instrument, the
majority of clients chose to play the drum. This may have been because the
drum is a safe and accessible instrument that is perceived to be simple to
play. Conversely, the piano is seen as a challenging instrument to play, where
skill and practice are required, and may be intimidating for participants
experiencing music therapy for the first time.
The participants improvised for varying lengths of time. One participant
improvised for almost 21 minutes, whereas another created two short pieces,
each 2½ to 3 minutes in length. After the improvisations, I asked the patients
about their experiences. Some of them were able to verbally articulate their
experience immediately, while it took a little while for others to respond. The
majority reported being “in” the music:
“It was like I wasn’t even here. It was weird. I wasn’t even thinking.”
(17-year-old boy)
“I just got into it, had fun.” (18-year-old girl)
“I got really into it. . . not really thinking about anything else.”
(17-year-old girl)
Perhaps the feeling of being in the music was related to this first improvisation
experience. Some participants may not have felt comfortable enough in the
session or with the music therapist to provide more elaborate or concrete
responses; others may have been concentrating on the music and not thinking
about their feelings.
The Middle: Establishing Connection
Building a secure connection with the participants in SSIMT generates
deeper exploration of feelings and emotions in a limited time period. This part
of the session was predominantly client-lead. Participants could choose to
improvise on the instruments provided, listen to a piece of music and discuss
the lyrics, or be involved in a songwriting process. Two participants were able
to do more than one intervention: one did music listening and songwriting,
and the other did music listening and improvisation. Of the other seven
participants, three chose music listening, three chose songwriting, and one
chose improvisation. Three of the four boys chose songwriting, four of the
five girls chose music listening, and one of each gender chose improvisation.
Preparing and executing clear interventions—including improvisation,
music listening, and songwriting—helps to create the relationship between
music therapist and client.
Improvising. Improvising provides a method of non-verbal connection
between therapist and client. According to Austin (2008), “clients need to
connect with the therapist; they need to be seen, listened to, understood
and truly known” (p.196). Clients can share their experiences and feelings
through the instrument of their choosing. My role was to build the
relationship through active listening and music-making. There are different
improvisational techniques.
In this project, one participant chose non-referential improvisation,
meaning he did not specify a theme (Wheeler, 2005). He created music
for approximately 6 minutes on the piano while I accompanied him on the
djembe. When asked about the song, he replied, “I’ve played that before, but I
kind of made it up on the spot. . . . Whenever I razz on the black keys, anything
goes together. Music! I love music!” He completed two more improvisations in
the session using a variety of instruments, including the tone chimes and the
xylophone. Playing music in the moment allows some clients to experience a
sense of joy and freedom. This participant actively engaged in music-making
without hesitation. He was familiar with the piano and drum, which may
have contributed to his overall comfort during the experience.
Another participant improvised on the idea of celebrating one’s self.
She chose the djembe and asked me to accompany her on the piano. This
experience was considered a referential piece (Wheeler, 2005), which is
achieved when “music is organized in reference to something other than
itself,” (Bruscia, 1987, p.10). After the music, I asked the client if she felt she
had celebrated herself, and she responded, “Yeah, I was using the drum a
lot more.” For some, referential improvisations are useful as they give the
participant a grounding idea upon which to expand.
Non-verbal communication through musical improvisation gives the
participants the opportunity to connect to the music therapist through music
when words are difficult to find and/or use.
Music Listening. Music listening allows clients to share their life
experiences at a symbolic distance. Ahonen-Eerikäinen (2007) described
symbolic distance as a situation where clients can “speak about the feeling
of the music rather than their own feelings” (p. 96). All of the participants
who chose music listening stated they could relate to the songwriter and the
message that was conveyed. My role was to witness and assist the clients in
exploring their feelings. Participants were given the choice of four different
pieces including Lady Gaga’s “Born This Way,” The Beatles “Let it Be,”
Eminem’s “Beautiful,” and Adele’s “Someone Like You.” As the researcher, I
chose songs that I felt were most accessible for the adolescent population. I
attempted to cover a range of genres and time periods with the four pieces.
Eminem’s “Beautiful” was the most popular song choice with three
participants choosing it. When asked for a response to this piece, one
participant said:
“Most people don’t really understand where other people come from.
. . . Why don’t you just try my life out for a day or so and see how you
feel after it? . . . It makes other people think my life’s not rough but
the person sitting next to me could have it extremely rough.”
The clients said they shared similar experiences with the songwriter, and
together we discussed their feelings. Highlighting specific lyrics seemed to
stimulate further exchange about their relation to the song. When asked
which line had the most importance, an 18-year-old girl responded:
“‘Don’t let ’em say you ain’t beautiful.’ . . . That part of the song got me
through because everybody . . . pushed me around, . . . so listening to
that song helps me to stand up to them, saying . . . piss off. I am who
I am; you are who you are. Everybody’s different. But everybody is
beautiful in their own way.”
Adele’s “Someone Like You” and The Beatles “Let it Be” were each
chosen by two participants. The clients, both male and female, who picked
the Adele song were able to relate the piece to romantic relationships in their
own lives. One participant stated, “I think it’s good… It’s about heartbreak,
right? I just got out of a relationship. . . . He said, ‘I just want to date; I don’t
want a relationship,’ and then it turns out he was actually dating another
girl.” The Beatles “Let it Be” reminded another participant of herself: “Lots
of people speak their words of wisdom to me.” From this point, I was able to
introduce a discussion about the impact of sharing wisdom. She talked about
being a source of knowledge for friends, and how “it makes me want to get
better . . . so it’s a good motivation.” These pieces allowed me to facilitate a
discussion of these adolescent themes and to understand similar situations
through the symbolic distance of the song.
Finally, Lady Gaga’s “Born This Way” was chosen by one participant.
She disclosed the song was important to her because “I have a lot of problems
with self-confidence and liking who I am as a person. . . . What people say
really affects me. . . . Lady Gaga [is] confident in herself and I really admire
that. I like her music.” The song provided a starting point for the client to
discuss aspects of her personal life that may have been difficult to talk about.
The results of this research study demonstrated that the most
important aspect of the pre-composed songs was the participant’s ability to
relate to the lyrics. As someone who is familiar with popular music, I could
facilitate a discussion about prominent issues in the participants’ lives using
these lyrics as a starting point.
Music listening promotes the idea of shared experience. Allowing the
clients to relate to familiar music encourages them to share their own life
events, which can then facilitate discussion and possible strategies. Being
acquainted with the song and introducing specific significant lyrics for
discussion paves the way for a therapeutic connection.
Songwriting. Participating in songwriting encourages clients to
share their own experiences and thoughts. My role in this intervention was
validating their ideas, giving them an experience adolescents may not often
get. Songwriting allows clients to tell their own stories. Four participants
in the study chose the songwriting intervention. Two of the participants,
however, decided that they wanted to compose but did not want to add lyrics.
When using words, the songwriting process was completed in four
steps: choosing a topic, brainstorming related ideas, creating lyrics, and
composing the music. The second participant chose to write to a significant
person in his life. He generated ideas by free association; then we reviewed
the notes and began to turn them into rhyming song lyrics. Below are a few
of the lines he created:
I just wish I could tell her, let her know how beautiful she was, how
beautiful she is. She’d never believe me. . . . Sometimes she says that
she thinks that she’s worthless and I try to tell her that she’s worth
everything to me and I just wish I could make her see.
Two participants who chose the songwriting intervention decided not
to use lyrics. One said, “I really would not like to sing,” and when asked if
he would like to create lyrics for me to sing, he responded, “I don’t know. I
can’t write,” but afterwards reported a positive experience: “I had a bit of
a feeling. . . . I got into it for one minute. For just a minute . . . enjoying it.”
Another preferred the lack of lyrics and asked, “Can it be instrumental? I
like instrumental music.” After the music, she commented, “It sounded really
good, it sounded sort of like a title opening of something.” Though they chose
not to use lyrics, both clients seemed to take pleasure from being involved in
creating a composition with my facilitation.
Songwriting allows individuals to bring together words and music in
a unique combination and helps participants gain confidence in their own
experiences. Furthermore, different elements can be used to communicate
feelings—when text is insufficient, music can be used. Those who did not use
words seemed to value the song-like structure of their improvised music.
The End: Establishing a Foundation
Establishing a foundation promotes the idea of giving strategies for
the participant to use after they have completed the session. In a one-time
experience, limited aims can be accomplished. However, providing clients
with music as an emotion regulating tool is an important objective. The
experience of relaxation reduces participants’ anxiety. Discussing ways to
use particular music encourages clients to use musical strategies once they
have been discharged.
Relaxation. I facilitated anxiety reduction with an active music-making
relaxation experience. I informed participants that I would be using my voice,
and they were invited, in addition to playing instruments, to experiment with
their voice as well. I felt most comfortable using my voice for this intervention
as it is my primary instrument. I began by giving a verbal induction, which
centered on helping the client visualize a relaxing location or happy
thought (Grocke & Wigram, 2007), and then moved on to improvising. The
improvisations ranged from 3 to 9 minutes. One participant, who played for 6
minutes, described the following image as his relaxing place: “It’s a path near
my house, flight of stairs going down to the back, and I just sit there.” Another
shared this image: “I thought of [when] I went on a vacation to sunny place last
year” after she finished a 4½-minute improvisation. These responses seemed
to demonstrate that more time spent in relaxation interventions led to clients
being more willing to share in their imaging experience. This intervention
allowed the client to create an image without increasing their anxiety. I
encouraged the clients to be comfortable as they began the transition to the
end of the session, and this relaxation intervention demonstrated the value
of self-care to clients.
Response. At the end of the session, I asked for participants’ feedback
on their experiences. All the clients stated they liked the session and a few
reported they found it helpful. The following is a sample of responses.
“It’s kind of cleansing.” (16-year-old girl)
“Found it relaxing. Took my mind off things that I didn’t really want
to think about. I guess music in general does that to me. It was a good
thing for me being in here cause music relieves the tension that I
have most of the time, so, it helped.” (18-year-old girl)
The majority of participants seemed eager to share their appreciation.
Many appeared to find the session relaxing and helpful. Although all of the
responses were positive, an increased sample size might have resulted in
some different observations. It is possible that an unwillingness to offend me
may have affected the participants’ feedback.
In the final discussion, I asked the clients about their strategies for
using music for emotional regulation. The majority of clients responded they
had not tried this coping mechanism in the past, although many seemed
open to the idea. A dialogue with the participants about the genres they were
familiar with helped to highlight the resources they could use to be active
in regulating their emotions independently. The identification of important
songs allowed clients to reflect on their musical choices. Asking the
participant for their feedback provided a sense of closure and emphasized
again the client’s control of their experience. Each participant was asked for
his or her feedback, which may not be a common experience for an adolescent
in a hospital setting.
The end of the music therapy session consisted of a relaxation
intervention and discussion with clients to gain their feedback about the
experience. Both interventions sought to reduce any anxiety the client may
have felt. With the relaxation interventions, my intention was to ground
participants and prepare them to transition back into their daily schedule
with a sense of security and empowerment. I also brought up with the client
the idea of using music as a coping strategy outside of the hospital.
Discussion
Reflections on the Framework
Establishing safety, connection, and a foundation are the three factors
required to create a successful SSIMT. Focusing on a safe relationship
through building connections will help the client to learn strategies that
promote healing. SSIMT is an efficient and appropriate method for shortterm treatment in mental health.
The SSIMT framework is similar to the approach used in long-term
therapy and uses many of the same interventions; however, some elements
are different. There is no formal assessment in SSIMT because of the limited
time constraint, and when using certain techniques in SSIMT, music therapists
must facilitate their completion as much as possible in the time allotted. (For
example, when using the songwriting intervention, participants may only
have time to compose lyrics and may have to finish the songs on their own.)
The focus of the SSIMT session is to show clients strategies for using music
to help themselves.
Future Work
In future, I would like to apply a similar study to different client
populations. It would be valuable to determine whether the positive
impact of a single session can be demonstrated with a range of age groups
and diagnoses. As health care moves towards a philosophy of short-term
treatment, music therapy practice may have to change to meet this demand,
and the SSIMT framework could be a resource. The method developed in this
research could be useful in outpatient treatment programs where clients are
unable to afford long-term therapy. The focus on creating effective strategies
in a short period of time for the client to practise at home would be beneficial
to those who are able to manage independent care.
I would be interested in exploring the application of this method to
group work. At the hospital where the research study was conducted, I also
facilitated single-session group music therapy (SSGMT). This was often
challenging work as the participants and the group dynamics change weekly.
Focusing on the principles of the establishment of safety, connection, and
building a foundation could provide a basis for developing effective group
interventions.
Conclusion
This research study allowed me to develop valuable techniques and
insights for future clinical work. It taught me about collaborating with other
professionals in a hospital setting, and I learned the importance of singlesession music therapy. The research process challenged me to review musical
interventions and to evaluate their effectiveness. Adding to the literature
on short-term music therapy, this study provides a clinical framework and
practical music therapy resources to use in single sessions. It is my hope that
this SSIMT framework will offer strategies to new and experienced music
therapists working in this unique clinical environment.
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An Opportunity for Positive Change and Growth: Music
Therapists’ Experiences of Burnout
Une occasion de changement positif et de développement
personnel : l’expérience de l’épuisement professionnel
chez les musicothérapeutes
Kiki Chang, MA, MTA
Music Therapist, Baycrest Centre, Toronto, ON, Canada
Abstract
In a study of burnout among music therapists, a phenomenological approach
was used to examine the question of how music therapists describe their
experience of being burnt out and the methods they use to find resolution. Six
music therapists practicing in Canada were interviewed. They had between
1 and over 15 years of experience in the field. Analysis of the interviews
identified four main themes: (1) previous knowledge of burnout before
experiencing burnout as a music therapist, (2) factors causing burnout
among music therapists, (3) symptoms of burnout, and (4) resolution of
burnout. The findings demonstrate a need for more discussion of burnout
and self-care during the music therapy training process as well as the creation
of support systems and resources should symptoms occur. The participants
emphasized the significance of self-awareness in their recovery process and
that this self-awareness has a key role in preventing future occurrences.
Most importantly, they expressed that burnout can turn out to be a positive
experience, allowing for self-growth and exploration.
Keywords: music therapy, music therapists, burnout, compassion
fatigue, recovery, self-care
Résumé
Une recherche d’approche phénoménologique sur l’épuisement professionnel
a été menée auprès des musicothérapeutes afin d’examiner la façon dont
ceux-ci décrivent leur propre expérience de l’épuisement professionnel
et les méthodes qu’ils utilisent afin de trouver des solutions. À cette fin,
six musicothérapeutes exerçant au Canada, détenant entre 1 et 15 ans
d’expérience dans le domaine, ont été interviewés. L’analyse des entrevues
ont permis d’identifier quatre thèmes principaux : (1) les connaissances
déjà connues sur l’épuisement professionnel avant l’expérience même de
l’épuisement professionnel en tant que musicothérapeute, (2) les facteurs
provoquant l’épuisement professionnel parmi les musicothérapeutes, (3) les
symptômes de l’épuisement professionnel, et (4) la guérison de l’épuisement
professionnel. Les résultats montrent le besoin d’augmenter les discussions
sur l’épuisement professionnel et la santé personnelle pendant la formation
de musicothérapie tout comme la création de services de soutien et des
ressources lors de l’apparition des symptômes. Les participants ont insisté
sur l’importance de la conscience personnelle au sein du processus de
guérison laquelle a un rôle clé dans la prévention de récidives. Et surtout,
ils ont affirmé que l’épuisement professionnel peut s’avérer une expérience
positive ouvrant la porte au développement personnel et à l’exploration.
Mots clés : musicothérapie, musicothérapeutes, épuisement
professionnel, fatigue de compassion, guérison, santé personnelle
As music therapists, we are musicians, artists, and healers. This
multifaceted identity allows us to interact with clients in many ways. Our
role is to enhance their well-being using the medium of music. We are there
to listen, support, and aid with their personal processes. This means we are
exposed to clients’ lives on a daily basis. They reveal their thoughts, feelings,
and experiences to us, and in turn we share parts of ourselves with them.
The very nature of our work makes us vulnerable, both emotionally and
professionally, and there are times when we carry our clients’ emotions with
us after strongly identifying with their experiences.
As a profession, we experience vulnerability in terms of work creation
and working style. Many music therapists hold contract positions, and it
can be difficult to find full-time work. Furthermore, since music therapy is
a relatively young profession in Canada, health care administrators often
misunderstand it, and there is a constant need to explain our roles within
the health care system. These stressors, among others, may bring about
a phenomenon known as burnout (Clements-Cortés, 2006). Like other
professionals working in human services fields, music therapists are not
immune to experiencing this phenomenon. It is likely that many of us may
experience burnout at some point in our careers, as the prevalence of burnout
among health care professionals around the world is increasing (Schaufeli,
Leiter, & Maslach, 2008).
Literature Review
Burnout
Freudenberger (1974) and Maslach (1976) were among the first to
use the term burnout. Burnout can be defined as a syndrome of emotional
exhaustion, depersonalization, and reduced personal accomplishment that
can occur among individuals who work with humans in some capacity
(Maslach, Jackson, & Leiter, 1996). Emotional exhaustion is the main symptom
of burnout and the easiest to recognize. It can be described as an inability to
care. Depersonalization is the therapist’s lack of sensitivity towards clients.
It is an attempt to distance oneself from clients, as clients’ demands are more
manageable when clients are seen as impersonal objects. A combination
of depersonalization and exhaustion decreases one’s ability to be effective,
leading to feelings of reduced personal accomplishment. When this develops
further, it can manifest into negative thoughts about oneself, as it can be a
challenge to feel a sense of accomplishment when emotionally exhausted or
indifferent towards clients (Lamont, 2004; Maslach, Schaufeli, & Leiter, 2001).
Burnout among health care professionals is most often measured using the
Maslach Burnout Inventory (MBI), which measures respondents’ scores on
the three dimensions/subscales (emotional exhaustion, depersonalization,
and personal accomplishment) of burnout. The MBI is a 22-item, 7-point
Likert-type scale (Kim, 2012). A high degree of burnout is indicated by high
scores on the emotional exhaustion and depersonalization subscales and in
low scores on the personal accomplishment subscale.
Compassion Fatigue
Compassion fatigue can be defined as “a state of tension and
preoccupation with the traumatized patients by re-experiencing the
traumatic events, avoidance/numbing of reminders, [and] persistent arousal
(e.g., anxiety) associated with the patient” (Figley, 2002, p. 1435). It is
“prevalent across all spectrums of the helping professions and is flourishing”
(Showalter, 2010, p. 239). Although some researchers (Austin et al., 2013;
Joinson, 1992) have stated that compassion fatigue is a type of burnout,
others (Berzoff & Kita, 2010; Devilly, Wright, & Varker, 2009) have suggested
that the two phenomena are different. Doman (2010) wrote that compassion
fatigue is a form of vicarious trauma only experienced by those in the
helping professions but that burnout can affect people in any profession.
Collins and Long (2003) proposed that burnout is a result of accumulated
stress associated with overwork, whereas compassion fatigue is caused
by secondary traumatic experience. This is echoed by Kearney, Weininger,
Vachon, Harrison, and Mount (2009), who added that stressors related to
the work environment influence the occurrence of burnout. However, both
phenomena have similar consequences, leading to a decrease in effectiveness
and feelings of being overwhelmed (Figley, 1995).
Factors Leading to Burnout
Vlăduţ and Kállay (2010) proposed that factors leading to burnout can
be grouped into two categories: situational characteristics and personal
characteristics. According to Maslach et al. (2001), situational characteristics
include workload, control, reward, community, and fairness. Workload is a
major predictor of burnout, and excessive workload is strongly correlated
with burnout, especially the dimension of emotional exhaustion (Schaufeli
& Enzmann, 1998; Vlăduţ & Kállay, 2010). Cordes and Dougherty (1993)
proposed that if a professional feels he or she is being controlled at work, it can
lead to feelings of emotional exhaustion. They also stated that when colleagues
or supervisors do not recognize work that is accomplished, this lowers both
the perceived value of the work completed as well as the employee’s sense
of personal value. Community is another factor that can lead to burnout. It
can be defined as social interactions in the work environment and includes
support received from colleagues and the frequency of conflicts with others
(Maslach & Leiter, 2008). People who report receiving inadequate support
from colleagues are involved in a higher number of conflicts and are more
likely to experience burnout (Jawahar, Stone, & Kisamore, 2007). Unfairness
in the workplace is also likely to lead to feelings of burnout (Maslach & Leiter,
2008). Personal characteristics include age, gender, and marital status, but
the literature shows mixed results regarding their accuracy in predicting
burnout.
Consequences of Burnout
Burnout affects people in both their professional and personal lives.
Maslach and Leiter (1997) proposed that an individual’s experience of
burnout can affect the workplace environment by “being associated with
negative reactions, low levels of satisfaction with the organization, low levels
of professional implication, high levels of absenteeism, and the intention to
leave or change the job” (p. 56). Ahola (2007) reported that burnout may
cause different types of mental and physical disorders. The most common
physical ailments include headaches, muscular pain, gastrointestinal
problems, hyperventilation, chronic fatigue, sexual problems, sleep
disorders, and cardiovascular disorders. In terms of emotional effects,
burnout was found to be linked with symptoms of depression and sleep
disorders (Vlăduţ & Kállay, 2010). Also, people who experience burnout
are more at risk for substance and alcohol abuse (Turnipseed, 1998).
Treatment of Burnout
Interventions to alleviate or reduce burnout can take place at both
individual and organizational levels. The majority of individual interventions
have focused on helping those affected cope with the workplace. The main
goal is to alleviate burnout (Maslach et al., 2001). However, Vlăduţ and Kállay
(2010) believed that changing an individual’s behaviour is not sufficient in
reducing the severity of burnout, as this alone does not ensure improvement
of the workplace environment. According to Maslach et al. (2001), studies
have shown that a focus on the workplace environment is essential for
burnout interventions, and these interventions consist of both managerial
interventions, which concentrate on changing areas of work life, and
individual interventions, which center around changing individual skills and
attitudes. Furthermore, they concluded that the most effective change occurs
when both of these areas are integrated.
Burnout among Music Therapists
Over the past 30 years, there have been a handful of studies examining
burnout among music therapists. The majority of these studies have been
completed using quantitative methods, with the exception of one qualitative
study. Oppenheim (1987) was one of the first researchers to study burnout
among music therapists in the United States, correlating data collected from
questionnaires that measured levels of burnout using the Maslach Burnout
Inventory (MBI). All respondents (N = 239) had moderate scores on five
out of six MBI subscales, and a correlation between longevity and degree
of burnout was also found—out of the 68 respondents who had worked
in the profession for at least five years, 29 respondents had a moderate to
high degree of burnout on at least one MBI subscale. Fowler (2006) did a
similar study on the connections between attitudes, work environment,
and the well-being of music therapists but, unlike Oppenheim, found that
participants who had more work experience had a low degree of burnout.
It appears that “music therapists who have either learned or have the innate
tendency to use positive coping strategies and preventive health measures
have the potential to sustain a long and satisfying career in music therapy”
(Fowler, 2006, p. 191). This is consistent with the results of Kim (2012), who
examined Korean music therapists’ job satisfaction, collective self-esteem,
and burnout. This study found that the older and higher-paid participants
had lower symptoms of burnout on the personal achievement subscale.
A study by Vega (2010) looked at possible relationships between
personality and the degree of burnout among music therapists in the United
States. Replies on questionnaires were analyzed using the Sixteen Personality
Factor Questionnaire (16PF) and the MBI. In this study, 11% of respondents
had a high degree of burnout (Vega, 2010). Most of the participants had an
average level of burnout, which is consistent with the findings of Oppenheim
(1987) and Kim (2012). Vega (2010) also found that the 14 personality
factors together were predictive of scores on the three subscales of burnout,
with anxiety being significantly predictive of emotional exhaustion.
Hills, Norman, and Forster (2000) examined burnout among British music
therapists in relation to multidisciplinary team membership. They compared
the MBI scores of music therapists working as members of multidisciplinary
teams with the scores of music therapists who worked independently. Their
results were consistent with those of Oppenheim (1987), Vega (2010), and
Kim (2012), as music therapists in their study also had an average degree
of burnout. However, there was a statistically significant difference on the
MBI subscale for personal accomplishment between music therapists who
were team members and those who were not. Participants who were part
of a multidisciplinary team scored higher on the personal accomplishment
subscale compared to those who worked independently (Hills et al., 2000).
This is similar to Kim’s (2012) finding that collective self-esteem plays a role
in reducing symptoms of burnout. Music therapists who work in team-based
environments tend to have higher levels of collective self-esteem, which
Butler and Constantine defined as “individuals’ perception of themselves as
members of a social group and . . . the value and emotional significance of
membership in this group” (as cited in Kim, 2012, p. 66).
In addition to the quantitative research examining burnout among music
therapists, there has also been some qualitative research. Clements-Cortés
(2006) completed a qualitative study on occupational stressors among music
therapists working in palliative care. Four music therapists were interviewed,
and the data from their interviews were grouped into themes and subthemes. The main themes that emerged were (1) background information
and variables that may contribute to stresses experienced, (2) stressors,
(3) additional variables to consider when looking at stress, and (4) coping
mechanisms. Sources of stress for the four music therapists interviewed
included a lack of understanding by other team members, ongoing issues
of loss, lack of appropriate space for music therapy sessions, feelings of
helplessness, juggling multiple roles, and not feeling appreciated. However,
they appeared to be coping well with their stressors and not suffering from
burnout.
The study by Clements-Cortés (2006) examined occupational stressors,
not burnout, and it focused on music therapists working in palliative care.
There is a need to investigate the lived experience of burnout among music
therapists, as there have mostly been quantitative studies on the topic.
A qualitative methodology allows for a deeper understanding of one’s
experience, as it provides participants with the opportunity to answer
specific questions. Information emerging from interviews has the potential
to educate music therapists about burnout and to suggest coping methods
should burnout occur. As a result, the following research questions were
created:
•
•
•
•
How do music therapists describe their experience of being burnt
out and the methods used to resolve this?
What is the experience of becoming and being burnt out for music
therapists?
What would the music therapists do differently to avoid burnout?
How can music therapists prevent burnout?
Methodology
The qualitative methodology of phenomenology was chosen to
answer the research questions. Forinash and Grocke (2005) stated that
phenomenology examines the human experience of being in the world.
Phenomenologists may study the lived experience of emotions, existential
concepts, and any other human experiences. Using this methodological
framework, data can be collected from a variety of sources, including selfreflections by participants, interviews conducted by the researcher(s),
writings on the subject, and “depictions of the topic in question as expressed
in works of art, in dance, or in poetry” (Polkinghorne, as cited in Forinash
& Grocke, 2005, p. 323). Information gathered from these sources is then
compiled and analyzed by the researcher(s) to provide a whole picture of the
lived experience of the phenomenon (Patton, 2002).
Participants
Participants were recruited via an email invitation distributed through
the Canadian Association for Music Therapy membership list in April 2011.
The invitation to participate was sent out in both English and French and
included a description of the criteria to qualify for participation in the study.
To be eligible to participate, music therapists (either former or current) had
experienced burnout during their practice as a music therapist and had since
resolved their symptoms of burnout. Prior to the invitation being sent out,
this study was approved by the research and ethics committee of Concordia
University’s Department of Creative Arts Therapies. There were 10 responses
to the email invitation, but three respondents failed to reply to subsequent
emails and were rejected from the study; therefore, seven respondents were
interviewed after giving informed consent. As one of these respondents
indicated in the interview that she had experienced burnout while working
in another field, not music therapy, she was also eliminated from the study.
All six of the remaining participants were working as music therapists in
Canada at the time of the study. The participants consisted of five women
and one man. Their years of experience in the field ranged from 1 to more
than 15. Client populations worked with varied among the participants, and
these included long-term care, children and adults with special needs, mental
health, and palliative care. Two participants worked on contract, two worked
as employees of institutions, one participant worked both on contract and as
an employee, and the remaining participant did not specify.
Design
The research design consisted of one qualitative interview with each
participant. Interviews were conducted using Skype, VOIP (online telephone),
or in the case of one interview, in person. Interviews were recorded using call
recorder software for Skype and VOIP and a digital recording device for the
in-person interview. The length of the interviews greatly varied, ranging from
35 to 58 minutes. Interviews were semi-structured, meaning that a list of
questions was generated before the interviews took place. Each participant
was asked the same list of 14 questions (see Appendix A); however, the order
of questions varied depending on the responses given by the participant.
Data Analysis
All interviews were transcribed, and the transcripts were reviewed
several times using Neuman’s (1997) three-phase approach to coding
qualitative data. The first phase, open coding, involved locating and assigning
labels to themes found within the transcripts and then listing those themes.
During the second phase, axial coding, the list of initial themes was closely
reviewed and examined, allowing for key concepts to be identified. In the
final phase, selective coding, the data and themes were scanned again, this
time looking specifically for moments in the transcripts that highlighted
established themes. The preliminary list of themes and sub-themes was
sent using email to all six participants for their input as a form of “memberchecking” (Lincoln & Guba, 1985). Participants were given time to review
the list and were invited to share any feedback they might have. Once all
six participants had responded to the email, some of the sub-themes were
regrouped based on the feedback received and then the list was finalized.
Results
All six participants reported that during their music therapy education
process, there was little or no mention of burnout. If the topic was discussed
during training, the focus was on prevention methods—that is, self-care was
addressed. There was little information given regarding the actual symptoms
of burnout or how to recognize them should they occur.
During the process of data collection and analysis, it became apparent
that while there were factors in general that led to burnout, music therapists
working in private practice experienced a specific group of factors that may
lead to burnout.
General Factors Leading to Burnout
Lack of self-awareness. All participants reported a lack of selfawareness. During the time that burnout occurred, participants were not
paying attention to how their music therapy work was affecting them on
emotional, spiritual, and mental levels. Some participants also stated that
they did not take time after each session to reflect on what had occurred
during the session; this included reflecting on any feelings of transference
and countertransference that may have come up. Participants also spoke
about not taking time to analyze material that had emerged in sessions. They
did not differentiate between material that was brought up by clients versus
the material that belonged to the therapist. One participant spoke at length
about not paying attention to warning signs that had manifested, such as
bitterness towards her job, discomfort at work, feelings of frustration, and a
sense of not being heard.
Others not understanding music therapy or the role of a music
therapist. Most music therapists are asked on a daily basis, “What is music
therapy?” As music therapy is still a relatively young profession, music
therapists must act as advocates, both for themselves and for the profession.
Over time, this can lead to feelings of frustration and may eventually lead
to feelings of burnout. Members of the interdisciplinary treatment team,
family members of clients, and even clients themselves need to be regularly
educated about music therapy and its benefits in order to ensure that the
discipline is being properly understood.
Amount of training to become a music therapist. Substantial training
is required to become a music therapist. Music therapists need to be trained
musicians before even entering the therapy training process. One participant
spoke at length about how the training process of becoming a music therapist
started the process of becoming burnt out. The school caseload was heavy, in
terms of both practicums and courses. This participant found it difficult to
balance the demands of schoolwork and tasks related to practicums such as
session preparation and documentation. Another participant echoed similar
sentiments. She felt that the long training process, including the internship,
was the reason for her experiencing burnout:
I considered leaving music therapy within the first couple of years of
working. I thought about whether or not I should keep doing this. But
because I spent so long getting my degree and working for it, I felt, “I
can’t really stop now.”
Multiple demands on music therapists in a facility. If a music
therapist has established a contract with a facility, they are typically there for
only 4 to 8 hours a week. As a result, there is a limited amount of work that
they can accomplish during this short period of time. Music therapists are
often asked to see an unrealistic number of clients during their time at the
facility in addition to preparing for and documenting sessions. There is even
less time for reflection after each session. One participant strongly felt that
a heavy caseload was a large factor in her experience of burnout. There was
not enough time for her to complete all the tasks that were expected of her,
and she felt she was being stretched too thin.
Factors Specific to Contract Work
Lack of benefits. According to the participants who worked on contract,
working without benefits is a huge stressor. These music therapists do not
receive the benefits that full-time employees typically receive, including sick
days and pension plans. If self-employed music therapists do not work, they
are not paid for the days of work that they miss. This also applies to vacation
days or taking time off for personal reasons. One participant mentioned how
the lack of a steady paycheque is a contributor to burnout. Contractors, unlike
employees at institutions who are paid on a bi-monthly basis, are often paid
in lump sums on a monthly basis after services have been provided, and these
cheques can arrive at random times,.
Feeling separate from the interdisciplinary team. Feeling separate
from other members of the interdisciplinary team can be a common
experience for music therapists working in private practice. Since they are
typically at the facility for only a few hours per week, it is difficult to develop
positive working relationships with colleagues. One participant stated that
she did not always feel like she was respected in facilities as a contractor.
Another participant stated that she always felt like an outsider. Additionally,
there are shared experiences that employed individuals at facilities have
the opportunity to experience such as staff appreciation days or staff
informational seminars. Contractors, including music therapists, are not
always on-site when these events occur, which may lead to further feelings
of isolation:
We’re not always part of a multidisciplinary team or we’re
misunderstood, as professionals, and I think that is something that can
also really weigh on me, weigh on our profession.
Symptoms of Burnout
The symptoms experienced by the participants can be grouped into
three categories: physical symptoms, psychological symptoms, and emotional
symptoms.
Physical symptoms. All of the participants experienced physical
symptoms of burnout, including insomnia, lack of energy, and physical
injuries. Insomnia was caused mostly by an inability to stop thinking about
work, leading to difficulty falling asleep at night. Some participants shared
that their lack of energy was due to putting a lot of effort and time into the
workplace, causing them to feel exhausted by the end of the workday. Physical
injuries were caused by the repetitive motion of playing music instruments
and not taking steps for injury prevention, such as taking time to warm up,
using proper technique, and listening to the body’s warning signs.
Psychological symptoms. One participant said that as a result of being
emotionally exhausted, she suffered from a lack of emotional reserves when
working with clients. She was unable to deeply explore emotional material
with them. This meant keeping sessions within specific boundaries even if
the client had a desire to further delve into their emotions. Other participants
reported an inability to provide adequate emotional support for clients. One
participant went on to describe how she was unable to hide emotions:
I would be so emotionally exhausted that I’d be working with somebody
who was singing about a trauma that they had, and tears would start
to come to my eyes. My emotions were just so bare that I didn’t have
any boundaries left or feeling to deal with them and keep processing.
I would just feel what they were feeling and want to cry, you know?
Several participants indicated that burnout resulted in experiencing
poor overall quality of life. One participant described feeling irritable, having
difficulty concentrating on both work-related and non-work-related tasks,
and being emotionally sensitive. She found that burnout gradually overtook
her entire life and became the focus of everything. She stated that burnout
was a slow and insidious experience, building over time until it became too
much to handle. This participant also said that she did not pay attention to
the warning signs, which added to poor quality of life. She felt trapped by
burnout and also felt hopeless and helpless. She did not know how to get
through each day or where to turn for help. Another participant stated that
she felt overwhelmed by everything and had no free time to herself. When
free time did present itself, she did not know what to do and felt overwhelmed
by that as well. A third participant said that she felt a lack of control over her
burnout and felt as though there was nothing to be done about the situation.
Emotional symptoms. One participant described her feelings of
shame. She was afraid that if she admitted she was going through burnout,
she would lose her job. This also made it difficult for her to seek help and
advice. As a result, she did not openly discuss the symptoms of burnout or tell
supervisors and colleagues what she was experiencing. Another participant
expressed similar sentiments. She could not understand why it was so
difficult to handle her caseload while her colleagues were able to do so. As
two music therapists related, this resulted in feelings of inadequacy:
I’ve always felt ashamed to label myself as burned out. Because music
therapy jobs are so few and far between, I felt if I divulged to one of my
colleagues that I’m burned out, I would feel somebody nipping at my
heels for my job.
Well, I think when you’re burnt out, you feel like you shouldn’t be burnt
out and that you should be able to handle it. It used to be easy; why is
this so difficult now? Other people are handling their caseload.
All participants stated that their feelings towards work had changed.
Prior to experiencing burnout, they had enjoyed working as music therapists.
In addition to this loss of enjoyment of work, they also had a lack of motivation
and passion. One participant described how she became resistant towards
work, did not want to be there, and preferred to be other places. Another
participant said that she had to fake enjoyment and enthusiasm while at
work because in reality she felt the opposite way.
Resolution of Burnout
Participants used a variety of methods to resolve their experiences
of burnout. Some reported seeking help from health care professionals.
Others were able to implement changes at work themselves, which had an
immediate effect on their feelings of burnout. Self-awareness played a role
in some participants’ recovery from burnout, as they were able to recognize
that they needed time away from the job in order to recover.
Taking better care of the self. All participants spoke about the
importance of self-awareness and taking better care of the self. They were
engaged in a continuous monitoring of self and realized that they must
do this for the remainder of their careers. One participant highlighted
acknowledging one’s needs and being assertive about having those needs
met. All participants were also strong advocates for self-care. They stated
that it is crucial for music therapists to balance the physiological, emotional,
and spiritual parts of the self. One participant believed that health care
professionals need to take care of themselves on the same level as they care
for their clients. This was echoed by another participant who said that music
therapists cannot take care of others if they do not take care of themselves.
This included looking after physical needs—such as sleep, proper nutrition,
and exercise—in addition to spiritual and emotional needs. Other participants
reported on engaging in self-reflection. This consisted of processing time
after client sessions, learning to be more aware of feelings of transference
and countertransference, and self-evaluation activities:
How vitally important it is for us as health care professionals to take
care of ourselves on the same level as our clients because, you know,
we really need to be whole and healthy first before we can start to be
there for others.
Seeking professional help. Two participants sought out verbal
counselling to help deal with their symptoms of burnout as they found
it helpful to speak about what they were experiencing. Other participants
found that therapies that involved the mind-body-spirit connection were
more helpful in aiding in their recovery. These included guided imagery and
music, naturopathy, massage therapy, and music therapy.
Making changes at work. One participant made changes when creating
contracts to ensure that all her work considerations were being met. This
included time for reflection during work hours, seeing fewer clients, and
having adequate time to complete session preparation and documentation.
Another participant noted that some aspects of her burnout could be
addressed at work by confronting politics, changing work schedules, and
decreasing the caseload. A third participant said that experiencing burnout
inspired a career decision around selecting the client population that she
truly wanted to work with.
Leaving the job/taking time off. Three participants spoke about the
decision to take time off work in order to recover from burnout. For one
participant, recovering from burnout was a long process, and the time off
work helped greatly in the recovery process. All participants used the time
away from work to rest, heal, and recover, and one participant still partakes
in short breaks from work, allowing her to return with a fresher perspective.
A fourth participant left her job completely and made the decision to return
to school.
Music. Participants were divided when it came to using music in the
resolution of burnout. It was either that music played an important role in
the recovery or that an absence of music was required during the resolution.
Two participants stated that music was very important during their recovery.
One engaged in music for herself—both making music and listening
receptively—and considered this outlet for creativity an important part of
healing. Another listened to music that she used in sessions with clients,
giving her the opportunity to process her own reactions to the music and
helping her develop deeper self-awareness.
Two other participants could not tolerate listening to music after working
hours. One said that music was too evocative for her while experiencing
burnout. The second said that she realized she was no longer burnt out when
she was able to enjoy listening to music again during her free time:
Sometimes playing music for myself was important. Sometimes I
couldn’t give it to myself; I needed someone else to give it to me.
I found it really hard to be engaged in music for myself. One of the first
things to go is my own music.
Discussion
The factors of burnout emerging from this study are similar to findings
in the literature. Several participants reported that a heavy caseload led
to burnout, which has been reported in studies by Schaufeli and Enzmann
(1998) and Vlăduţ and Kállay (2010). Many participants also reported being
asked to complete tasks that were not part of their job description, causing
them to feel as though they were lacking autonomy at work. This lack of
control can lead to feelings of emotional exhaustion (Cordes & Dougherty,
1993). The participants who worked on contract expressed receiving
less professional and emotional support compared to other health care
professionals at facilities where they worked. The lack of community led
to feelings of burnout, similar to findings by Jawahar, Stone, and Kisamore
(2007).
Participants experienced consequences of burnout that are consistent
with the literature. Some expressed a desire to leave the field, and others
reported a high level of absence from work, comparable to results found by
Maslach and Leiter (1997). In terms of personal consequences of burnout,
similar to Ahola’s results (2007), several participants experienced physical
ailments, such as headaches and chronic fatigue. Participants also had
symptoms of depression, comparable to the findings of Vlăduţ and Kállay
(2010).
To resolve their feelings of burnout, participants in this study made
changes at both the individual and organizational levels. Maslach et al.
(2001) stated that the most effective change occurs when both of these areas
are integrated. All participants in Maslach’s study stressed the importance of
self-awareness. They also took part in self-reflection and self-care activities.
Some participants in the current study engaged in these activities and also
made changes at work, such as working fewer hours and decreasing the sizes
of their caseloads.
The results from the present study did not support any connection
between career longevity and degree of burnout. While Oppenheim (1987)
found that participants in her study who had worked as music therapists for
at least five years had a moderate to high degree of burnout, Fowler (2006)
found that music therapists with more work experience had a low degree of
burnout. The participants in this study varied in their years of experience in
the field and there did not appear to be a relationship between number of
years of experience and incidence of burnout.
Four participants in this study stated that they worked either on
contract or as employees of institutions. One participant stated that she
worked both as an employee and on contract. The remaining participant did
not specify. The data from this study did not find any difference in feelings
of personal accomplishment, which is inconsistent with Hills et al. (2000),
who found that participants who were part of an interdisciplinary team had
higher levels on the personal accomplishment subscale compared to those
who worked in private practice or on contract.
Occupational stressors emerging from this study are somewhat similar
to findings from Clements-Cortés (2006). Participants from her study
reported that a lack of understanding by other team members and feeling
helpless were sources of stress. Participants in the current study described
similar feelings of helplessness, particularly when it came to finding ways
of resolving their symptoms of burnout. They also depicted a lack of
understanding from co-workers about the discipline of music therapy and
the role of a music therapist in a health care setting.
Need for Training and Education
There is a definite need for music therapy educators to provide
information about self-care and burnout to students. Most participants
commented how these subjects were not discussed during their education.
They did not feel equipped to deal with their symptoms of burnout, and some
participants also stated that they did not recognize the symptoms of burnout
when they appeared.
If more attention were placed on burnout and self-care during music
therapy training, future music therapists might know how to better respond
to burnout. Simply telling music therapy students and interns that burnout
exists is insufficient prevention. They need to be provided with a proper
definition of burnout, its symptoms and causes, and how to deal with
symptoms should they occur. One participant suggested that if internship
supervisors were educated about burnout, they would be able to recognize
symptoms in their interns and provide adequate support. Additionally,
more time needs to be devoted to self-care during music therapy education,
including the internship. Self-care is different for everyone. Some people see
self-care as participating in activities that are enjoyable for them. Others
equate self-care with taking care of the entire body, which includes caring
for the emotional and physical components of the self. Students and interns
should be asked to engage in self-reflection during the training process
in order to determine what their definition of self-care is. Although it is
individual, self-care must be integrated into one’s work.
It may also help to have supports and resources in place for music
therapists when they experience feelings of burnout. Several participants
stated that they felt alone and helpless and did not know where to seek help.
Kim (2012) proposed that “music therapy organizations should provide
supervision opportunities to their members” (p. 70). This would allow
music therapists to receive support, to increase their collective self-esteem,
and to feel less isolated. For music therapists living in rural communities,
online communication methods such as Skype may be used for supervision
purposes.
Balance Between Professional and Personal
The experience of burnout allowed several participants to realize that
a balance is required between professional life and personal life in order
to prevent burnout. We cannot spend all of our time and energy on work
and ignore family responsibilities, or the other way around. Additionally,
participating in hobbies is an important part of self-care, which also plays
a role in preventing burnout. One participant believed in distinguishing
between the musician self and the music therapist self. The musician self
may be involved in music-related pursuits that focus on the self and others,
whereas the role of the music therapist is based solely on the needs of clients.
Understanding these two different aspects of the self may aid in developing
an increased sense of self-awareness.
The Stressors of Contract Work
Based on descriptions provided by the participants who worked on
contract, it appears that self-employed music therapists have a different
set of warning signs to look out for. Working as a contractor can be very
stressful. The participants stated that commuting between facilities, the
lack of benefits, and a heavy caseload created a stressful work life and
environment. While travelling from facility to facility, it is easy to feel rushed
and pressured, especially if traffic is heavy or if there is inclement weather.
Several participants spoke about how the lack of benefits is a large source of
stress. They are hesitant to take sick days, as they are not paid for hours not
worked. Participants described a dilemma of choosing between taking time
off work due to illness or personal reasons or continuing to work. Ironically,
one participant said a big dilemma for her was deciding either to take an
absence from work to recover from burnout, or to continue to work because
there would be no income if she took time off from work. Another participant
stated that music therapists would be largely healthier as a profession if
contract jobs had more benefits. This is a difficult situation to resolve, as
many music therapy jobs are contract positions. However, increased selfawareness and reflection will help self-employed music therapists recognize
the symptoms of burnout earlier and take steps to resolve them.
Burnout Can Be a Positive Experience
While burnout is typically viewed as a negative experience, participants
surprisingly stated that this does not necessarily have to be the case. They
shared that experiencing burnout allowed them to implement changes
in their lives with positive effects. Due to her experience of burnout, one
participant realized that she was unhappy working with a certain clientele.
This realization led her to begin working with a new client population that she
is truly passionate about. Another participant reported that her experience
of burnout provided her with an opportunity to learn more about herself. For
example, she became involved with activities that filled a void she did not notice
before. In today’s society, people may view burnout as something to avoid,
but it can be an opportunity to create change in one’s life, often for the better.
Research Recommendations
One of the main limitations of this study was the small sample size. As
of November 2014, there are more than 700 accredited music therapists in
Canada (Canadian Association for Music Therapy, 2014), and it is impossible
to generalize the experiences of the six participants to all music therapists
working in Canada. A future quantitative study looking at the incidence,
factors, symptoms, and resolution of burnout would be useful. Depending on
the sample size, the results may provide a better picture of burnout among
music therapists in Canada.
Another limitation of this study was that it excluded music therapists
no longer in the profession. The invitation to participate asked current
Canadian Association for Music Therapy members to consider forwarding
the invitation to former colleagues who had left music therapy, but there
were no responses from former music therapists. As Vega (2010) pointed
out, it is difficult, if not impossible, to contact former music therapists who
are no longer members of professional organizations. She suggested that a
way around this problem is to contact music therapists who have considered
leaving the profession, or who are currently leaving the field. This could be a
research focus in future studies examining burnout.
A third limitation is that this study excluded music therapists who had
not fully resolved their feelings of burnout, including those still working in
the profession as well as those who left to pursue other lines of work. The
main purpose of this study was to look at the complete experience of burnout,
which is why participants needed to have recovered from their symptoms. A
future study that focuses solely on burnout symptoms or factors leading to
burnout could include this group of people.
One final recommendation is for further research involving greater
numbers of participants by recruiting music therapists from other countries.
Not only would this give more validity to the study, but it would allow for a
comparison of experiences of burnout among different countries to see what
the similarities and differences are. It could also reveal cultural differences
in the perception of burnout as well as helping to determine which factors of
burnout are specifically related to the profession of music therapy.
Conclusion
Music therapy, as with other health care professions, has its own set of
challenges that can lead to burnout. These challenges may result in music
therapists becoming emotionally exhausted and losing the capacity to care
about their clients. They may find themselves lacking the emotional reserves
to be sincerely concerned about the well-being of their clients, which may lead
to a lack of motivation and concern in providing quality care. Music therapists
can also develop cynical feelings towards their clients, which could take the
form of blaming clients for their problems, viewing their clients as objects
rather than people, and seeing clients as lesser beings. Reduced personal
accomplishment can affect music therapists in several ways. They may view
their work as inconsequential and unimportant and may be unable to receive
praise and compliments from co-workers, colleagues, and family members
of clients. Additionally, music therapists may not adequately judge progress
in their clients over time due to an inability to see the accomplishments and
goals that have been achieved over the duration of the treatment period.
When music therapists find themselves in the midst of burnout, they
may be unsure of how to proceed, where to turn for support, or how the
symptoms may be resolved. Admitting that they are experiencing symptoms
is just the beginning of the journey. Following this crucial step, a music
therapist has to identify the factors that are causing the feelings of burnout,
as it is only by identifying these factors that he or she can begin the process
of resolving feelings of burnout. As stated by the participants, the resolution
of burnout can take many different paths. Self-awareness is the core of the
recovery process. A music therapist must figure out what methods work for
him or her as they are different for everybody. Additionally, it is important
to remember that burnout does not necessarily have to result in negative
consequences. It may lead people to work with a different client population,
discover new hobbies, or partake in more self-care activities. Experiencing
burnout may provide an opportunity for positive growth and change, leading
one to become a more passionate, knowledgeable, and effective music
therapist.
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Appendix A: Interview Questions for Participants
1.
2.
3.
4.
5.
6.
7.
8.
9.
What is your current occupation? Can you tell me a little about your
current work?
When were you a music therapist? What client population do/did you
work with? Where do/did you work? How long did you work as a music
therapist?
When and how were you introduced to the concept of burnout?
If you were speaking to someone who was not familiar with burnout,
how would you describe burnout to him or her?
During your music therapy education, what were your feelings about the
importance of being educated about burnout? What further steps, if any,
did you take to learn more about burnout?
What are your thoughts about the importance of self-care?
Some music therapists feel that burnout is a private matter; while others
believe it is a topic that needs to be discussed more openly. What are
your beliefs about that?
You have identified yourself as a music therapist who has experienced
burnout. When did you realize you were afflicted with burnout? What
symptoms did you experience? How did you feel?
What do you consider to be the factors that led to your experiencing
burnout?
10. Did the symptoms of burnout impact your work? Your personal life? If
so, how?
11. Could you describe the process you undertook to overcome the symptoms
of burnout?
12. For some music therapists, engaging in some type of creative arts process
helps in the burnout recovery process. Some people create artwork,
while others turn to music. How about you? Do you have any examples
that you would be willing to share?
13. Suppose I was a music therapist experiencing burnout. What advice
would you give me?
14. That is it for my questions. Is there anything you would you like to add?
Emotion Without Words: A Comparison Study of Music and
Speech Prosody
L’émotion sans mots : Une étude comparative de la
prosodie musicale et de prosodie de la parole
Sarah Faber, BMT(Hons), MA, MTA
Research Assistant, Anglia Ruskin University, United Kingdom
Anna Fiveash, BPsy (Hons), MA
Doctoral Student, Macquarie University, Australia
Abstract
Music and language are two human behaviours that are linked through their
innateness, universality, and complexity. Recent research has investigated
the communicative similarities between music and language and has
found syntactic, semantic, and emotional dimensions in both. Emotional
communication is thought to be related to the prosody of language and the
dynamics of music. The purpose of this study was to investigate whether
language’s prosody can successfully communicate a phrase’s emotional
intent with the lexical elements of speech removed, and whether the results
are comparable with a musical phrase of the same perceived emotion.
Eighty-five participants ranked a selection of emotional music and prosodic
vocalizations on scales of happy and sad. Results showed consistency and
correctness in the emotional rankings; however, there was higher variance
and lower intensity in the speech examples across all participants and
more consistency in music examples among musicians compared to nonmusicians. This study suggests that speech prosody can communicate a
phrase’s emotional content without lexical elements and that the results are
comparable, though less intense, than the same emotion conveyed by music.
This study has implications for the field of music therapy through support for
the accurate identification of emotional information in non-verbal stimuli.
Keywords: music therapy, prosody, emotion, language, music,
semantics, dynamics
Résumé
La musique et le langage sont deux comportements humains liés par leur
complexité et leur universalité innée. La recherche récente a examiné les
similarités se rapportant à la communication entre la musique et le langage et
des dimensions syntaxiques, sémantiques et affectives ont été décelées dans
les deux cas. Il est usuel de penser que la communication affective est reliée
à la prosodie de la parole ainsi qu’aux dynamiques musicales. Le but de cette
étude est d’examiner si la prosodie de la parole peut réussir à communiquer
une phrase contenant une intention affective sans les éléments lexicaux de la
parole et si les résultats sont comparables à une phrase musicale contenant
la perception de la même dimension émotive. Quatre-vingt-cinq participants
ont classé une sélection de musique émotionnelle et des vocalisations
prosodiques sur des échelles allant de « heureux » à « triste ». Les résultats
montrent de la cohérence et de l’exactitude dans les catégories d’émotions;
cependant il y a de plus grands écarts et une intensité plus faible dans les
exemples parlés parmi tous les participants et plus de cohérence dans les
exemples musicaux parmi les musiciens comparés aux non-musiciens. Cette
étude suggère que la prosodie de la parole peut communiquer le contenu
émotionnel d’une phrase sans éléments lexicaux et que les résultats sont
comparables, toutefois moins intenses que la même émotion transmise par la
musique. Cette étude a des implications pour le domaine de la musicothérapie
et ce par l’entremise de l’identification exacte de l’information affective
transmise, dans un stimulus non verbal.
Mots clés : musicothérapie, prosodie, émotion, langage, musique,
sémantique, dynamiques
Strong connections have been identified between music and language,
especially in relation to evolutionary background (Perlovsky, 2012), brain
connectivity (Koelsch, Gunter, Wittfoth, & Sammler, 2005), and skill transfer
(Besson, Chobert, & Marie, 2011). Some evolutionary theorists have suggested
the connection between music and language is in their communicative uses
(Cross, 2009; Juslin & Laukka, 2003), and a common communicative use
is emotional communication. It has been further suggested that language
is a more advanced form of emotional communication derived from music
(Mithen, 2009) and that both music and language derive from a pre-linguistic
system, which shared elements of music and language for communicative
purposes (Masataka, 2009). Such theoretical ideas combined with empirical
research on the topic (e.g., Johnansson, 2008; Levitin & Menon, 2003; Patel,
2008) show there are many shared similarities between music and language
in terms of emotional communication. As emotional expression is considered
paramount in communicating internal feelings and actions to others
(Scherer, 1995), and both music and language have been shown to effectively
communicate emotions (Steinbeis & Koelsch, 2008), it is useful to compare
the similarities and differences in how emotion is communicated through
both music and language. These connections will be explored throughout the
literature review.
Literature Review
Emotional Communication in Language and Music
Emotional communication in language and music is thought to be
related to the prosody of language (Pell, 2006), the dynamics of music (Van
der Zwaag, Westerlink, & Van den Broek, 2011), and how they effectively
convey meaning and emotion. Prosody in language is defined by intonation,
loudness, and tempo (Mitchell, Elliott, Barry, Cruttenden, & Woodruff, 2003)
and can be independent of the lexical elements of speech, defined as the word
and word-like elements of language (Friederici, Meyer, & von Cramon, 2000).
The combination of semantic content and different combinations of prosodic
elements lead to emotional communication. The dynamic aspects of music,
which help to express emotion, are said to include but are not limited to
tempo, mode, harmony, tonality, pitch, rhythm, tension–resolution patterns,
and timing (Thompson, 2009). Different combinations of prosodic or dynamic
information display differences in the type of emotion communicated both
in music and in language. Interestingly, neuroimaging studies have shown a
primary emotion pathway activated in response to both musical and spoken
emotional content as well as distinct networks activating different areas of
the right hemisphere of the brain (Steinbeis & Koelsch, 2008). Music and
language also share processing pathways, and the processing of music and
language interact and affect each other in the brain (Fiveash & Pammer,
2014). The ability of both speech and music to communicate emotions has
been widely researched, and a growing body of evidence is pointing towards
strong connections between music and language, particularly in relation to
their respective emotional communication abilities.
Communicative Connections Between Music and Language
The extent of the connection between music and speech emotions can
be seen when looking at neuropsychological cases where impairment in one
domain affects performance in the other. While there are many processing
differences between music and speech (Zatorre & Baum, 2012; Zatorre, Belin,
& Penhune, 2002), there are also many similarities. For example, Nicholson,
Baum, Kilgour, Koh, Munhall, and Cuddy (2003) studied an amusic patient
who, following a right hemisphere stroke, was unable to detect differences
in music pitch and rhythm or recognize different melodies. After numerous
tests they found that the patient’s pitch and rhythm recognition in speech
was similarly affected. He was unable to process intonation or discriminate
a question from a statement. He was, however, able to perceive speech in
other ways and carry on normally in most aspects of speaking life. Such a
phenomenon was also observed in two other amusic individuals, who
had similar issues with detecting intonation and rhythmic differences
across both speech and music stimuli (Patel, Peretz, Tramo, & Labreque,
1998). Such evidence from neuropsychology suggests elements of prosody
and musical dynamics are linked in the brain, and therefore theoretical
connections between musical dynamics and speech prosody are warranted.
Such connections have also been found in other areas of research.
Further links between speech prosody and musical dynamics support
the existence of a connection between emotional communication in music
and in speech. Patel, Iversen, and Rosenberg (2006) looked at the differences
in instrumental music in England and France compared to the respective
prosody of English and French languages. They found that the composed
music had a number of similarities to the respective languages and that
the music reflected differences in prosodic speech. Such research suggests
language and music are mutually influential and share similar evolutionary
roots. Bowling, Sundararajan, Han, and Purves (2012) suggested there are
universal underpinnings of emotional communication in music dynamics
and speech prosody. They compared Western and Eastern (South Indian)
music and found similarities in tones used to express basic emotions as well
as similarities in emotional prosody within the different languages. This led
to the conclusion that universal prosodic and musical utterances exist across
cultures. Such evidence outlines the evolutionary basis for the connection
between music and speech prosody in terms of emotive communication. This
can be seen more clearly when looking at transfer effects between music
training and emotional identification of speech prosody.
Musical Expertise and Emotional Identification in Speech
Correlations have also been found between musical expertise and a
higher ability to correctly identify emotional content in speech prosody (Lima
& Castro, 2011; Thompson, Schellenberg, & Husain, 2004). Such transfer
effects have been found in musically trained adults of different ages (Lima
& Castro, 2011; Thompson et al., 2004) as well as in children who have been
taking music lessons for only one year (Thompson et al., 2004), suggesting
cross-domain effects of practice between musical expertise and emotion
identification in speech. In addition to increased recognition of speech
prosody in unintelligible utterances, musicians have also been shown to
understand speech prosody in foreign languages better than non-musicians
(Thompson et al., 2004). Such transference has been linked to musicians’
greater sensitivity to pitch sounds through training, which in turn influences
pitch sensitivity in language (Schön, Magne, & Besson, 2004). Other theories
suggest musical training leads to enhanced emotional sensitivity and
emotional intelligence (Thompson, 2009), which facilitates a greater ability
to detect emotional expression in speech prosody (Trimmer & Cuddy, 2008).
Such transfer effects give strong support to the theory that music and speech
share similar emotional communication mechanisms, which has implications
in the practice of music therapy.
Music Therapy Implications
Therapeutically, the ability to convey and perceive emotions through
non-verbal means (whether through non-verbal utterances or instrumental
improvisation) is an incredibly important skill in working and communicating
with non-verbal, minimally verbal, and communicatively impaired clients
(Wigram, 2004). In practice, being aware of the emotive quality of vocal
and musical phrases allows clients and music therapists to communicate
emotions effectively without engaging in speech (Bruscia, 1998), which
may be difficult or impossible for some clients, as seen in those with stroke,
aphasia, and autism, for example. Awareness of emotional, behavioural, and
musical features can also aid the music therapist in empathic improvisation
(see Bruscia, 1987, for a description of Alvin’s methods) and in reacting to
the utterances of communicatively impaired clients. This influenced the
present study.
Purpose of the Study
The significant body of research suggesting connections between
musical dynamics and speech prosody in terms of emotional communication
led to the main research question of whether the same emotion can be
communicated through both music and speech prosody. When the lexical/
verbal elements of language are removed, the listener must rely on linguistic
prosody alone. Compared to the dynamics and melody within the music, it
was hypothesised that both music and speech prosody would convey similar
emotions. It was also hypothesized that musicians would be able to perceive
emotions in speech prosody better than non-musicians.
The proposed research questions aimed to investigate whether speech
prosody can accurately convey emotion, the extent to which the prosodic
speech ratings are comparable to ratings of emotional music, and the
differences in ratings between musicians and non-musicians.
Method
Participants
Eighty-five subjects with a mean age of 35.87 years (range = 15 to 72
years) participated in a survey comprising short audio clips of film music
and prosodic speech. Prior to beginning the survey, participants were asked
their age, native language (85% native English speakers), and other known
languages with self-reported level of fluency. They were then asked to rank
their musicianship using one of the following: non-musician (11%), musicloving non-musician (41%), amateur musician (26%), semi-professional
musician (16%), or professional musician (6%). Participants followed a
public link on a social media site to access the survey and could withdraw
from the study at any time. Participants remained anonymous (identifying
characteristics, such as names and addresses were not collected) and did not
receive financial compensation for completion of the survey. Ethical approval
was granted from the University of Jyväskylä, Finland, prior to data collection,
and participants gave written consent prior to participation.
Design
To test the hypothesis that participants would be able to identify
emotion at a similar level in both music and prosodic examples, six film music
excerpts (three happy and three sad) and six emotional speech excerpts
(three happy and three sad) were selected for the listening examples. The
musical excerpts were adapted from Eerola and Vouskoski’s (2011) study
on emotion in film music, and the emotional speech excerpts were adapted
from the Surrey Audio-Visual Expressed Emotion (SAVEE) database, which
contains recordings of voice actors reading lines of text in specific emotions
as rated by a test panel. Five of the music excerpts were reduced from full
score to a single midi instrument line using Finale NotePad software. The
sixth excerpt was a single-line piano melody that did not require further
reduction. Reductions retained the tempo, dynamics, solo instrumentation,
and articulation of the original pieces. The speech excerpts were re-recorded
by a voice actor deliberately muffling his voice to retain the prosody of the
phrases while obscuring their lexical elements. Excerpts were between
18 and 24 seconds long. The survey was designed using Qualtrics (www.
qualtrics.com) and was then distributed via social media networks.
Procedure
Participants were asked to rate each film music excerpt and each speech
excerpt on a Likert scale of emotional intensity ranging from 1 for not at all to
5 for very in response to the questions “How happy did the audio sound?” and
“How sad did the audio sound?” Each excerpt was rated for both happiness
and sadness. The music excerpts, besides the happy and sad ratings, had an
additional scale of 1 to 5 for familiarity. The excerpts were randomized and
participants were able to repeat them as needed. There was no time limit for
completion of the survey.
Results
To evaluate the happiness and sadness ratings of each condition (happy
music, happy vocals, sad music, sad vocals), the Likert scale ratings were
averaged and a final number for each condition was calculated. This resulted
in eight averaged responses.
A repeated measures one-way analysis of variance (ANOVA) was run to
see if there was a difference in responses between the eight groups. For coding
purposes, HM = happy music, HV = happy vocals, SM = sad music, and SV = sad
vocals. The results for the questions “How happy/sad did the audio sound?”
can be seen in Table 1, and are visualised in Figure 1. The ANOVA was run with
a Greenhouse Geisser correction as sphericity was not assumed. The result of
the ANOVA was significant, F(7,84) = 156.9, p < .001. A bivariate correlation
was run to see whether familiarity scores were correlated with music ratings.
A significant positive correlation was found between happiness ratings on
happy music and familiarity scores, r = 0.31, p < .01. All other correlations
between familiarity and music ratings were non-significant.
TABLE 1
Mean and Standard Deviation Scores Across Conditions
Condition
HM (Happy)
SM (Happy)
HM (Sad)
SM (Sad)
HV (Happy)
SV (Happy)
HV (Sad)
SV (Sad)
Mean
3.55
1.70
2.09
3.94
3.05
2.04
2.13
2.64
Standard Deviation
0.69
0.65
0.59
0.81
1.06
0.83
0.85
0.99
Note: HM = happy music; SM = sad music; HV = happy vocals; SV = sad vocals. The
conditions Happy and Sad refer to the ratings of the question, “How happy/sad did
the audio sound?”
Figure 1. Graph of emotion rating (where 1= not at all; 2 = not very; 3 = somewhat;
4 = quite; 5= very) for stimuli type (HM = happy music; HV = happy vocals; SM = sad
music; SV = sad vocals) to the question, “How happy/sad did the audio sound?” Error
bars indicate one standard error either side of the mean.
To determine which differences between groups were significant,
post hoc tests using the Bonferroni correction were conducted. For coding
purposes, (happy) or (sad) refers to the happiness or sadness ratings of the
questions, “How happy/sad did the audio sound?” Pairwise comparisons
were made between the means of HM (happy) and HV (happy), HM (sad) and
HV (sad), SM (happy) and SV (happy), SM (sad) and SV (sad), SV (happy) and
HV (happy), SV (sad) and HV (sad), SM (happy) and HM (happy), SM (sad)
and HM (sad). All comparisons showed significant differences (p = 0.00)
except for the comparison of HM (sad) and HV (sad), which was p = 1.00.
Musical Ability
To assess whether the results differed depending on musical ability,
participants were grouped into those who rated themselves as a non-musician
(non-musician or music-loving non-musician; n = 44) and those who rated
themselves as a musician (amateur musician, semi-professional musician,
or professional musician; n = 41). T-tests were run for the eight groups
compared above with a Bonferroni corrected alpha level of αi = α/n, making
the required significance level 0.05/8, = 0.006. Most comparisons remained
significant; however, for musicians the comparison between HM (happy) and
HV (happy) was non-significant: t(40) = 2.527, p = .02. For non-musicians,
the comparison between SM (happy) and SV (happy) was non-significant,
t(43) = 1.547, p = .13. Figures 2 and 3 graph the difference in responses
between the four levels of rated musicianship and illustrate that sad music
was rated as more sad than sad vocals, whereas the difference between happy
music and happy vocals was not as profound but still apparent.
Figure 2. Answers to the question, “How happy did the audio sound?” on a scale of 1
to 5, where 1= not at all and 5 = very, depending on whether the stimuli was happy
music (HM), happy vocals (HV), sad music (SM), or sad vocals (SV). Error bars
indicate one standard error either side of the mean.
Figure 3. Answers to the question, “How sad did the audio sound?” on a scale of 1 to 5,
where 1= not at all and 5 = very, depending on whether the stimuli was happy music
(HM), happy vocals (HV), sad music (SM), or sad vocals (SV). Error bars indicate one
standard error either side of the mean.
Discussion
This study investigated the perceived emotional content of melodic and
speech prosodic phrases. Participants were presented with six single-line
musical excerpts and six prosodic phrases, three happy and three sad, and
were instructed to rate the happiness and sadness of each stimulus.
The initial results showed significant differences in the ratings across
music and vocal stimuli. While it was hypothesised that the music and
prosodic samples would convey similar levels of emotion and the samples
with the same intended emotion would not have significantly different
ratings, this only occurred for the happiness ratings of the sad music and
sad vocal stimuli. All other comparisons were significantly different in the
overall analysis. However, while results were not completely as hypothesised,
participants were able to discriminate intended emotions in both the music
and vocal prosody examples (though at different levels), indicating that both
vocal prosody without the lexical/verbal elements and musical excerpts can
effectively communicate emotion to varying degrees.
Significant differences between ratings of music and prosody with the
same intended emotion may be due to the nature of the tasks: participants
were not screened prior to the experiment and were able to control the stimuli
in terms of repetition, volume, and the equipment used to play the samples.
When separated into musician and non-musician categories, the results were
non-significant for happiness ratings across happy stimuli in musicians,
indicating that happy music and happy prosody were communicating
happiness at a similar level for musicians. In relation to the hypothesis, this
could suggest that musicians were better able to discriminate happiness in
the prosodic excerpts, perhaps due to greater pitch training. Sadness ratings
across happy stimuli in non-musicians were also non-significant. While nonmusicians did not rate the intended emotion at similar levels, this result
shows that they were aware that the sad music and prosody examples were
not communicating happiness. This is encouraging in indicating that, across
all excerpts, happiness in both music and prosody was rated with little
variance, offering some support for the idea that music and prosody have
universally communicative potential (Bowling et al., 2012).
A notable difference was observed in the variance between the ratings
for music and prosody. Results indicated greater variance in the ratings for
vocal prosody compared to music, indicating a more consistent response to
music among participants. A possible reason for this could be the context
in which participants typically process musical and linguistic information.
Humans are generally exposed to music every day, whether intentionally,
as with consciously listening to a personal listening device or going to a
concert, or unintentionally, as with having a radio or television playing in the
background (North, Hargreaves, & Hargreaves, 2004). Music in everyday life
is strongly linked to emotional expression and perception (Juslin & Laukka,
2004), and this frequent exposure to music may prime us for perceiving
emotion during future exposure to different musical stimuli (Thompson,
2009).
Language, conversely, is most often coupled with lexical elements that
express, clearly, the speaker’s intentions (Cross et al., 2013). Past studies
have found that incongruously paired speech–voice stimuli results in delayed
identification of the meaning of the stimulus (Ishii, Reyes, & Kitayama, 2003;
Kitayama & Ishii, 2002) and that prosody can affect visual tracking patterns
(Rigoulot & Pell, 2012); however, little research exists on emotional accuracy
ratings of speech prosody alone. It can be argued that, when removed
from a secondary source of emotional cueing (such as lexical speech, facial
expression, or gesture), prosody may be more difficult to classify than music,
as indicated by the variance observed. It is also possible that the prosodic
excerpts in this experiment, which were specific to the English language,
could have been difficult to rank for the participants who were not native
English speakers (15% in this study), or were bi- or multilingual, as it has
been shown to be easier to understand the prosody inherent in a person’s
native language (Pell & Skorup, 2008). Further research on emotional
perception in speech prosody could be conducted to investigate the role of
visual information in emotional identification of prosody as well as crosscultural studies incorporating languages with differing prosodic patterns.
Another possibility to account for the variance between music and
prosody, as well as the intensity of the music ratings, may be found in the
structural elements of each stimulus. As per Mitchell et al. (2003), the
elements of linguistic prosody are intonation, loudness, and tempo, whereas
music also includes mode, pitch, tension, harmony, and other elements
(Thompson, 2009). Given the scope of music’s dynamic elements and the
relative frequency with which music is used to communicate emotion
without the benefit of visual or lexical partnering, it would seem music is
more emotionally robust than language when the latter is reduced purely
to prosody. Greater consistency in results may have been observed with a
greater number of excerpts as well.
An interesting pattern is in the consistency in ratings of sad stimuli. No
significant discrepancies existed between participants for the sad prosodic
and musical stimuli, possibly indicating more universal communicability in
sadness. Furthermore, ratings for sad music were rated as more sad than
happy music was rated happy despite a positive correlation with familiarity
for happiness ratings in the happy music condition. This contradicts past
findings on emotional ratings of music with and without lyrics (Ali &
Peynircioglu, 2006) and may suggest an emotional memory-based influence
on the happy ratings of the happy music stimuli. This may also be due to the
original context and cultural specificity of the music. Film music is composed
with the intent to augment the atmosphere of a specific scenario and may be
more successful at expressing sadness when reduced to a single-line melody.
Further research using musical feature analysis software could be employed
to investigate this occurrence, as well as controlling the familiarity of the
musical stimuli.
Implications for Music Therapy
The use and identification of emotional aspects of music and speech
are important in the delivery of music therapy, particularly with non-verbal
or communicatively impaired client populations. The ability to identify the
intended emotion in a non-verbal utterance or melody is a vital component in
a music therapist’s understanding of a client’s emotional state and music in
therapy. Similarly, being able to convey emotion allows the therapist to react
to, support, and communicate with that client. This study provides support
for the consistent accuracy in which individuals can correctly identify happy
and sad emotions in music and prosodic vocalisations (Bowling et al., 2012;
Steinbeis & Koelsch, 2008). This knowledge can be used by music therapists
to analyze emotional characteristics in a client’s instrumental music and
vocalization in session and in post-session analysis of musical and emotional
data. Future research incorporating additional basic emotions such as fear
and anger should be completed to expand what is known about the perception
of emotions in music and speech prosody.
Conclusion
Music and spoken language are both advanced cognitive processes that
convey emotion, whether through the intentions of the speaker, composer, or
musician or the perception of the listener. The aim of this experiment was to
investigate whether music and speech prosody could convey comparatively
similar emotions and whether the perception of emotions would be greater
in musicians compared to non-musicians. It was found that music and speech
prosody did appear to communicate the same emotions with some degree of
accuracy; the musicians showed greater statistical reliability in their ratings
of happiness across happy stimuli and the non-musicians greater statistical
reliability in their ratings of happiness across sad stimuli. The results indicated
stronger and less varied ratings of music than speech prosody, possibly due to
music’s dynamic elements, with the highest degree of similarity in ratings of
sad stimuli. More research could be done incorporating additional emotions
and a greater number of excerpts to further enhance knowledge surrounding
music and prosody as related communicative processes.
Acknowledgements
We would like to acknowledge the support and contributions of Dr. Geoff Luck
and Dr. Stephen Croucher from the University of Jyväskylä, both of whom
encouraged us in this project and contributed valuable feedback throughout
the research and writing process.
We would also like to acknowledge the support of the University of Jyväskylä,
where this research was conducted.
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Canadian Music Therapists’ Perspectives on the Current
State of Music Therapy as a Profession in Canada
Les perspectives des musicothérapeutes sur le statut
actuel de la musicothérapie en tant que profession au
Canada
Erin Gross, MA, MTA
Sunnybrook Health Sciences Centre, Toronto, ON, Canada
Laurel Young, Phd, FAMI, MTA
Concordia University, Montreal, QC, Canada
Abstract
Although the profession of music therapy has made many advances since the
Canadian Association for Music Therapy (CAMT) was established in 1974, it
is still a relatively new profession and, as such, faces a variety of challenges.
However, it is not known how these challenges are perceived by Canadian
music therapists who live in diverse regions of a geographically large country
and work within different provincial and regional health care and education
systems. Furthermore, it is not known how these diverse experiences impact
upon Canadian music therapists’ views of the profession. The purpose of this
study was to examine Canadian music therapists’ perspectives on the current
state of music therapy as a profession in Canada. In Fall 2012, participants
(N = 87) completed an online survey that examined their perceptions of the
CAMT definition of music therapy, scope of practice, professional certification,
government regulation, and professional advocacy. Results indicated that a
majority of respondents believed that both the CAMT’s definition of music
therapy and the Music Therapy Association of Ontario’s (MTAO) scope
of practice statement are representative of the current profession and
practice of music therapy in Canada. However, respondents’ perceptions
were more varied in other areas of the survey. Potential implications and
recommendations for the profession and for further research are discussed.
Keywords: music therapy, music therapist, Canada, profession,
professionalization, survey
Résumé
Même si la musicothérapie en tant que profession a grandement évolué
depuis la fondation de l’Association de musicothérapie du Canada (AMC)
en 1976, elle demeure une profession relativement jeune qui fait face à de
nombreux défis. Cependant, nous ne savons pas comment ces défis sont perçus
par les musicothérapeutes canadiens qui habitent les différentes régions
d’un vaste pays, et comment ceux-ci travaillent au sein de divers systèmes
de santé et d’éducation tant provinciaux que régionaux. De plus, nous ne
savons pas comment ces expériences variées influencent les perspectives
des musicothérapeutes canadiens sur la profession. Le but de cette étude
vise à examiner les vues de musicothérapeutes canadiens sur le statut actuel
de la musicothérapie en tant que profession au Canada. En Automne 2012,
les participants (N = 87) ont remplis un sondage en ligne lequel révèle leurs
perceptions de la définition de la musicothérapie de l’AMC, des champs
d’application, de la certification professionnelle, de la règlementation
gouvernementale ainsi que des associations professionnelles. Les résultats
démontrent qu’une majorité de répondants croient que la définition de la
musicothérapie de l’AMC ainsi que les champs d’application de l’association
de musicothérapie de l’Ontario (MTAO) sont représentatifs de la profession
actuelle et des champs d’application de la musicothérapie au Canada. Cependant,
les perceptions des répondants ont été plus diversifiées dans d’autres sections
du sondage. Des applications potentielles et des recommandations pour la
progression et la continuité de la recherche sont discutées.
Mots clés : musicothérapie, musicothérapeute, Canada, profession,
professionnalisation, sondage
Music therapy in Canada is a relatively young and emerging profession.
Since the first documented practices began in Toronto in the 1950s, the
field has made significant gains. Our national professional association,
the Canadian Association for Music Therapy (CAMT) was formed in 1974
(Alexander, 1993), and this is one of the most notable of these gains. Currently,
the CAMT has approximately 816 members, 541 of whom are accredited
music therapists, and seven provincial chapters (CAMT, 2013). It publishes
a peer-reviewed journal and hosts an annual national conference. There are
six CAMT–approved university training programs that have varying types of
involvement in research initiatives, two of which provide education at the
master’s level (CAMT, n.d.-a). A national non-profit organization called the
Canadian Music Therapy Trust Fund (CMTTF) was formed in 1994 and to
date has raised approximately 4.8 million dollars, which has helped to fund
over 450 clinical music therapy projects across the country (W. Gascho-White,
Chair, CMTTF Board of Directors, personal communication, September
5, 2013). Finally, there have been several recent features in the Canadian
media on music therapy, which not only help to increase public awareness
but may also increase public acceptance of the field as a legitimate form
of professional practice (e.g., Canadian Broadcasting Corporation, 2011;
Gordon, 2011; Jolly, Pettit, & Mahoney, 2011; Nadeau, 2011; Rooy, 2013;
Ubelacker, 2013). However, in spite of these advances, Canadian music
therapists still struggle to find work in their chosen profession. Insufficient
funding has often been cited as the primary reason for this situation
(Alexander, 1993; CAMT, 2004a, 2004b); Pearson, 2006), but the literature
also indicates that there may be other important factors to consider.
The Professionalization Process
In general, a profession may be defined as the highest level of
occupational functioning in a particular area (Emener & Cottone, 1989).
More specifically, Imse (1960) defined a profession as
an occupational group identified by (1) its fund of specialized
knowledge and (2) its highly trained membership, who (3) acting
with individual judgment, (4) intimately affect the affairs of others.
It is usually characterized by (1) its code of ethics, (2) its spirit of
altruism, and (3) its self-organization. (p. 41)
Similarly, Millerson (1964) identified common traits of a profession, which
include skills based upon professional knowledge, the provision of training
and education, testing the competence of members, organization, adherence
to a professional code of conduct, and altruistic service. Aigen (1991) stated
that the field of music therapy consists of “professional standards and
responsibilities, educational competencies, certification criteria, acceptable
forms of practice, and the function of the accrediting bodies” (p. 80).
Therefore, according to the criteria outlined above, music therapy in Canada
can indeed be legitimately defined as a profession. However, the literature
search also revealed that new professions often experience a process referred
to as professionalization.
Professionalization is “the process by which a gainful activity moves
from the status of ‘occupation’ to the status of a ‘profession’” (Emener &
Cottone, 1989, p. 6). Professionalization is necessary in order to safeguard
quality, effectiveness, and ethical integrity of practice (Rostron, 2009). Yet,
“no occupation becomes a profession without a struggle” (Goode, 1960,
p. 902). It seems that music therapy in Canada is no exception.
According to the literature, new professions often have difficulties
differentiating themselves from occupations with similar client bases
(Goode, 1960), or face impingement by other professions (Emener &
Cottone, 1989). According to the CAMT’s definition of music therapy, in order
for an intervention to fall under the scope of music therapy practice, it must
be carried out by a qualified music therapist, (CAMT, 1994); however, in
Canada potential employers (e.g., hospitals, long term care facilities, schools)
may overlook hiring a music therapist and instead secure the services of
amateur, semi-professional, or professional musicians. These individuals
may offer various types of music programs for free or at a significantly lower
rate than a professional music therapist. Other health care professionals
(e.g., nurses, counsellors, recreation therapists, spiritual care practitioners)
sometimes incorporate music into their clinical work (Le Navenec & Bridges,
2005; Mitchell, Jonas-Simpson, & Dupuis, 2006; Sung, Lee, Chang, & Smith,
2011). This may inadvertently imply that a music therapist is not needed
or that someone other than a music therapist can provide music therapy
intervention. Finally, the emergence of other certified music practitioners
such as harp therapists or sound therapists may confuse potential employers
and the public, particularly with regard to who is actually qualified to practice
as a music therapist and what activities are contained within an accredited
(i.e., certified) music therapist’s scope of practice (Bunt, 1994; Stige, 2005).
Another challenge faced by new professions is the potential for internal
fragmentation, which can lead to the development of rival associations,
differences in education competencies, and varied methods and approaches
to practice (Gray, 2011; Summer, 1997). Indeed, challenges have arisen over
the years within and between the national, provincial, and regional music
therapy bodies in Canada. Some of these challenges have included isolation
due to Canada’s large geography, difficulties communicating nationally due
to lack of effective means of communication (especially prior to technological
advances such as video conferencing or e-mail), and differences amongst
individual associations’ goals or aims (F. Herman, Canadian music therapy
pioneer, personal communication, June 4, 2013).
There also could be fragmentation of music therapy in Canada in the
future due to potential differences in required education competencies. As
noted above, there are six CAMT–approved music therapy training programs
in Canada. After initial CAMT approval, these programs are subsequently
reviewed by the CAMT on a regular basis according to a set of professional
competencies that have been established by the CAMT. However, it may be the
case that future government regulation in some provinces will necessitate
changes to these processes and establish competencies that may only be
relevant for particular provinces. This may not only lead to differences
among programs in term of training standards, it may also lead to even wider
diversity in practice across the country (Castle-Purvis, 2010).
Although diversity in practice has been viewed as a positive part of
the collective Canadian music therapy identity (Buchanan, 2009; Dibble,
2010), it also presents challenges. A recent qualitative study by Byers (2012)
examined 24 international music therapists’ perspectives on ideas related to
diversity and unity within the field of music therapy. Results indicated that
diversity was seen to be natural and necessary, having been created
by music therapy’s response to client needs. [However,] problems
created by diversity included inner tensions, [poor] communication
within and outside the field, and the development of a wide scope
of practice that has contributed to the profession’s question about
identity and has raised concerns around communication and
training. (p. 243)
Unfortunately, Byers’ study did not indicate the applicability of these results
to music therapy in Canada specifically.
On the other hand, Dibble (2010) interviewed nine professional
Canadian music therapists in order to explore their perspectives on the concept
of a collective identity in relation to the profession of music therapy in Canada.
Results indicated that although the majority of participants believed that
Canadian music therapists have a collective identity, there also appeared to be
as many diversities (e.g., nationalities, races, ethnicities, cultural backgrounds,
individual identities, geographic locations) as commonalities (e.g., similar
educational backgrounds, sense of unity, and an acknowledged importance of
identity) among the participants. Although these results are informative, they
cannot be generalized to Canadian music therapists as a whole, given the small
sample size and the qualitative nature of the study. However, they do indicate
that further investigation is warranted into understanding Canadian music
therapists’ perspectives on the profession at large.
Another challenge for new professions is that they may also struggle with
internal divisions regarding the evaluation of professionalization (Goode,
1960). After training is completed, many professions require practitioners
to complete a certification process. The overall purpose of this process is to
recognize a high degree of excellence and knowledge in a specific area, to
demonstrate expertise and achievement, and to recognize professional growth
and lifelong learning (Miracle, 2007). In Canada, the certification process for
music therapy was established in 1979 and is referred to as accreditation
(Alexander, 1993). Recent assessments of the accreditation process by the
CAMT Board, Canadian music therapy educators, and CAMT provincial
association representatives revealed various challenges with the current
system (e.g., difficulties recruiting volunteer reviewers, subjective evaluation
criteria, long processing times, and discrepancies among accreditation
review board members due to lack of clear guidelines on how to review files).
However, these assessments also revealed varying perspectives (i.e., internal
divisions) on how these issues should be addressed, thus making it difficult
for any systemic changes to be implemented in a timely fashion (ClementsCortés, 2012; LeMessurier-Quinn, 2007).
Another challenge faced by new professions is that they often exhibit
a slow and inadequate reaction to political and legal forces that affect the
provision of services (Emener & Cottone, 1989). In music therapy in Canada,
this challenge seems most evident in provinces that have been experiencing
issues related to government regulation.
In Nova Scotia, the Counselling Therapists Act was passed into law
in 2008. This act resulted in the formation of the Nova Scotia College of
Counselling Therapists, which now regulates the act of counselling in that
province (Nova Scotia Legislature, 2008). However, music therapists in Nova
Scotia were not made aware of the proposed legislation until after it had
passed, thus rendering them unable to contribute to the legislative process.
As it currently stands, music therapists in Nova Scotia do not have the
credentials needed to belong to the college nor seemingly any legal means
by which they could lobby to qualify to become part of the college (C. Bruce,
CAMT chapters liaison, personal communication, July 4, 2013). Therefore, it
appears that music therapy will not be regulated in this province anytime
soon. In fact, only three provinces currently have active formalized initiatives
occurring in relation to government regulation of music therapy, and these
initiatives have also experienced challenges.
Music therapists in British Columbia have been seeking government
regulation since 1990. At this time, the emergence of the Health Professions
Act resulted in a need for government regulation in order to gain protection
for the title of music therapist. The Music Therapy Association of British
Columbia (MTABC), a provincial association and a chapter of the CAMT,
sought this protection through the Occupational Title Protection application
(Kirkland, 2007). However, it was deemed that the formation of an
independent music therapy college was not possible due to the cost and
relatively small number of music therapists. In 1999, MTABC joined the Task
Group for Counsellor Regulation who were (and are) advocating for a college
of counselling therapists (MTABC, 2013). However, up to this point in time,
the task group’s efforts have been unsuccessful as changes in government
(i.e., different political parties in power) have prevented the task group from
getting the regulatory college bid on the agenda of the government or of the
opposition parties (MTABC, 2014a; Shepard, 2013).
In Quebec, organizations referred to as professional orders serve
as regulatory bodies of health professions (Conseil interprofessional du
Québec, 2014). In that province a small group of creative arts therapists,
which includes music therapists, have been working together in an attempt
to form a professional order of creative arts therapies since 2004 (S. Snow,
personal communication, July 23, 2012). This ongoing effort has become
especially important since the implementation of Bill 21 in June 2012, which
restricts the practice of psychotherapy to those who belong to governmentdesignated professions or orders. However, the provincial government has
indicated resistance to supporting the formation of any new orders (S. Snow,
personal communication, July 23, 2012). Furthermore, although advocacy
efforts are ongoing, there have been varying perspectives among the creative
arts therapies professionals with regard to how scope of practice should be
defined, thus making it challenging to organize a united lobbying effort in
this province (S. Snow, personal communication, July 23, 2012).
In Ontario, the Ontario Coalition of Mental Health Practitioners (now
known as the Ontario Alliance of Mental Health Practitioners) was formed
in 2002, and the Music Therapy Association of Ontario (MTAO), another
provincial association and chapter of the CAMT, became a member of
this group (Canadian Counselling and Psychotherapy Association, 2013;
Ontario Alliance of Mental Health Practitioners, 2013). Although it is still
unclear as to what aspects of music therapy practice will or will not fall
under the college’s definition of psychotherapy, music therapists (along
with other mental health professionals) will qualify to apply to practice
psychotherapy in spring 2014 as members of a new regulatory body––the
College of Registered Psychotherapists of Ontario (CRPO), formerly known
as the College of Registered Psychotherapists and Mental Health Therapists
of Ontario (Castle-Purvis, 2010; College of Registered Psychotherapists
of Ontario, 2014). It is important to note that this advocacy process has
experienced struggles. According to the Canadian Association for Music
Therapy’s membership directory (2013), not all music therapists living in
Ontario belong to the MTAO, and it has therefore been difficult to effectively
inform and involve all music therapists living in this province. Essentially, a
small group of Ontario music therapists have been almost solely responsible
for leading lobbying efforts and representing the interests of the profession.
This has likely contributed (at least to some extent) to the lengthy process
that it has taken to get to this point, as unified lobbying efforts involving all
potential members of the CRPO have been needed to bring the matter to the
attention of members of parliament and to keep it in their current awareness
(J. Hedican, CAMT government regulation chair, personal communication,
May 26, 2013).
Given all of the factors outlined above, it appears that music therapy
in Canada has indeed been experiencing a process of professionalization
that is typical of new professions. However, the voices of the vast majority
of Canadian music therapists themselves are missing from this conversation.
It is not known if issues related to the professionalization of music therapy
in Canada are understood or experienced differently by a relatively small
population of diverse clinicians who live in urban and rural regions of a
geographically large country and who work within different provincial and
regional health care and education systems. Increased knowledge about
Canadian music therapists’ perspectives on these issues could not only help
to clarify the collective professional identity of the field in Canada but also
highlight unique perspectives. This information could potentially help to
increase understanding of commonalities and differences among Canadian
music therapists as a whole, as well as help to identify national and regional
strategic priorities that are needed to advance the profession. Therefore,
the purpose of this survey study was to examine Canadian music therapists’
perspectives on the current state of music therapy as a profession in Canada.
Method
Participants
This study included music therapists who at the time of data collection
were accredited members (MTAs) in good standing with the CAMT and
currently practicing as clinicians and/or educators in Canada. Persons who
were retired or who became inactive members within the past five years were
also eligible to participate. (Inactive members are those who are not currently
practising music therapy but who maintain their CAMT membership under
this category.) The CAMT administrative coordinator emailed the Invitation
to Participate and Consent document to all eligible participants (N = 493).
Accessing and completing the web-based survey confirmed each individual’s
informed consent to participate. A total of 87 MTAs (10 males, 74 females,
and 3 who did not indicate gender) returned surveys for a response rate of
17.6%.
Materials
The first author created a survey to gather information from Canadian
music therapists about their perspectives on the current state of music
therapy as a profession in Canada. Drafts of the survey were reviewed by the
academic advisor (the second author) as well as by two other professionals––
one who had experience with survey methodology and another who had
extensive knowledge about professional issues in music therapy. The survey
was revised according to their feedback. The final survey and all other related
correspondence were translated into French by a university translation
service and made available to all potential participants in both French and
English.
The survey consisted of 20 questions. The first 12 questions
gathered relevant demographic data. Challenges related to the process of
professionalization (as identified in the literature and described above) were
conceptualized within the profession of music therapy and used to construct
eight additional survey questions that examined Canadian music therapists’
perceptions of the profession (as defined by CAMT), scope of practice,
professional certification, government regulation, and professional advocacy.
For these eight questions, respondents rated their perceptions on a 5-point
Likert scale (1 = strongly disagree to 5 = strongly agree) and were also asked
to provide additional qualitative information to help explain the answers that
they chose. Respondents could skip any question, and the missing data were
taken into account in the data analyses.
Procedures
Approval for this study was obtained from the Concordia Creative
Arts Therapies Research Ethics Committee prior to any data collection. An
online survey company (SurveyMonkey) was used to distribute the survey.
Participants submitted information in such a way that their identities or email
addresses were unknown to the authors or SurveyMonkey. All information
gathered was stored in a secure, password-protected location.
Data Analysis
Two weeks after the designated deadline, the survey was closed and
the anonymous data was downloaded to a password-protected computer
to ensure safe and ethical storage of data. Data was exported into an SPSS
statistics program and analyzed using correlational and descriptive statistics.
Differences were considered to be significant when the probability (p value)
was equal to or less than .05. Given the small sample size and the unique
population of interest, results that approached statistical significance (p ≤ .10) will
also be discussed. The total population of Canadian music therapists is relatively
small, and it is reasonable to assume that most of these trends would have
reached significance with a larger sample. Qualitative data gathered from
participants’ written responses were used to inform the interpretation of
the quantitative results. Responses written in French were translated into
English by a university translation service.
Results
Demographic Characteristics
The average age of respondents was 40.92 years, SD = 11.44. Skewness
and kurtosis fell within acceptable parameters. Twelve people did not indicate
their age. Twelve respondents (13.8%) completed the survey in French
and 75 (86.2%) completed the survey in English. (The 12 who responded
in French were from the province of Quebec; seven additional respondents
from Quebec completed the survey in English.) Table 1 contains frequencies
and percentages pertaining to other demographic characteristics.
A one-way ANOVA revealed a significant main effect for number of
years practising music therapy on place of residence, F(4,75) = 3.30, p = .02.
A post hoc analysis using the LSD procedure indicated that collectively,
respondents from British Columbia had a significantly higher number of
years practising music therapy than respondents from the Atlantic provinces
(p = .003), Quebec (p = .01), Ontario (p = .03), and the Prairie provinces
(p = .004). Due to a small number of respondents in particular provinces/
territories, geographic regions were collapsed into five areas for the final
data analysis. The Atlantic provinces included respondents from Nova
Scotia, New Brunswick, Prince Edward Island, and Newfoundland. The
Prairie provinces included respondents from Manitoba, Saskatchewan, and
Alberta. Respondents [n = 3] from outside of Canada were not included
in the analyses that involved geographic regions.) A statistical trend also
suggested that male respondents might have had a higher number of years
of practising music therapy than female respondents, F(1,81) = 2.78, p = .10,
but results that indicate differences between male and female respondents
should be interpreted with caution given the relatively small number of male
respondents.
Table 1
Demographic Characteristics
Variable
Gender
Male
Female
Prefer not to say
N
85
Province
Atlantic provinces
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Northern Canada (NWT, YT, Nunavut)
Currently live outside Canada
84
Total Years of Music Therapy Practice
Less than 5 years
5-10
11-20
More than 20 years
84
Currently Practice Music Therapy
Full time
Part time regular
Part time sporadic
Not currently practicing
85
Current Context of Music Therapy Employment
Permanent employee at facility or business
Contract employee at facility or business
Self employed
Combination of self and facility employment
Not currently employed in the field
78
Level of Music Therapy Education
Bachelor of Music Therapy degree
Postgraduate certificate/diploma
Master of Music Therapy degree
PhD/Doctorate in music therapy
85
Currently member of provincial chapter/regional association
Yes
No
85
f
Percentage1
10
74
1
11.8
87.1
1.2
9
19
23
5
4
7
14
0
3
10.7
22.6
27.4
6.0
4.8
8.3
16.7
0
3.6
23
23
18
20
27.4
27.4
21.4
23.8
37
35
6
7
43.5
41.2
7.1
8.2
13
18
12
35
0
16.7
23.1
15.4
44.9
0
51
13
18
3
60.0
15.3
21.2
3.5
74
11
87.1
12.9
1
Percentages are based on the total N (number of respondents) for each question and rounded to the nearest tenth.
Current Perspectives of Canadian Music Therapists
Participants answered eight questions related to their perspectives on
the current state of music therapy as a profession in Canada. Table 2 provides
an overview of their responses. Pearson r correlations were used to detect
linear relationships between non-categorical variables. The correlation
matrix is displayed in Table 3 for all applicable variables. One-way ANOVAS
were used to analyze mean differences rather than multiple t tests in order to
lessen the possibility of Type 1 error.
Current Perceptions of the Profession and Scope of Practice
A majority of respondents (92.9%) either agreed or strongly agreed
that the following definition of music therapy, which was established by the
CAMT in 1994, represents the current profession in Canada:
Music therapy is the skillful use of music and musical elements by an
accredited music therapist to promote, maintain and restore mental,
physical, and emotional and spiritual health. Music has nonverbal,
creative, structural and emotional qualities. These are used in the
therapeutic relationship to facilitate contact, interaction, selfawareness, learning, self-expression, communication and personal
development. (CAMT, n.d.-b)
Likewise, 89.0% of respondents felt that the MTAO scope of practice
statement, established in 2010, represents current practice in Canada:
The services performed by an accredited music therapist include
the knowledgeable use of established music therapy interventions
within the context of a therapeutic/psychotherapeutic relationship.
This relationship is developed primarily through music-based,
verbal and/or non-verbal communications. Music therapy processes
can work to restore, maintain, and/or promote mental, physical,
emotional, and/or spiritual health of all persons across the lifespan
and functioning continuums (including those who have severe and
debilitating cognitive, neurological, behavioural and/or emotional
disorders such as those outlined in the DSM-IV/V). Music therapists
conduct client assessments, develop treatment plans, implement
therapy processes/treatment plans, evaluate progress, participate
in research, provide clinical supervision to students/interns/
professionals, work within interprofessional healthcare teams, work
in private practice, and act as consultants to other professionals and
the general public on the use of music to promote health and well
being. (MTAO, n.d.)
Table 2
Current Perspectives of Canadian Music Therapists
Variable
CAMT definition of music therapy represents the profession as it is currently practiced in
Canada
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
N
84
Scope of practice statement reflects current music therapy practice in Canada
Strongly disagree
Disagree
Agree
Strongly agree
82
Scope of practice statement reflects current music therapy practice in respondentÕ s
province/territory
Strongly disagree
Disagree
Agree
Strongly agree
81
Current Canadian accreditation process achieves criteria for professional certification
Strongly disagree
Disagree
Agree
Strongly agree
82
Government regulation of music therapy is a relevant issue in the respondentÕ s province
Strongly disagree
Disagree
Agree
Strongly agree
83
Government regulation of music therapy in other provinces will impact the respondentÕ s
province
Strongly disagree
Disagree
Agree
Strongly agree
81
Music therapists in Canada are effectively advocating for their profession
Strongly disagree
Disagree
Agree
Strongly agree
82
Music therapists in the respondentÕ s province are effectively advocating for their
profession
Strongly disagree
Disagree
Agree
Strongly agree
83
f
Percentage
0
0
6
54
24
0
0
7.1
64.3
28.6
0
2
7
51
22
0
2.4
8.5
62.2
26.8
0
5
11
47
18
0
6.2
13.6
58.0
22.2
5
13
12
30
22
6.1
15.9
14.6
36.6
26.8
2
5
17
21
38
2.4
6.0
20.5
25.3
45.8
1
2
18
43
17
1.2
2.5
22.2
53.1
21.0
2
13
28
33
6
2.4
15.9
34.1
40.2
7.3
3
9
25
39
7
3.6
10.8
30.1
47.0
8.4
Table 3
Correlational Statistics
Variables
Age
TYP
DMT
CSOP
PSOP
PC
GRMP
GROP
CPA
PPA
Age
Ð
.74**
-.06
-.07
-.04
-.05
-.07
-.08
-.17
.02
TYP
Ð
-.18
-.11
-.07
-.13
-.01
-.20
-.09
.15
DMT
Ð
.52**
.37** .48**
.22*
.16
.21
.06
CSOP
Ð
.75** .36**
.27*
.18
.21
.26*
PSOP
Ð
.33**
.20
.12
.25*
.31**
PC
Ð
.28**
.14
.33**
.11
GRMP
Ð
.39**
-.08
-.23*
GROP
Ð
.08
-.07
CPA
Ð
.55**
PPA
Ð
Note. TYP = total years of music therapy practice; DMT = definition of music therapy; CSOP = Canadian scope of practice;
PSOP = provincial scope of practice; PC = professional certification; GRMP = government regulation in my province; GROP =
government regulation in other provinces; CPA = Canadian professional advocacy; PPA = provincial professional advocacy
* Correlation is significant at the 0.05 level (2-tailed).
** Correlation is significant at the 0.01 level (2-tailed).
Furthermore, a strong positive correlation was found between the CAMT
definition and the scope of practice statement, indicating that those who
felt the definition was representative of the current profession in Canada
were also more likely to feel that the scope of practice statement was
reflective of Canadian music therapists’ current practice, r(82) = .52,
p < .001. These same respondents were only somewhat more likely to feel
that the scope of practice statement was reflective of the current practice
in their provinces, r(81) = .37, p = .001. However, a strong positive
correlation was found between the scope of practice statement as it applies
to Canada and the scope of practice statement as it applies to respondents’
provinces, indicating that those who felt that the statement is reflective of
current practice in Canada were also more likely to feel that it is reflective
of current practice in their provinces, r(81) = .75, p < .001. For place
of residence, a one-way ANOVA suggested a statistical trend for the CAMT
definition, F(4,75) = 2.21, p = .08. Post hoc analyses using the LSD
procedure suggested that respondents from British Columbia might have
been less inclined than respondents from the other four geographic regions to
believe that the CAMT definition is representative of the current profession in
Canada (Atlantic provinces, p = .003; Quebec, p = .008; Ontario, p = .03; Prairie
provinces, p = .004).
Current Perceptions of Professional Certification
Professional certification, as defined by Miracle (2007), is
...a process designed to recognize a high degree of excellence and
knowledge in a specific area, to indicate expertise and achievement,
and to denote professional growth and lifelong learning. If a person
successfully completes this process, a credential is granted by
the organization or association that monitors and upholds the
prescribed standards for the particular profession involved. (p. 72)
Only 63.4% of respondents agreed or strongly agreed that the CAMT’s
current accreditation process (current in Fall 2012) achieves the necessary
criteria for professional certification. However, those who felt that the CAMT
definition is representative of the current profession in Canada, r(82) = .48,
p < .001, or who felt that the scope of practice statement is reflective of
current practice in Canada, r(82) = .36, p = .001, or who felt that the scope
of practice statement is reflective of current practice in their provinces,
r(81) = .33, p =.003, were all somewhat more likely to feel that the current
accreditation process achieves the criteria for professional certification. For
place of residence, a one-way ANOVA revealed a significant main effect for
the belief that the current accreditation process achieves the criteria for
certification, F(4,74) = 2.85, p = .03. Post hoc analyses using the LSD procedure
indicated that respondents from Quebec had a significantly stronger belief
than the other four geographic regions that the current accreditation process
achieves the criteria for certification: Atlantic provinces (p = .01), Ontario
(p = .05), Prairie provinces (p = .04), British Columbia (p = .05). This finding
was further supported in that French language respondents were significantly
more likely than English language respondents to believe that the current
accreditation process achieves the criteria for certification, F(1,80) = 9.78,
p = .002. However, results that indicate differences between French language
and English language respondents should be interpreted with caution given
the relatively small number of French language respondents.
Current Perceptions of Government Regulation
Several respondents (71.1%) either agreed or strongly agreed that
government regulation is a relevant issue in their province. Respondents
who felt that the CAMT definition is representative of the current profession,
r(83) = .22, p = .04, or who felt that the scope of practice statement is
reflective of current practice in Canada, r(82) = .27, p = .02, or who believed
that the current accreditation process meets the criteria for certification,
r(82) = .28, p = .01, were all slightly more likely to feel that government
regulation is a relevant issue in their province. For geographic region, a oneway ANOVA revealed a significant main effect for the belief that government
regulation of music therapy is a relevant issue in respondents’ provinces,
F(4,74) = 7.08, p < .001. Post hoc analyses using the LSD procedure indicated
that respondents from the Atlantic provinces were significantly less likely
to believe that government regulation is a relevant issue in their provinces
when compared to respondents from Quebec (p = .001), Ontario, (p < .001),
and British Columbia (p = .05). Respondents from Ontario were significantly
more likely than respondents from the Atlantic provinces (p < .001), the
Prairie provinces (p < .001), and British Columbia (p = .03) to believe that
government regulation is a relevant issue in their province. Respondents
from the Prairie provinces were significantly less likely than respondents
from Quebec (p = .002) and Ontario (p < .001) to believe that government
regulation is a relevant issue in their provinces. Respondents from British
Columbia were significantly less likely than respondents from Ontario
to believe that government regulation is a relevant issue in their province
(p = .03) but significantly more likely than respondents from the Atlantic
provinces to believe that it is a relevant issue in their province (p = .05).
Finally, respondents from Quebec were significantly more likely to believe
that government regulation is a relevant issue in their province when
compared to respondents from the Atlantic provinces (p = .001) or the Prairie
provinces (p = .002). A statistical trend also suggested that French language
respondents might have been more likely than English language respondents
to believe that government regulation of music therapy is a relevant issue in
their province, F(1, 81) = 3.5, p = .07. For level of music therapy education
attained, a one-way ANOVA revealed a significant main effect for the
perceived relevance of government regulation in respondents’ provinces,
F(2, 80) = 3.54, p = .03. Post hoc analyses using the LSD procedure indicated
that respondents with advanced training in music therapy (master’s degree
or PhD) were more likely to believe that government regulation is relevant
in their provinces than those with a bachelor’s degree in music therapy
(p = .01). (Given the small number of PhD respondents, those with master’s
and PhD degrees were collapsed into one category for analyses involving
levels of music therapy education).
Many respondents (74.1%) either agreed or strongly agreed that
government regulation of music therapy in other provinces will impact
music therapy in their province. A moderate positive correlation indicated
that respondents who felt that government regulation is a relevant issue
in their province were somewhat more likely to feel that government
regulation in other provinces will have an impact on music therapy in their
provinces, r(81) = .39, p < .001. A statistical trend suggested that female
respondents may have been more likely than male respondents to believe
that government regulation of music therapy in other provinces will have an
impact on music therapy in their provinces, F(1,78) = 2.89, p = .09. English
language respondents were significantly more likely than French language
respondents to believe that government regulation of music therapy in
other provinces will have an impact on music therapy in their provinces,
F(1,79) = 4.68, p = .03. Accordingly, for geographic region, a significant main
effect was found for the belief that government regulation in other provinces
will impact on music therapy in the respondents’ provinces, F(4, 72) = 2.66,
p = .04. Post hoc analyses using the LSD procedure indicated that respondents
from Quebec were significantly less likely than respondents from the Atlantic
provinces (p = .01), Ontario (p = .01), and the Prairie provinces (p = .06) to
believe that government regulation in other provinces will impact music
therapy in their province.
Current Perceptions of Professional Advocacy
A little under half (47.5%) of the respondents either agreed or
strongly agreed that music therapists in Canada are effectively advocating
for the profession. Similarly, a little over half of the respondents (55.4%)
either agreed or strongly agreed that music therapists in their province
are effectively advocating for the profession. A strong positive correlation
indicated that respondents who believed that music therapists are effectively
advocating for the profession in Canada were more likely to believe that
music therapists are effectively advocating for the profession in their
provinces, r(82) = .55, p < .001. Respondents who felt that the scope of
practice statement is reflective of practice in Canada were slightly more likely
to feel that music therapists are effectively advocating for the profession in
their provinces, r(82) = .26, p = .02. However, no significant relationship was
found between this same variable and the belief that music therapists are
effectively advocating for the profession in Canada (at large). Respondents
who felt that the scope of practice statement is reflective of practice in their
province were slightly more likely to feel that music therapists are effectively
advocating for the profession in Canada, r(80) = .25, p = .02 and somewhat
more likely to feel that music therapists are effectively advocating for the
profession in their provinces, r(81) = .31, p = .01. Respondents who felt that
the accreditation process achieves the criteria for professional certification
were somewhat more likely to feel that music therapists are effectively
advocating for the profession in Canada, r(81) = .33, p = .003. However, no
significant relationship was found between this same variable and the belief
that music therapists are effectively advocating for the profession in their
provinces. A statistical trend suggested that French language respondents
may have been more likely than English language respondents to believe
that music therapists are effectively advocating for the profession in Canada,
F(1, 80) = 3.52, p = .06. Similarly, a statistical trend suggested that male
respondents may have been more likely than female respondents to believe
that music therapists are effectively advocating for the profession in Canada,
F(1,79) = 2.82, p = .10. For geographic region, a one-way ANOVA suggested a
statistical trend with regard to the belief that music therapists are effectively
advocating for the profession in Canada, F(4, 73) = 2.24, p = .07. Post hoc
analyses using the LSD procedure suggested that respondents from Ontario
might have believed less strongly than respondents from the Atlantic
provinces (p = .02), Quebec (p = .09), and the Prairie provinces (p = .06) that
music therapists are effectively advocating for the profession in Canada. The
analyses also suggested that respondents from British Columbia may have
believed less strongly than respondents from the Atlantic provinces that music
therapists are effectively advocating for the profession in Canada (p = .04).
However, no significant differences were found between geographic regions
with regard to the belief that music therapists are effectively advocating
for the profession in their provinces. Finally, a weak negative correlation
indicated that those who felt that government regulation was a relevant issue
in their provinces were slightly less likely to feel that music therapists were
effectively advocating for the profession in their provinces, r(83) = -.23, p = .04.
Discussion
Canadian Music Therapists’ Perceptions of the Profession
As previously noted, a majority of respondents either agreed or strongly
agreed that the CAMT definition of music therapy is representative of the
current profession of music therapy in Canada. Although six respondents
neither agreed nor disagreed and a few offered comments that were
somewhat critical (e.g., “I feel it’s accurate but not compelling. Very technical
rather than ideological”), there were no respondents who indicated that
they disagreed or strongly disagreed with the CAMT definition. This is an
interesting finding in that defining health professions can often be a difficult
task due to the wide range and types of problems addressed, settings
in which professionals work, levels of practice, interventions used, and
populations served (Gibelman, 1999). Perhaps the CAMT definition may truly
be considered as part of the common national identity of Canadian music
therapists. One respondent stated that “[the definition] is comprehensive
while still encompassing diversity in practice.” Others commented, “I feel
confident, based on reading about Canadian music therapists’ work, as well
as what I have seen at conferences and in speaking with colleagues, that the
definition matches what is currently being practiced here,” and “I find this
definition sufficiently detailed and inclusive.”
The results also indicated, however, that respondents from British
Columbia may have been less inclined (i.e., agreed less strongly) than
respondents from other geographic regions to believe that the definition
is representative of the current profession. It is also important to note
that respondents from British Columbia had on average a significantly
higher number of total years of music therapy practice than respondents
from other regions. These results make sense in that as compared to other
regions, British Columbia has a long and active music therapy history. The
first Canadian music therapy training program was founded in Vancouver
in 1977, only three years after the CAMT was established (Alexander, 1993;
Kirkland, 2007), and the MTABC became the first official provincial chapter
of the CAMT in 1982 (MTABC, 2014b). As previously noted, advocacy efforts
related to government regulation have been happening in British Columbia
for more than 20 years. Perhaps as music therapy becomes increasingly
established in particular areas of the country, there will be a greater need
for definitions that reflect regional issues. Unfortunately, the current survey
study did not ask respondents to indicate if the CAMT definition represents
the profession as it is currently practiced in their provinces, and this could
have provided important additional information.
Other professions, such as social work, have recognized the need to
develop new definitions that reflect current practices, values, attitudes, and
opinions that have emerged as the profession matured (Ramsay, 2003; Risler,
Lowe, & Nackerud, 2003). In Defining Music Therapy (1998), Bruscia stated
that “definitions of music therapy continually need to be changed to reflect
the state of the art. Thus, when definitions are compared over a period of
time, one can actually see the stages of individual and collective development
in the field as well as in the health community at large” (p. 4). Given that the
current CAMT definition is nearly 20 years old, it is very likely that revisions
will need to be made in the near future.
The written comments from some respondents also indicated that
although they agreed that the definition was representative of the current
profession in Canada, it might not be well understood by those outside of the
profession:
“Music therapists know this; however, most Canadians do not.”
“I think that the definition is broad enough to more or less cover how
various MTs practice in Canada. However, it is rather abstract and
could be interpreted in a variety of ways––especially by those who
are unfamiliar with the profession.”
Potential implications of these perspectives will be discussed below.
Canadian Music Therapists’ Perceptions of Scope of Practice
Many respondents either agreed or strongly agreed that the MTAO
scope of practice statement reflects the current scope of music therapy
practice in Canada and in their provinces (89.0% and 80.2%, respectively).
Additionally, respondents who felt that the scope of practice statement is
reflective of practice in Canada were also significantly more likely to feel
that it is reflective of current practice in their provinces. This is particularly
interesting given that the statement was developed to address scope of
practice in Ontario only. It was used for this study as it is the only “official”
music therapy scope of practice document that exists in Canada. In fact, one
respondent asked, “Where did you get this? I have been looking for a scope
of practice for an employer.” It may be the case that some Canadian music
therapists may not consciously differentiate between their own regional and
national perspectives or have a great deal of knowledge outside of their own
immediate experiences. One respondent stated, “I agree [that the statement
is reflective of practice in Canada], though I don’t have as much knowledge of
the practice within Canada, as compared to the practices of music therapists
within my circle of contacts [who are] from a variety of different cities and
provinces.”
A profession’s scope of practice determines which services a professional
is qualified to perform. Although respondents appeared to agree with the
statement overall, several comments in the survey indicated that respondents
felt that not all Canadian music therapists could or should provide all of the
services contained in the MTAO scope of practice statement:
“Generally speaking, I agree. However, I believe there are many
music therapists who do not possess the skills or self-awareness to
work within the entire scope of practice.”
“I believe that the above statement includes an ideal version of
the current scope of practice of a music therapist in Canada. I do
not believe that all Canadian music therapists’ work is necessarily
reflective of this scope of practice, and that may be due to their
personal choice or due to restrictions placed upon them by their
place of employment.”
“Not all of this statement would apply to every music therapist.”
Finally, some respondents highlighted potential differences in scope of
practice among provinces due to provincial laws:
“Because of provincial laws, music therapy methods vary from one
province to another.”
“As MTs in Quebec are currently not legally permitted to practice
psychotherapy (because of Law 21), there is a legal issue with including the
word ‘psychotherapy’ in our scope of practice. This is a significant issue
for MTs in Quebec who feel that they practice music psychotherapy.”
The need for provincial/regional versus a national scope of music therapy
practice in Canada is a complex issue with no easy solution. Potential
implications for the profession and recommendations for future research
will be addressed below.
Canadian Music Therapists’ Perceptions of Professional Certification
Only 63.4% of respondents agreed or strongly agreed that the
accreditation process in place at the time of the survey (Fall 2012) achieves
the necessary criteria for professional certification. Although some
respondents’ comments contained supportive elements, all comments but
one (36 comments in total) indicated specific problems and challenges that
respondents perceived with regard to the current accreditation process:
•
•
•
•
•
The subjective nature of the process and possibility for human error.
“The accreditation process is non-standardized and subjective.
Therefore, the degree of excellence and knowledge acquired by
persons who are granted this credential is in reality highly variable.”
Failure to meet a high degree of excellence and standards of
knowledge.
“I certainly do not feel that the internship and accreditation process
recognizes a ‘high degree of excellence and knowledge’ in general,
and certainly not ‘in a specific area.’ Perhaps in some cases, but not
all. I am in fact concerned about the possibility that the current
process allows for interns to become accredited without achieving
even highly competent skills as music therapy practitioners.”
Lack of credential recognition by other professionals.
“I think it is a start, but it is only as successful at denoting professional
certification as is recognized by professional bodies outside CAMT.”
Failure to evaluate musical skill.
“The accreditation process does not evaluate musical skill and is
only based on what is presented in writing by the person looking to
be accredited.”
Failure to measure ongoing education and professional development.
“[I] do not believe accreditation covers areas of professional growth
or lifelong learning. I believe it is a snapshot of the therapist at that
particular time in their professional career.”
With regard to this last point, although the CAMT requires that music
therapists accrue continuing education credits to maintain accreditation
(MTA) status, the current study’s survey did not clearly indicate this in the
question about certification. This omission may have impacted participants’
responses on the extent to which they believed that the current accreditation
process meets the criteria for certification as defined in the survey.
Interestingly, respondents from Quebec had a significantly stronger
belief than the other geographic regions that the accreditation process
achieves the criteria for professional certification. Furthermore, French
respondents had a significantly stronger belief than English respondents that
the accreditation process achieves the criteria for professional certification.
Although there may be various explanations for these findings, it is important
to note that because fewer files are submitted in French, it generally takes
less time for French accreditation files to be processed than English files
(A. Lamont, CAMT accreditation chair, personal communication, June 5,
2013). Furthermore, a smaller number of French submissions require fewer
French than English accreditation review board teams, which may mean that
the evaluation standards are more consistent for French files. It is possible
that overall, French respondents were feeling less frustrated with the current
system than English respondents and that this was reflected in the current
study’s results.
As noted earlier, the CAMT has recently identified some challenges
within the current accreditation process, and it seems that many of this
study’s respondents have identified very similar challenges. These results
appear to support a pressing need for the current process to be reviewed and
modified in order to address the above listed concerns.
Canadian Music Therapists’ Perceptions of Government Regulation
Several respondents (71.1%) either agreed or strongly agreed that
government regulation is a relevant issue in their provinces. One respondent
stated, “I believe and hope that, over the long term, it will help us gain further
credibility and recognition and open up more opportunities for permanent
employment.” Although the statistical analysis revealed differences among
regions with regard to how strongly they believed that government regulation
is a relevant issue in their provinces, the results are rather complex and
difficult to interpret. However, it does appear that overall, respondents from
Quebec, Ontario, and British Columbia were more likely than respondents
from the other geographic regions to believe that government regulation is a
relevant issue in their provinces. This makes sense as regulation is currently
an active issue in these three provinces. A respondent from outside of these
provinces stated, “There are too few of us at this moment for this to even
be a consideration.” It is also interesting to note that respondents from
British Columbia were significantly less likely (i.e., believed less strongly)
than respondents from Ontario to believe that government regulation is a
relevant issue in their province. On the one hand, this is surprising, given that
government regulation has been an active issue in British Columbia for more
years than in any other province. On the other hand, this result may simply
speak to the fact that government regulation (of music therapy practice
as it relates to psychotherapy) is more immediately imminent in Ontario,
whereas the future outcomes of regulation efforts in British Columbia are
still essentially unknown.
Results indicated that respondents from Quebec were significantly
less likely than respondents from other geographic regions to believe that
government regulation in other provinces will impact regulation in their
province. It may be the case that respondents from Quebec felt that the
unique language, culture, and laws of their province distinguishes them from
other provinces and thus distinguishes their regulatory process from those
of other provinces It could also be the case that Quebec’s unique struggles
in relation to the regulation of the creative arts therapies in that province
(briefly outlined above) have left them feeling isolated and disconnected
from other parts of the country that are experiencing quite different issues.
One respondent from Quebec stated, “Each province seems to have a different
approach.”
While there were differing perceptions on the extent to which
government regulation will impact individual provinces, several respondents
expressed hope that regulation in one province would set a helpful precedent
for the rest of the country:
“With each province that is regulated, it can set a precedence and
provide a template or example, potentially”
“I think regulation in one province could facilitate quicker
development of regulation in other provinces.”
In principle, this study’s results support modifications of the Accreditation
Process implemented by CAMT in September 2014. Further modifications
may still need to be considered.
Canadian Music Therapists’ Perceptions of Professional Advocacy
Less than half of respondents (47.5%) either agreed or strongly agreed
that music therapists in Canada are effectively advocating for the profession.
A slightly larger number (55.4%) either agreed or strongly agreed that music
therapists in the respondents’ provinces are effectively advocating for the
profession. Several of these respondents indicated concerns with regard to
current advocacy efforts (or lack thereof) within Canada or their provinces:
•
Lack of unified efforts.
•
“We could be more unified and involved with advocacy. Some are
carrying the brunt of the work.”
•
“I think some try, but it is not a coordinated effort, and I don’t feel
that CAMT offers any leadership in this area.”
“Yes, every day we explain what we do, promote ourselves to our
employer. Individual MTAs are too tired and busy to be doing
advocacy on a larger scale––we need the CAMT and the ethics
committee to be advocating on our behalf on a larger scale. There is
more power in many voices.”
•
“I basically feel that the average music therapists tend to leave it up
to someone else to advocate, unless it directly affects their income.”
“I feel that there is a lot of apathy. People are trying to make a living
and are mostly focused on their own practice and trying to keep their
own work alive. I see very little effort, with the exception of small
pockets, in making sure that music therapy is promoted, understood,
and accessible for everyone.”
•
Lack of national leadership.
Lack of individual involvement.
Differences between provinces.
“There is a disconnect between the different practices of MT
between provinces. Until everyone is on the same advocacy ship, MT
will continue to be an industry of stagnancy.”
Being reactive rather than proactive.
“I don’t necessarily think that we are effectively advocating for
our profession. Many efforts . . . seem to be focused on what other
professions, or musicians, are doing in health care. While this is
important information, I think that effective advocacy entails critically
examining our own profession, clinical practice, competencies, and
scope of practice. We need to be proactive for our own profession
rather than reactive to the professions of others.”
•
Lack of resources.
“I think that there is always room for improvement, but it is not
easy for music therapists to become actively involved in all aspects
of their profession. Unfortunately, appreciation for and promotion
of the profession ranks lowest after clinical tasks, cases, meetings,
teaching duties. . . . I feel that perhaps we lack the resources to help
us move ahead more quickly in this field.”
Finally, it is interesting to note that respondents from Ontario may
have been less inclined (i.e., believed less strongly) than respondents from
the Atlantic provinces, Quebec, and the Prairie provinces to believe that
music therapists in Canada are effectively advocating for the profession.
Additionally, respondents who felt that government regulation was a relevant
issue in their provinces were slightly less likely to feel that music therapists
were effectively advocating for their profession in their provinces. Given that
government regulation of psychotherapy is imminent in Ontario and that
many, if not all, music therapists will be part of the CRPO in that province,
it may be the case that respondents from Ontario felt an increased sense of
urgency in relation to advocacy issues (e.g., a need to educate other health
professionals and the public or a need to feel more support from music
therapists outside of Ontario as changes unfold).
Limitations
This study had some limitations that must be considered. The sample
was relatively small and contained only 87 out of a possible 493 respondents
(17.6% response rate). Therefore, the views expressed by the respondents
may not be an accurate representation of the total population of MTAs
in Canada. Furthermore, the survey was only distributed to MTAs in good
standing and did not include the perspectives of professional associate
members (i.e., those not yet accredited). Additionally, the sample may have
been biased in that persons who were most interested in or involved with
music therapy professional issues may have been more motivated than
others to participate in the survey. In an attempt to represent the profession
of music therapy in a positive light, it is also possible that some respondents
may have answered questions in a “socially desirable” way rather than
being fully truthful. This could have contributed to the very high percentage
of respondents who either agreed or strongly agreed with both the CAMT
definition of music therapy and the MTAO scope of practice statement.
However, the level of social desirability bias is difficult to assess, given that
only 32% of respondents chose to provide additional information to explain
their survey question answers.
Potential Implications and Recommendations for the Profession
The results of this study have several potential implications for
the profession. If one were to take the results of the present study at face
value, it appears that Canadian music therapists may be satisfied with the
current CAMT definition of music therapy. However, as pointed out by some
respondents, this definition may not be well understood by those outside of
the profession. Therefore, it would be useful for the CAMT to consider either
creating a separate definition for non–music therapy professionals or adding
components to the existing definition in order to address this need.
Overall, the respondents indicated that the MTAO scope of practice
statement reflects current music therapy practice in Canada; however, this
statement was developed from the perspective of one province. Historically,
the lack of a national scope of practice has resulted in what McMaster (cited
in Howard, 2009, p. 6) referred to as “the often challenging negotiations
between Canadian music therapists who had been trained in different
countries and different traditions.” Therefore, the current authors would
like to recommend that a scope of practice document be developed through
a national practice analysis survey, similar to that which is conducted by
the Certification Board for Music Therapists every five years in the United
States. The results of this inquiry could help to determine standards and
protocols, create a sense of unity, increase knowledge about the diverse
work that is happening across the country, and assist individuals in terms
of their ability to relocate and work in different parts of the country (i.e., a
Canadian scope of practice document should contain and distinguish
between national and regional issues). A thoughtfully formulated national
scope of practice document could also assist with many other important
professional initiatives including those related to accreditation, education,
and professional advocacy. Therefore, the current authors also recommend
that developing such an initiative be a priority area of consideration for the
CAMT board and provincial associations.
Several respondents indicated that there are challenges with the current
CAMT accreditation process, and these challenges are similar to those that
the CAMT is currently attempting to address. Woody (1997) stated that it is
the ethical obligation of mental health professional associations who grant
credentials not only to closely monitor these credentials but also to educate
the public about the meaning of the credential. Therefore, in addition to the
efforts that are currently underway in revising the accreditation process,
the current authors would like to recommend that the CAMT and the
provincial and regional associations make increased organized efforts to
educate the public, relevant professions, and other potential stakeholders
(e.g., government representatives, health care managers, funding sources)
about the meaning and relevance of the MTA credential.
Finally, many respondents expressed concern with regard to lack of
effective professional advocacy initiatives. This is in line with Myers and
Sweeney (2004), who surveyed counsellors regarding the importance of
advocacy. They found that the lack of a coordinated effort among counselling
organizations was the main barrier to effective advocacy and that the
development of coalitions to support advocacy efforts was necessary for the
further development and promotion of the profession. Similarly, in a study by
Jugessur and Iles (2009), nurses who did not have clear advocacy definitions
and training from professional organizations were found to lack necessary
skills, knowledge, and support to advocate effectively.
Therefore, the current authors would like to recommend
•
that the CAMT and provincial associations work together to organize
advocacy initiatives that take both national and regional needs and
perspectives into account,
•
that the CAMT re-establish the currently defunct professional
advocacy committee and include representation from all of the
provincial and regional associations, and
•
that the CAMT develop continuing education training opportunities
such as online courses and conference workshops.
These steps would inform Canadian music therapists about the need for
advocacy, address perceived issues of apathy and barriers as they relate to
advocacy, and provide members with the knowledge, resources, and skills
they need for organizing more effective advocacy initiatives.
Recommendations for Research
As previously noted, the scope of the present study was delimited to
explore key aspects of the profession (i.e., definition of music therapy, scope
of practice, accreditation, government regulation, and professional advocacy)
in a general way. Taking the results of the current study into account, each
one of these areas could be explored in more detail. For example, it would be
helpful to know more about Canadian music therapists’ perceptions of the
CAMT definition as it relates to their provinces. Additionally, as suggested
above, a practice analysis survey study could be conducted on a regular basis
in order to formulate and maintain a current Canadian scope of practice
document. As the current study was limited to MTAs in good standing, it
would be also be beneficial to gather perspectives of non-accredited music
therapists, interns, and students to provide broader perspectives on some of
these issues. It would also be interesting to survey the public or other health
professionals about the profession of music therapy in Canada to determine
how the perceptions of the public differ from those within the profession.
Finally, as this study did not include Canadian music therapists’ perspectives
on education and training, any type of research in this area would provide
important information, as there is limited research on this topic.
Although it goes beyond the scope of the present inquiry, it is important
to note that several respondents expressed concerns or fears related to
government regulation:
“I see the benefits of government regulation but fear the changes.”
“I am currently conflicted about this question. While I appreciate
the concept of regulation and the need to protect the public, I am
uncertain it pertains to all areas of MT practice, and I am concerned
about the potential [that] regulation may have to fracture our music
therapy profession as a whole. I am unclear how this would play
out if we don’t call ourselves psychotherapists, but practice music
therapy (which is, essentially, a psychotherapy).”
Investigations on the benefits and challenges of government regulation as
perceived by Canadian music therapists could yield very interesting and
important information.
Concluding Remarks
Music therapy in Canada has made great strides in its journey as an
emerging profession. As the CAMT celebrates its 40th anniversary, this seems
like an appropriate time to examine where we are at as a profession and to
consider potential future directions while keeping the voices and experiences
of all Canadian music therapists in mind. Hopefully this study will act as a
springboard for the additional research, dialogue, and constructive action
that are needed in order for the profession to continue to move forward and thrive.
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Hermeneutic Inquiry on Musical Gestures in a Music
Therapy Context
Recherche herméneutique sur le geste musical dans un
contexte musicothérapeutique
Danielle Jakubiak, MMus, MA(MT), MTA
Private Practice, Montréal, QC, Canada
Abstract
This hermeneutic research project focused on interpreting the gestures of
two music therapists and their clients while they were engaged in playing
or listening to music. The study incorporated transcriptions of four music
therapy sessions and a systematic analysis of the transcriptions. These
were used to examine communications via musical gestures and how the
music therapists used the gestural repertoire of their clients to inform their
interactions. The study showed that each dyad had characteristic gestural
interactions that were shaped by clients’ diagnoses, the music therapist’s
personal therapeutic style, the pre-existing therapeutic relationship, and
other factors in the sessions themselves. The clients communicated their
level of engagement, emotional state, attention, and relationship to the music
partly through musical gestures. The music therapists generally recognized
these musical gestures and processed them verbally and through mirroring,
prompting, or redirecting. This research suggests that further study into the
role of musical gestures in collaboration with diverse disciplines could help
music therapists augment their analysis of client behaviour, allowing them to
better understand client intentions and motivations.
Keywords: musical gesture, hermeneutics, music therapy, context,
movement analysis
Résumé
Ce projet de recherche herméneutique se concentre principalement sur
l’interprétation du geste musical de deux musicothérapeutes et leurs clients
lesquels sont observés pendant le jeu ou une écoute musicale. L’étude
incorpore des transcriptions de quatre séances de musicothérapie ainsi
qu’une analyse systémique de ces transcriptions. Ces dernières sont utilisées
pour étudier la communication à travers le geste musical et la façon dont les
musicothérapeutes utilisent le répertoire gestuel de leurs clients pour nous
informer sur les interactions. L’étude démontre que chaque dyade possède
des interactions gestuelles lesquelles sont modelées sur les diagnostiques
des clients, le style thérapeutique personnel du musicothérapeute, la
relation thérapeutique préexistante ainsi que d’autres facteurs inhérents
aux séances. Les clients communiquent leur niveau d’engagement, leur
état émotif et leur relation à la musique partiellement par un geste musical.
Les musicothérapeutes reconnaissent généralement ce geste musical et
l’intègrent verbalement dans leur intervention et par des techniques comme
le reflet, l’incitation et la redirection. Cette recherche suggère que de plus
amples études sur le rôle du geste musical, en collaboration avec d’autres
disciplines, contribueraient à aider les musicothérapeutes à améliorer leur
analyse du comportement de leur client, leur permettant ainsi de mieux
comprendre leurs intentions et motivations
Mots clés : geste musical, herméneutique, musicothérapie, contexte,
analyse du mouvement.
This hermeneutic research project was primarily focused on musical
gestures and how they act as a mode of communication between therapists
and clients. There was also a focus on how a client’s context affects these
gestures. Musical gestures are body movements associated with the act
of making music, including postures, facial expressions, or movements
intended to create sound on an instrument (Godøy & Leman, 2010). I also
included a secondary focus on context for two reasons. During my training
as a music therapist, I became interested in culture-centred and community
music therapy theories developed by Pavlicevic (1997), Ruud (1998), and
Stige (2002), and I saw the importance of taking context into account when
working with clients. Examining the context of oneself as researcher and
the “text” (in this case, the transcript and analysis of the gestural content of
music therapy sessions) is a fundamental part of the hermeneutic process.
Although many studies have been conducted on musical gestures and
their meaning (Godøy & Leman, 2010; Nakra, 2000; Tolbert, 2001) and
the phenomenon of embodied cognition (Iyer, 1999; Leman, 2008; Leman,
Desmet, Styns, van Noorden, & Moelants, 2009; Leung, Qiu, Ong, & Tam,
2011), little work in the field of music therapy specifically has addressed the
role of musical gestures in the therapeutic process. The meaning of these
gestures has not been discussed, yet I believe that most music therapists
intuitively recognize non-verbal signals in sessions without overtly discussing
them. It is my hope that in bringing interdisciplinary sources together to
elicit discussion around the meaning of musical gestures in music therapy
contexts, a new discourse will emerge in music therapy.
The primary focus of this study was to answer the question, “What is
communicated in the musical gestures of a music therapist and their client in
a music therapy context?”
The following were secondary foci:
•
•
•
•
What constitutes a musical gesture versus a speechaccompanying gesture?
What kinds of different musical gestures can be seen within
music therapy sessions?
How do clients’ musical gestures affect music therapists’
subsequent actions?
How does the music therapist use the client’s gestural repertoire
to inform the therapeutic relationship?
The study focused on the analysis of the gestures associated with
the creation of music (i.e., playing instruments) only. It did not include a
discussion of all non-verbal behaviour in a music therapy session, nor did it
include an in-depth discussion of verbal or musical exchanges in the music
therapy sessions.
Defining Musical Gestures
For the purposes of this project, a musical gesture was defined as a
gesture that accompanies the playing of or listening to music and was analyzed
from both phenomenological and functional perspectives. The gestures were
not analyzed from intrinsic perspectives since member-checking was not a
component of this study.
Assumptions
I began this research with the assumption that musical gestures
would be self-evident, identifiable, and that they would be specific to each
individual. I believed that there would be a significant portion of each session
devoted to improvisation together and that I could examine musical gestures
in the context of free associative music-making. I thought this kind of social
interaction (within a musical improvisation) would be an ideal environment
in which to examine distinctive gestural patterns. Furthermore, upon
becoming aware of the clientele I would be working with, I began to form
assumptions about the types of gestures I might see in the music. Initially,
I believed that a client with autism would exhibit repeating patterns of
gestures with few that were intentional or communicative. I also believed
that it would be challenging to identify communicative gestures in a client
with full body paralysis. I thought that the effects of culture or context on
gesture would be self-evident. Through the process of analyzing the data,
new information emerged during each level of processing.
Literature Review
This review of literature encompassed an interdisciplinary
understanding of how the inner experience of music is translated into
outward, observable behaviours, specifically musical gestures. Scholarship
in the field of cognitive psychology, creative arts therapies, music therapy,
musicology, music technology, linguistics, ethnomusicology, and sociology all
come together to form a fascinating body of work on gestures, culture, and
music. The review prompted questioning into the effects of gesture analysis
on a music therapist’s understanding of the client’s experience.
Gesture and Context
Research has shown that some gestures are correlated to cultural
contexts. A seminal work on the relationship of gesture and culture is
seen in Kendon (2004), who gave a succinct history of gesture studies
and methodologies for gesture analysis in everyday settings. Yelle (2006)
discussed the creation of meaning in culture-specific gestures:
The interpretation of gesture depends upon the knowledge of the
appropriate cultural code, possession of which belongs to a group
that may be co-extensive with an entire culture, as in the case of
basic gestures of greeting; or that may be limited to a subgroup of
savants of even esoteric initiates. (p. 237)
A broad literature review of the discourse on gesture and culture is
seen in Kita (2009). Using case studies from linguistics, Kita demonstrated
that spatial information and motion are conceptualized differently across
cultures, that there are distinct cognitive differences in cultural gestures,
and that conceptions of motion vary across cultures. Molinsky, Krabbenhoft,
Ambady, and Choi (2005) conducted a study where participants were given
a test determining whether they could distinguish between real and fake
gestures of a new culture. They concluded that being able to perceive gestures
accurately is correlated with intercultural competence (capability to adapt to
and understand subtleties of a new culture or context).
Music and Gesture
A musical gesture was defined by Godøy and Leman (2010) as “a
meaningful combination of sound and movement” (p. ix). It could be argued
that instead of sound, the authors meant music in this definition; however,
the inclusion of meaning is a key factor. Musicians use musical gestures,
which are distinct from movements themselves, to convey meaning to their
audience. Several studies (Cadoz & Wanderley, 2000; Godøy & Leman, 2010;
Iyer, 1999) have shown that, even unconsciously, musicians relate aspects of
the music to their body movements while playing.
Eitan and Granot (2006) considered how participants associated musical
stimuli with images of motion. They found that all musical stimuli evoked
certain images of motion and that music–motion analogies are deeply rooted
in the cognitive patterns of people, which corroborated the assumption that
musical ideas are mapped onto motor ones. Godøy and Leman (2010) drew
on the works of experts in the field of music and gestures and provided a
starting point for the study of musical gestures, and they called for further
research on musical gestures and culture:
This also goes for the largely unexplored field of social identities in
musical gestures, such as studying how different cultures of cultural
subgroups have developed specific features of musical gestures and
how they seem to work in various social contexts. (p. 34)
Cadoz and Wanderley (2000) portrayed a case study of a performing
clarinettist whose gestures were found to be directly related to musical
constructs such as dynamics, timbral changes, and pitch. The authors
searched for a definition of musical gesture and found that there was no
simple definition of the phrase. A musical gesture could mean a figure in
a composition of a particular, identifiable quality; movements a musician
makes when playing an instrument; or perhaps even movements made by
those listening to music. Within the concept of musical gesture, there are
many different functions depending on the perspective— phenomenological,
functional, or intrinsic—from which one analyzes them (Cadoz & Wanderley,
2000).
Embodied Cognition
Embodied cognition is an interdisciplinary field based in cognitive
science that attempts to explain how the body and mind interact with and
are influenced by the environment in ways that contribute to good health. In
his work studying embodied cognition in music, Leman (2008) introduced
the idea of second-person descriptions, which are “used to show, express and
articulate the private experience from one subject to another” (p. 82). Since
musical gestures are shaped by individual experience and action ontologies,
they are bound to be subjective in nature.
In Leman et al. (2009), participants listened to a pre-recorded
performance of unfamiliar music played on the guqin, a traditional Chinese
instrument, and moved their arms in response to the music. The authors
found a strong correlation between the movements made by the performer in
the video recording (which the participants did not see) and the participants’
own arm movements. They also found that these movements were strongly
linked to musical properties such as tempo, change in dynamics, and phrasing.
Aldridge (1996) called for more attention to be paid to the mind’s
influence on the body, especially in creative arts therapies, and stated that
“meanings provide a bridge between cultural and physiological phenomena”
(p. 107). He contended that the body in its role as a social agent is increasingly
a concern of post-modern discourse and that the expressive arts therapies
are a particularly important part of this because “they emphasize the lived
body as being sensed, not only as being said” (p. 108).
Iyer (1999) focused on embodied cognition in West African and AfricanAmerican music. He argued that pulse and metre are not discerned in the
same way across cultures. Iyer further claimed that there are embodied
dimensions to all music, which are dependent on the role of the rhythmic
aesthetics of a type of music. A study published by Sedlmeier, Weigelt, and
Walther (2011) found that participants’ body movements, whether they
were executed or even thought about, could affect musical preference.
Overy and Molnar-Szakacs’ (2009) review of scholarship on the
mirror neuron system (MNS) and its significance for the understanding of
perception–action mechanisms, human communication, and empathy is
significant. The development of language and music-making has been proven
here to have a neuropsychological basis in the mirror neuron system. Mirror
neurons are those that allow humans to observe, understand, and replicate
the behaviours of others. The MNS is the cognitive model for intersubjectivity,
and movement plays a large role in its functioning.
Music Therapy and Context
Several publications in the field of music therapy show a shifting focus
for music therapists towards a discussion of culture. Moreno (1988) coined
the term ethnomusic therapy and offered suggestions for using a variety of
world music genres with clients from other cultures. Brown (2001) gave an
analysis of the meaning of music in various cultures, a more specific definition
than Moreno’s, including age, disability, religion, ethnicity, social status,
sexual orientation, and indigenous heritage. Brown stated that “cultural
empathy is a dynamic concept that is experienced in three human domains:
emotions, cognitions, and behaviours” (p. 15). Shapiro (2005) also discussed
the importance of cross-cultural competency in music therapy.
Reilly (1997) discussed employing a gestural controller (a digital musical
instrument that uses gestures as input) to analyze movements of clients with
different diagnoses. When Reilly analyzed trials with two groups of music
therapy clients, one with manic and one with depressive symptomatology, he
found great differences in the range of movement between the two. Lem and
Paine (2011) found that using sonification (which they define as digitizing
movements and converting them to sounds) with physically disabled adults
was effective as a free improvisation tool in music therapy but that the extent
of its effectiveness depended on the range of movements available to the
participants.
Music therapy clients are typically not professionally trained musicians
and so do not necessarily have the same highly developed relationship with
their instruments as the music therapist. However, research by Overy and
Molnar-Szakacs (2009) on the mirror neuron system supports the idea that
even mimetic movements, such as the synchronous movements when a
therapist and client play in the same tempo, may be the basis for a successful
therapeutic relationship.
Ruud (1998) presented a cohesive thesis on the role of music therapists
as social researchers. He argued that music therapists can use hermeneutics
and communications theory as a means to discover hidden meanings in
improvisations. According to Ruud, “music anthropology . . . made me realize
not only how deeply music is embedded in our culture but also to how great
an extent it produces culture and transforms social organization” (p. 16).
Stige (2002) promoted a music therapy practice that is culture-centred,
which he defined as having “a focus upon individuals and groups in context”
(p. 207). He argued that it is important for us as music therapists to situate
our practice within the contexts of the institution, the community, the political
sphere, and aesthetically (p. 209). He also promoted the use of hermeneutics
as a means of analysis in culture-centred music therapy (p. 302). Given the
exploratory nature of the current study, these aspects of context were not
deeply investigated, and context was explored mainly in terms of my own
stance as researcher.
The studies cited in this literature review mostly used quantitative
rather than qualitative methods. This may be due to the fact that the study
of gestures in music is a relatively new mode of inquiry, and large data sets
are necessary to support any claims made about relationships that may
exist between the gestures and the music. Qualitative methods, however, are
often very effective in discovering motivation and intention behind human
action. For this reason, I chose to direct this study towards a more descriptive
understanding of musical gestures and what they may mean for music
therapists and their clients.
Music Therapy and Gesture
Discussions of music therapy and movement are uncommon in the
current body of music therapy research. Ruud (1998) briefly discussed the
role of gesture in analyses of improvisation as communication in music
therapy. According to Ruud, “we can postulate that music is a language of the
body, through gestures and so on” (p. 74). He later likened the music therapy
experience to a text, which comprises “interplay among musical structures,
the client’s experiences, and the therapist’s interventions” (p. 110). He
argued that music itself lives somewhere between the world of gestures and
the world of language, and it is in the dialogue between these worlds that
improvisation takes place.
Behrends, Muller, and Dziobek (2012) explored the effects of an
interactional movement intervention on the development of empathy. They
posited that this kind of intervention could help people with autism spectrum
disorders develop empathetic relationships with significant others in their
lives. According to the authors, “recognizing the body of another person
as an expressive unity and the quality of one’s own nonverbal expression
(coordination of one’s own bodily responses such as emotion-congruent
gesture and posture) plays an important role throughout life” (p. 109). They
defined a reciprocal bodily interaction as the interaction between one’s own
perception and expression of oneself, the perception of the expression of
another, and the interaction itself, which may take the form of “imitative/
mimicry, complementary and contrasting elements” (p. 109). The authors
also referred to several studies in music therapy with autistic clients
that examine synchronous movements and the clients’ ability to enhance
interactive abilities (p. 111). These have not been translated into English at
the time of this study.
Goodill (2009) made an extensive study of the use of breathing in music
therapy and found that changes in breathing patterns can contribute to
integration of body and mind and to verbal and non-verbal congruence. Music
therapists often use breathing exercises for relaxation or as an introduction
to vocal exercises.
Holck (2007) used an ethnographic approach with video microanalysis in
her work with children with autism. These clients had severe communicative
limitations, and her method of interaction analysis included looking at how
deviations from established norms of communication and interaction in
the therapeutic relationship could inform observers about the nature of the
interaction. Temporality for Holck was easily established by music itself,
which served to organize all other elements in a music therapy session. She
proposed a two-way analysis (vertical for co-occurrences and horizontal
for patterns over time) in which these deviations could be examined in
contrast to expectations (which were observable, for Holck, in gesture and
facial expression) and an interpretation about the interaction could begin to
emerge. The main premise for her research was Wolcott’s (1990) question,
“What do people in this setting have to know in order to do what they are
doing?” Examining the pre-existing knowledge of clients and therapists and
their expectations based on this knowledge could therefore form the basis of
interpretations of a third-party observer of a music therapy session.
Method
Rationale and Definition
The methodology for this research project was an ethnographically
informed hermeneutic inquiry. Hermeneutic inquiry is a method that was
first developed to interpret the meaning of the Bible in the Middle Ages.
Modern secular hermeneutics was propagated by Dilthey (1996), Gadamer
(1960/2004), and Ricoeur (1990). This type of inquiry is defined as the
theory of interpretation. The process of hermeneutic inquiry necessitates
deep reflection, whereby the researchers examine their historical and cultural
contexts and how these inform the interpretation of data: the researcher
enters into the hermeneutic circle, moving back and forth between the
data and the interpretation, in order to search for an increasingly objective
account and a deeper subjective understanding at the same time.
Stige (2002) and Wheeler (2005) both discussed the use of hermeneutic
inquiry as a method to analyze interactions in music therapy sessions. Stige’s
main argument for using hermeneutics as a method of analysis in music
therapy was that music itself and the interactions that occur in a music
therapy session constitute a sort of text (p. 159). He discussed the importance
of studying meaning in music, interactions, and texts alike. For Stige, music
therapy research should aim for an eclectic approach that encompasses
hermeneutics, pragmatics, and empiricism (p. 307). Kenny, Jahn-Langenberg,
and Loewy (2005) sought to define hermeneutics for all music therapy
researchers; to summarize their view is beyond the scope of this paper, but
their final remarks were some of the most influential for me as I embarked
upon my own hermeneutic inquiry:
Hermeneutic research is not the type of inquiry that offers proof
of the existence of any phenomenon, unless, of course, we want to
say that we exist because we understand. It is an open-ended and
circular process that can be marked by diversity and creativity as
well as increasing levels of understanding. (p. 347)
Through undertaking the process of interpretation, I began to recognize
the importance for music therapists of understanding their client’s gestures
and how they are interacting with clients. In music therapy research, one
exemplary study by Loewy (1994) used hermeneutic inquiry to analyze a
panel’s assessments of videotaped sessions with an emotionally disturbed
boy to determine how music therapists come to know and assess clients. This
study and Holck’s (2007) study were the models which informed my own
inquiry.
Reflexivity in the Hermeneutic Method: Personal Process
I kept a research journal throughout the research process. This is a
recommended method for promoting reflexivity in both the qualitative and
hermeneutic traditions. Due to the nature of hermeneutic inquiry, I cycled
between levels of interpretation, and part of that interpretation involved
my own awareness of the contextual lens that informed my analysis of the
data. This journal provided me with valuable insights that grew from my first
impressions of the clients and the therapeutic relationship even before the
video analyses began.
Research Process
Participants. The research design and procedures were approved by
the approved by the research ethics review board at Concordia University
prior to my contacting several music therapists in nearby areas to be research
participants.
The first person who responded recruited a colleague working in the
same facility. I provided both music therapists with preliminary information
about the study, including an overview of the research question, methodology,
and procedures. I also provided them with information about the type of client
I was seeking for participation. I sought clients for the study who had worked
with a music therapist for at least six weekly sessions and had an established
therapeutic relationship, were comfortable with being videotaped, and were
able to give consent or attain consent from guardians to participate. I allowed
the music therapists to use their discretion in selecting individual clients for
the study.
At our first meetings, I provided the music therapists with a letter of
information about the study and a consent form. I then met with the clients
and their families to discuss the project, to answer any questions, and to
obtain written and verbal consent. They were given the details of the study
and information about the procedures. They were informed of possible
benefits and risks associated with participation and informed that they
could withdraw at any time. Each client gave verbal or gestural consent, and
consent forms were signed by their legal guardians.
Because of the nature of the videotaping process, I had brief telephone
consultations with each music therapist to screen the clients for possible
factors that could contribute to heightened anxiety or discomfort, such as
severe mental health problems, current issues in their lives, or other factors
deemed important by the music therapists. This screening took the form of a
brief telephone consultation with the music therapist.
Data Collection. I arranged to videotape two consecutive music therapy
sessions, approximately 30 minutes long, with each music therapist–client
dyad. I set up the video camera in the music therapy room prior to these
sessions but was not present for the sessions themselves, thus ensuring
that there was minimal effect on the gestures and emotional states of the
participants. The videotaped sessions were then transferred to a locked
folder on my personal computer for transcription and analysis.
Data Analysis. My analysis of the gestures began by using a simplified
version of Guest’s (2004) Laban movement analysis (LMA), a qualitative
descriptive model used to analyze dance movements. The aspect of LMA I
concentrated on for the purposes of this project was effort analysis, the
analysis of the intention behind a movement, which contains the subcategories
of space (either direct or indirect), weight (strong or light), time (quick or
sustained), and flow (bound or free). Effort terminology was useful for me in
my transcriptions to categorize and differentiate movements.
Holck’s (2007) interaction analysis (IA) method, based both in
ethnography and in music therapy, was felt to be particularly relevant to this
project. IA involves in-depth analysis using music as a temporal organizing
factor as well as analysis of session, episode, therapy event, and moment-bymoment process. Holck stated that “the object of ethnographically informed
research is typically the repeated actions, themes, or interaction patterns
of everyday situations. . . . Repeated interactions between people show that
these actually are interactions and not arbitrary parallel incidents” (p. 30).
Holck recommended a time analysis on two orientations—on the vertical
axis to show moment-by-moment co-occurrences and on the horizontal
axis to show patterns over time. In this way, the analysis can show how the
behaviours of the music therapist and client influence each other in the
moment and at the same time how the behaviours change or stay the same
over the session. Holck’s hypothesis was that if a pattern is established, an
outside observer can determine expectations of the participants. Deviations
from the pattern can be determined by how the music therapist reacts to the
client and vice versa.
Following this model, I used an Excel spreadsheet with headings
for time, music therapist gesture, client gesture, musical content, verbal
content, effort qualities, interaction analysis, and subjective notes. Time
was organized in 10-second sections for the purposes of consistency. The
amount of material retrieved from a 10-second span varied greatly. The
gesture analyses contained objective observations such as “right hand moves
upwards and touches guitar.” Musical content was analyzed in terms of which
instruments were being played, chord progressions, tempo, dynamic level,
and rhythmic qualities. Music was only notated in standard Western notation
if it was particularly significant to the gestures of either the music therapist
or client. Verbal content was transcribed in a similar manner. Effort qualities
were transcribed in LMA continuums—space (direct/indirect), flow (bound/
free), weight (strong/light), and time (sustained/quick).
Gestures can also be analyzed as serving epistemic (perception of
environment), semiotic (communication to the environment), or ergotic
(material action) functions (Cadoz and Wanderley, 2000). The main focus of
this analysis was on the semiotic function of gestures. When transcribing, I
noted which gestures occurred the most, were repeated, were most salient,
or were reflected by the therapist. I watched for which gestures fit the
categories of speech-accompanying or musical gestures. With the musical
gestures, I observed which could be categorized as instrumental gestures
(creating the sounds on an instrument) or ancilliary gestures (expressive in
nature) and which were in reaction to the sounds created.
I found that the most intuitive and appropriate method for a final
analysis of the transcriptions was based on music analysis methodology. I
chose to look at the structure of the gestural interactions in each session in
terms of gesture frequency, duration, size, simultaneity (music therapist and
client), part of the body, and repeated gesture sequences. A sample of these
analyses is included in the appendix.
I then colour-coded all transcriptions into five categories: (a) incomplete
descriptions that needed more information, (b) subjective observations that
needed to be justified, (c) assumptions, (d) observations that delineated
patterns or were indicative of repetitive behaviours, and (e) interactions
between the music therapist and client. Finally, I cycled between the
transcriptions, reviewed the original video recordings, and journalled in an
effort to gain greater understanding about the effects of musical gestures on
the interactions between the music therapist and client.
Hermeneutic Inquiry. I followed a method developed by Ricoeur as
summarized by Schmidt (2006). Ricoeur suggested that a hermeneutic inquiry
can be executed with mindful analysis on three levels. First, an inquirer must
analyze the text independent of the author’s intention (distanciation). In this
study, the text comprised the gestures, relevant musical elements, and any
significant verbal content. The first step involved transcribing the gestures,
speech, and music as objectively as possible, keeping all subjective analyses
coded and separate from the objective descriptions of the gestures.
Second, Ricoeur suggested completing a structural analysis to determine
the underlying form of the text (explanation). In this study that analysis took
the form of the IA and music analysis.
Last, an inquirer must compare the context in which the text was
created and the context of the inquirer themself and then deepen the inquiry
with respect to all of the information that was obtained in the first two stages
(interpretation). In this study, I analyzed the context of the music therapy
sessions, including the relationship between the therapist and client and the
context in which that relationship came to be. The final stages of the inquiry
included consideration of how I was using my own context as a lens through
which I was interpreting the data (the self-hermeneutic).
Results of Transcription Analysis. The sessions were transcribed
with a focus on the musical gestures and the interactions between music
therapist and client. I transcribed significant musical and verbal moments
if I saw that they were directly influencing the musical gestures themselves,
and I described the gestures in objective terms, such as “Samantha’s left hand
moves upward to brush away her hair on the left side of her face.” The process
of highlighting a pattern of movements when I noticed that it had occurred
more than once began to reveal structures in the text, which led me toward
preliminary explanations about what the text was saying.
Results
The two music therapist–client dyads are referred to here as Dyad 1 and
Dyad 2, with pseudonyms for all participants: for Dyad 1, the music therapist
was Paul and his client was Samantha; for Dyad 2, the music therapist was
Korina and her client was Jennifer.
Dyad 1: Samantha and Paul
Dyad 1 had been working together for four years on a weekly basis, since
Samantha was 2 years old. Their 30-minute sessions were a combination
of highly structured and client-directed music therapy. Samantha had a
diagnosis of autism and was mainly non-verbal except for one- to two-word
utterances and vocal sounds. The main feature of Samantha’s speech was that
it was highly repetitive but significant. For example, when Samantha took
Paul’s hand to begin the first of the two taped sessions, she urged him on with
“Go, go, go!” My first impression of this dyad was that they were comfortable
in each other’s company. Samantha appeared to be very familiar with the
structure of the sessions, while Paul seemed in tune with small changes in
Samantha’s demeanor; this is analyzed in detail in the gesture analysis below.
Samantha and Paul were also rhythmically attuned from the moment they
walked hand in hand into the music therapy room together.
Session 1. Samantha and Paul’s sessions were music-based with many
music improvisation and instrument playing interventions. The sessions
were quick paced with short transitions between each intervention.
Samantha played instruments, sometimes with hand-over-hand help from
Paul. Samantha’s gestures were repetitive on their own but also formed larger
complex repeated phrases. In LMA terms, her gestures could be described as
indirect, bound, strong, and quick whereas Paul’s were direct, strong, and
slower than Samantha’s. The frequency of Samantha’s gestures was very
high, having up to six or seven gestures occurring within a 10-second time
span. The quality of the gestures was of quickness, unpredictability, and
suddenness. Samantha’s gestures were often directly in response to the
music, especially since there was very little verbal content in Samantha and
Paul’s sessions.
Paul did not, as a rule, reflect Samantha’s gestures. His gestures were
infrequent compared to Samantha’s and were often employed to have a direct
effect on Samantha’s actions. There were moments in which he redirected,
prompted, and attempted to guide Samantha to focus on the intervention. For
example, he played tremolos on the guitar, which accompanied or prompted
Samantha’s head shakes. In this session Paul invented a game of patty-cake
with Samantha and, with gentle upward pushes, prompted her to remain in
time with the rhythm of the music.
The frequency of gestures was such that it was necessary for me to
analyze only the moments that involved some musical engagement. Each
gesture was coded as a number. The gestures were repeated often and with
little variation. This allowed me to discover overarching patterns present in
this session and across both sessions with Samantha and Paul. Some patterns
that emerged are as follows:
•
•
•
When Samantha shook her head back and forth, she tended also to
make eye contact with Paul, which she did not otherwise do unless
prompted first by Paul. Often, Paul played a tremolo to accompany
the head shake.
Samantha had a repetitive clap in which she clapped her right first
into her open left hand palm. This clap often matched the rhythm
of the music accurately. This gesture was often terminated with
Samantha clapping her right hand over her mouth.
When Samantha became very excited (squealing, laughing, and
smiling), she tended to bounce up and down on the circle drum
on which she sat, flap her hands (with elbows bent up and hands
shaking at shoulder height), and then slap her thighs. This was a
pattern that was repeated frequently, with some variance, over
this and their second session. This “dance” could also accompany
negative excitement or agitation (squealing, crying, screaming, and
frowning). Paul often responded to the dance with a change in tempo,
especially a slow ritardando, or a change in music. Often Samantha
immediately followed this dance with a sudden stillness, shifting her
gaze to her upper left-hand side, and dropping her arms to her sides,
with her hands touching the circle drum.
Samantha’s preference for certain sounds and music was clearly
communicated through her gestures. During this session, when Paul began a
song she did not like,, she immediately clapped her hands over her ears, and
her gestures became frantically paced while she bounced up and down and
flapped her hands quickly and suddenly. In general her level of engagement
was also clear through her gestures. She reflected rhythms in her movements
(particularly in her swaying, excitement dance, and hand gestures). The
frequency of her movements was often directly correlated to an increase in
the tempo of the music.
The patterns above formed the basis for what could be the expected
gestural content of these research sessions. The appendix contains a list of
significant gestural moments in the sessions analyzed.
Some atypical movements in the first session with Samantha and Paul
were as follows:
•
•
•
An unexpected song was played, and Samantha moved quickly
backwards, placing her hands on her ears.
Samantha guided Paul’s hand back to playing the guitar after he
paused for a moment.
Samantha had an infrequent hand gesture that may have been
significant—her right hand opened in front of her torso, palm inward
to the side, and she opened her fingers wide. This gesture occurred
with Samantha leaning inward and making eye contact, so it may be
that this gesture was an attempt for Samantha to make contact with
Paul.
Frequency of gestures in this session ranged widely but was generally
quick and sudden. Moments of frenetic movement were followed by abrupt
stillness. Paul’s gestures were slow and predictable, not sudden, and they
helped to ground Samantha’s gestures. The frequency of gestures significantly
slowed between songs.
Samantha’s movements could be classified as automatic, reflexive, or
intentional, according to Cadoz and Wanderley’s (2000) definitions. They
formed repeated, complex patterns that appeared to be related to rhythmic
and melodic aspects of the music, but these patterns changed rapidly and
unpredictably, and it was not clear whether Samantha always had control
over her movements. Paul’s gestures, on the other hand, were made with
the intention to interact with Samantha. Samantha’s movements primarily
served a semiotic function as they communicated to Paul what her intentions
and reactions were, opening the channel of communication between her and
Paul.
Session 2. Samantha and Paul’s second meeting was very similar in
structure to the first, with many improvisation and instrument playing
interventions. In this session, Samantha’s gestures followed a dynamic
pattern with clear phrasing and changes in tempo with gradual accelerandi
and decelerandi. Her “excited dance,” for example, took on slight variations,
becoming more complex and varying in size. Each time, the pattern was
followed by complete stillness. This dance–stillness pattern occurred six
times in this session, at regular intervals. The consistent frequency of gestures
was higher in the second session that it was in the previous one. Although
simultaneous occurrence of gestures was high in the first session, there
was consistently at least one gesture every 10 seconds in this session. The
occurrence of prompted eye contact that Samantha met was twice that of the
first session—six times versus three times. The amount of hand-over-hand
redirection in this session had also increased—Paul redirected Samantha’s
hands twelve times versus four times in the first session.
Although this data may be different from the first session, it was not
necessarily atypical, as Paul did not appear to take special notice. Moments of
significance are determined by whether they form a pattern over the session
or across sessions, by the reaction of the music therapist or client, or if the
gestures occur simultaneously between the music therapist and client. Some
examples of these atypical moments are listed below:
•
•
•
Samantha did not respond to Paul’s prompts in a way that was
expected when (a) she did not place her hand on Paul’s chin for
the hello song, (b) she did not shake her head on certain tremolos,
and (c) she did not make eye contact in certain instances when
Paul leaned in and attempted to make eye contact.
Paul subtly imitated Samantha’s head shake at the midpoint of
the session.
Samantha closed up her posture towards the end of the session,
and this was followed by a dramatic shift in tempo of gestures—
the gestures promptly became slow and had a flowing quality
(normally they had a more jerky quality), but then they suddenly
sped up towards the end of the session.
Samantha seemed to be repeating long-standing patterns of gesture
in this session but was also playing with those patterns through variation,
permutation, and lengthening/shortening. She indicated her need for
interaction and space via gestures in this session. Her gaze was indicative of
where her attention rested, and in this session, she looked downward and to
the right—directions in which she did not normally even glance. Samantha’s
emotional state was evident in the size and frequency of her gestures.
She accompanied unwanted songs or sounds with frenetic bouncing and
squealing, and Paul’s reaction indicated that he was eager to help regulate
her actions as soon as possible. Her moments of stillness seemed to be a kind
of self-regulation when we consider that they often followed almost frantic
periods of activity where gestures were larger, faster, and more repetitive.
Dyad 2: Jennifer and Korina
Korina had been working with Jennifer for under a year. When
videotaping began, they were seeing each other for the first time after a
2-week hiatus. Jennifer was a 28-year-old woman who was left paraplegic
after a car accident. Jennifer had previously been seeing Paul for an extended
period before Korina took over, so music therapy was not unfamiliar to
her. Jennifer was completely non-verbal but indicated choice with small
hand movements. Both music therapists agreed that much of their basis for
understanding Jennifer’s emotional state was her facial expressions.
My first impression of Jennifer was the same; although it may be
possible to analyze her gestures using a technical micro-gesture analysis, it
was evident that in Jennifer’s eyes lay a wealth of meaning. Indeed, it can
be seen below that an analysis of Jennifer’s gestures on first glance might
not provide an accurate picture of what Korina reacts to and is interacting
with in the sessions. It seemed to me that Korina was particularly receptive
to Jennifer’s non-verbal language, especially in relation to her emotional
state. She effortlessly recognized Jennifer’s subtle facial expressions and
interpreted them to mean, for example, that Jennifer was happy, was upset
by some content in the songs they sang, or had had enough for the day.
Session 1. Both music therapy sessions with Korina took place with
Jennifer lying in bed and Korina sitting by her side with her guitar. Korina
employed two interventions with Jennifer—songwriting and receptive music
listening, and Jennifer’s gestures were often in response to questions posed
to her. She raised her right hand when she wanted to say yes and did not move
when she wanted to say no. I was able to make inferences about the meanings
of these gestures based on how Korina responded to those gestures during
their moments of verbal interaction. Small variations on these movements
and her facial expressions gave Korina more information about how much
Jennifer wanted to engage. Jennifer did not play any musical instruments
during these sessions; therefore, when I talk about her musical gestures, it
refers to how she moved while listening to Korina play music. In LMA terns,
her gestures could be described as bound, direct, light, and slow.
The following are examples of Jennifer’s music-listening posture:
•
•
Her mouth would open and close, often imitating the syllables
sung by Korina
Her left foot often rose up in conjunction with significant
changes in the music such as a gradual crescendo, an increase in
tempo, or an ascending melody line.
And the following are examples of Korina’s music-playing posture:
•
•
•
Her head swayed in time with particularly rhythmic passages of
the music.
Her body leaned in slightly over the guitar towards Jennifer.
Her gaze was directed at all times on Jennifer, and her chin was
up and out while singing.
Jennifer’s body often moved slowly and subtly, but the movements were
significant. Her gestures were more frequent at the beginning and end of
songs. At the end of a song, Jennifer would often become still unless she was
prompted by one of Korina’s questions. Jennifer’s breathing patterns and the
openness of her posture at moments in the songs—sitting up straight with
shoulders back, hands far apart and looser than normally held—followed the
phrasing of Korina’s songs quite accurately. Jennifer’s gestures in this session
consistently indicated that she was engaging with the phrasing, dynamics,
and tempos of the music.
Korina did not observably reflect Jennifer’s gestures while singing
and playing guitar but instead would check in at the end of the song, asking
Jennifer if she felt something or if she wanted to continue or stop. Korina
observed small changes in Jennifer’s mood and would check in with her to
confirm if what she saw was actually happening. For example, there were
some moments where Jennifer suddenly became still and her left foot moved
downward abruptly. In those moments, Korina stopped and asked Jennifer if
she would like to continue. The most atypical moment in this session occurred
when, at the end of a song, Jennifer became completely still. Her shoulders
curled inward and her hands moved close in front of her chest, creating a
closed posture; her gaze drifted away from the music therapist; and her left
foot moved rightward (where normally it moved up and down only). At this
point, Korina checked in, and the session ended soon after due to Jennifer’s
distraught emotional state. This distress was communicated directly through
her body and in her facial expression
According to Cadoz and Wanderley’s (2000) terminology, all of Jennifer’s
movements were intentional, simple, rhythmic (in the case of the mouth
and eye movements), and slow. They serve both epistemic and semiotic
functions—they relate to how Jennifer perceives her environment and how
she wants to communicate with it. Korina’s movements may be analyzed as
being intentional or automatic, depending on the level of rehearsal these
songs have had. Functionally speaking, Korina’s movements serve all three
purposes of a musical gesture—they are semiotic, epistemic, and ergotic,
also fulfilling the purpose of material action on an object.
For Jennifer and Korina, the frequency of gestures, their size, and the
gestural repertoire itself remained mainly static (changing, but predictable)
except during the atypical moment outlined above. It seemed from analysis
that gestural patterns were established in prior sessions. It becomes evident
that Korina’s observation of Jennifer’s body language allowed her to be aware
of anomalies and to address them.
Session 2. The second videotaped session with Jennifer and Korina took
on much the same structure as the first. The session began with a songwriting
intervention and then led into a music-listening intervention. The pace of the
second session, however, tended to be much slower with fewer gestures per
song than the first. Both Jennifer and Korina’s gestural repertoire remained
similar, with some atypical moments. There was a less varied gestural
repertoire in Jennifer’s case. During this session, she did not open her mouth
wide (she did this in the first session during verbal interactions, presumably
to express amusement), and her right foot never moved downward as it had
in the first session, but her posture did open more frequently than it had in
the first session. There was also less physical contact between Jennifer and
Korina than in the previous session.
During the first songwriting intervention, Jennifer’s gaze drifted away
from Korina, and her movements were smaller and slower than they had
been in the previous session. As the session progressed Jennifer became more
physically engaged. Her left foot moved up and down along with the beat of
the second song performed by Korina. During the third song, Jennifer’s mouth
opened and closed throughout the duration of the song, clearly articulating
an inaudible “la, la, la, la.” Suddenly, after “singing” these syllables, Jennifer’s
posture closed—her shoulders curled inward, her hands met in front of
her chest, and her gaze moved downward. Her right hand moved upwards
(normally signifying yes), and her left foot suddenly darted upwards. There
were several moments during this session where Jennifer became very still,
not moving, with her gaze directed straight ahead.
Summary
Analysis of communication occurring via musical gestures can elicit
greater understanding of the non-verbal dynamics between a music
therapist and their client. Both these dyads developed characteristic gestural
repertoires over time while working with each other, and these gestural
repertoires served as a non-verbal mode of communication that was easily
understood by both client and therapist.
Discussion
Originally, my methodological design for this project involved a separate
type of analysis for each step of the hermeneutic inquiry in order to answer
the question, “What is communicated in the musical gestures of a music
therapist and their client in a music therapy context?” As I dove into the
project, I noticed that no one method was going to be completely subjective
or objective and that the only way to recognize the subjectivity was to be
conscious as I proceeded as to why I was attributing a particular meaning to
any one gesture. For example, why does a raised eyebrow convey skepticism
or disapproval to me? I noticed that this process of questioning my own
subjectivity began early on. As I transcribed the gestures in each session,
the salient moments were colour-coded. These moments were highlighted
for further analysis because they were the moments that would begin to
answer my research question and seemed to give meaning to the participants
themselves.
As my focus became sharper, however, it became clear that I wanted
to know more about the act of non-verbal communication itself. The idea of
looking at instruments was abandoned, and the question of culture became
secondary to the main focus of communication. It was very important for
me at this stage to become aware of my own assumptions and biases. To me,
this was the real beginning of the hermeneutic process, as I was beginning
to investigate my own context as researcher. After engaging with the
transcription data, some themes emerged that began to answer the question
of what was being communicated by these musical gestures in the context
of these sessions. Prevalent among these themes were context, holding and
stillness, and flow.
Context
Each instance of a subjective observation or assumption needed to be
carefully analyzed. What made me think that Samantha was agitated when
she bounced up and down and squealed, for example? The systematic nature
of the analysis allowed me to notice how the therapist interacted in these
moments, which in turn indicated whether there was some expectation that
was broken. It also allowed me to see the gesture in the context of the music,
the verbal content, and the larger overarching patterns of gesture that I
would not have noticed otherwise. My own process of journalling and inquiry
helped to elucidate the effects of my own context on my perceptions. For
example, I had preconceived notions about the functions of self-stimulating
behaviours in autistic individuals that were challenged during this analysis
by the level of interpersonal interactions present. The journals allowed me
to reflect on how the contexts of the clients and music therapists could be
shaping their behaviours.
The dyads had been working together for different periods of time. After
the analysis, I noticed that each dyad had a characteristic level of familiarity.
With time, it seemed, the therapist and the client tended to predict each
other’s gestural languages. The rhythm of Paul’s music-making and
Samantha’s gestures often harmonized, and his redirection of Samantha’s
gestures occurred almost in tandem with the gesture itself whereas Korina’s
verbal check-ins were reserved for the end of an intervention.
The gestural interactions of the dyads were also shaped by the diagnoses
of the clients themselves. Jennifer’s paraplegia allowed her to use only hand
movements, facial expressions, and small foot movements. This meant that
her gestures were often subtle and could easily be missed but also that they
were deeply meaningful. Samantha has autism, which is often characterized
by repetitive hand movements such as hand-flapping and rocking. According
to Volkmar, Paul, Klin, and Cohen (2005), research on autistic individuals
shows that gestural imitation is in many cases impaired, and in Samantha’s
case, her gestures were usually in time with the beat of the music. In fact, she
did not imitate Paul’s gestures, but she did make eye contact and provide
hand-over-hand assistance to Paul, which may indicate that she had learned
some gestures from Paul over their time together.
Holding and Stillness
Winnicott (1965) theorized that a therapist can provide an extension
of the safe mother–child environment through holding, a state of being in
which the therapist in the role of caregiver creates an environment that is
shaped around the client’s needs. In both dyads above, the music therapists
were much less active than their clients, producing fewer gestures over the
entire session and moving less in general. This may be indicative of the music
therapist’s desire to create a holding environment for their clients. It could
also be the result of taking an observational stance and being more receptive
in these moments.
In Korina and Jennifer’s first session, the effect that stillness can have on
a music therapist’s perception of client engagement became evident. When
Korina and Jennifer engaged with each other, their bodies were constantly in
some state of motion. Micro-gestures such as small facial twitches, clasping
of hands, or scratching the face may have given them some information about
each other’s inner state. When Jennifer became still, Korina may have seen
this as either an intense state of concentration and focus or, alternatively, a
disconnection, a desire to disengage. With both Jennifer and Samantha there
were significant moments of stillness, which communicated just as much to
the therapists as the gestures did in and of themselves. One such moment
came when Jennifer’s gaze drifted off and her body became still and no longer
responsive to the music. This was a cue to Korina as music therapist to wait in
silence and then check in verbally with Jennifer.
Flow
Both dyads presented significantly different gestural language outside
of music-accompanied moments than within them. Jennifer’s and Korina’s
movements became more rhythmic, and Jennifer’s foot movement often
matched the phrasing of the music, shown in the analysis. Outside of the
music her gestures only occurred in response to questions. Korina’s and
Paul’s gestures were also more rhythmic, whether or not they were the ones
producing the music. Samantha’s gestures were more prolific while playing
or listening to music than in the pauses between interventions. In general,
the most influential musical element on gestural style was rhythm, followed
by phrasing. Both clients typically moved in time with the beat. Samantha’s
gestural patterns often formed larger phrases, especially in the case of
her dance–stillness pattern, but these phrases were not evidently related
to musical phrasing. In Samantha and Paul’s second session, Samantha’s
gestures began to show a subtle relationship to dynamics, growing bigger
and smaller, more frequent and less frequent, with changes in the music.
Choice of instrumentation did not have a noticeable effect on the gestural
production of either client, but this may have become more evident over a
larger sample or over time.
The effect of music on the gestures of both clients and music
therapists was to create an underlying organizational force, or flow (see
Csikszentmihalyi, 1990) for the gestures to follow. Outside of the music,
gestures became predictable only in response to language. During the music,
gestures became patterned, predictable, and sometimes more flexible (in
the case of Samantha’s malleable gestural patterns in their second session).
Based on these observations, I can hypothesize that a speech-accompanying
gesture in these music therapy contexts is one which immediately follows
a question from the music therapist and is always intended to have a
semiotic function. Musical gestures in these contexts are both expressive and
pragmatic. They can be used to communicate, but even in those cases they
carry expressive content that is directly tied to musical elements like rhythm,
dynamics, and phrasing.
Self-Hermeneutic
I began the self-hermeneutic analysis by highlighting when I had made
assumptions, questioning what those assumptions were based on, and
investigating my own intuitions to better understand how my own context
was colouring perceptions and what I gave importance to. The research
journals served as a key to acknowledging my own bias—for example, that
meaning is mainly contained in gestures and less so in stillness. This process
also helped me to see the importance of the smallest of micro-gestures,
which can give a wealth of information about a client’s inner state. I noticed
that my own music therapy practice began to be shaped by the process I
was undergoing in the analysis of this data. I began to observe my clients’
gestures closely. I experimented with reflecting micro-gestures and facial
expressions and noticed how this helped me develop a deeper awareness
and understanding in my own practice. I found that these experiments often
helped to create exciting moments of play as conceptualized by Winnicott
(1965).
The process of watching the videotaped sessions repeatedly and of
separating my transcriptions into subjective and objective observations
helped me to analyze what I myself was seeing and what was perceived by
the music therapists and their clients. As Holck (2007) pointed out, actual
interactions, and not mere coincidences, are observable through the actions
of those whom we observe. When I saw Korina checking in with Jennifer, it
was my cue to go back and note exactly what was occurring with Jennifer that
encouraged Korina to respond that way. In this way, repeated viewings of the
videotapes allowed me to gain a more objective view of the gestures. My first
reactions were based on intuition. Repeated viewings let me check in with
the music therapist, observe the precedents to their responses, and integrate
this information across sessions.
When I was trying to engage with the data, I would visualize the gestural
repertoire of each client and therapist. This had an interesting effect when
thinking of a gesture in particular, since I could immediately visualize the
totality of the person. To me, this indicated that each person’s gestures are
so unique that they actually have the ability to portray a person’s personality.
When I reflected on this point in conjunction with the reading I had done
in preparation for this project, I realized that I may have been experiencing
Behrends et al.’s (2012) phenomenon of reciprocal bodily interaction.
Considering this made me wonder what the difference between an outside
observer’s and a music therapist’s experience of reciprocal bodily interaction
may be. Did the music therapists see the clients the same way I did? If not,
how could my own perceptions be shaping my observations?
Reflections
The accuracy of the analysis depended on my ability to determine the
meaning of each gesture. The choice of a hermeneutic inquiry meant that the
study focused on finding meaning through both the data being analyzed as
well as through self-inquiry and reflection on the analytical process.
I chose not to look at my own clinical practice because there is a
fine distinction between hermeneutic and heuristic inquiry, and for the
purposes of this study I have chosen to make this line clear. Though the
reflexive part of the hermeneutic inquiry included a discussion of my own
context as researcher, the main body of the inquiry needed to be about the
communication between the participants in the dyads. Indeed, my limited
experience with the populations represented by the clients in this study may
have caused me to miss significant musical gestures that a music therapist
more experienced with these populations may have noticed.
Musical Gesture as Communication
Wigram (2004) discussed using musical gestures to prompt, redirect,
empathize, and reflect, and both music therapists did so. Korina had decided
upon strumming patterns and rhythms with Jennifer in prior sessions. She
performed them while observing Jennifer’s gestural reactions, and altered
phrasing and tempo depending on Jennifer’s reactions. Paul used handover-hand to prompt and redirect Samantha if she was unresponsive or
temporarily unfocused. On several occasions he subtly imitated Samantha’s
gestures. Both music therapists incorporated the perceived intention behind
their clients’ gestures into the therapeutic process, showing their empathy
with the clients’ non-verbal behaviours. For example, Korina stopped playing
to check in if Jennifer’s gestures showed disengagement or distress. Paul
changed songs, redirected Samantha’s posture or gaze, and verbally reflected
her changes in mood in response to her gestural language.
An analysis of the musical gestures and the interactions they provoke
in these music therapy sessions has shown that Korina and Paul acted
as receivers of Jennifer’s and Samantha’s musico-gestural signals. They
processed these signals and this helped them to shape their therapeutic
responses, similar to therapeutic responses to verbal language. This may
show that a music therapist’s attention to gesture is just as developed as their
attention to verbal content.
Recommendations for Future Research
This study was limited to a small number of participants with specific
characteristics. Both clients were mostly non-verbal, which allowed the
research to focus on the role of gestures accompanying the music. Future
studies in this area could include clients and therapists from various
populations, which would help to paint a more diverse picture of clients’
motivations to respond to therapists with gestures and at the same time
highlight how different clients and therapists use musical gesture. Quantitative
studies may be able to further elucidate changes in the frequency of gestures
across several sessions or in relation to changes in musical content.
The findings of this study demonstrated the interpersonal and relational
effects of gestural imitation within the therapeutic setting. Future research
in this area could concentrate more systematically on the effects of gestural
imitation and synchrony on client and therapist attunement (see Stern, 1985).
Some interesting avenues of inquiry could include types of musical
gestures possible, the influence on gesture of other elements of music (e.g.,
harmony, texture), the role of mastery (comfort level on an instrument) on
musical gestures, and the role of socialization in the forming of musicogestural repertoire. Future research into musical gestures in music therapy
would benefit from collaboration with experts in dance/movement therapy,
musicology, and cognitive psychology. A more in-depth discussion of the
effects of cultural factors on musical gestures could help to expand on a
gestural approach to music therapy with clients as well as the development
of a body-centred approach in clients who have motor deficits, physical
disabilities, or autism.
As a music therapist, I have noticed that my own responses to musical
gesture in sessions are intuitive. These responses come from my own
experience of being human—from observing others and making meaning
of their gestures in my everyday life. These responses also develop from
training and practice as a music therapist. Therapists are trained to be keen
observers and listeners, and music therapists are specialists in observing the
effects of music on their clients. In conducting this study, I came to a deeper
understanding of the motivating factors for intuitive gestural interactions in
music therapy sessions. This awareness gave me an enhanced perspective on
client cognitions, emotional states, and levels of engagement. It is my feeling
that the development of a technique for analyzing musical gestures that is
intrinsic to music therapy would be invaluable in helping to better relate to
clients.
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Appendix: Significant Gestural Moments
Samantha and Paul: Generalized Patterns
•
•
•
•
•
•
When Samantha shook her head back and forth, she tended to
make eye contact with Paul (which she did not otherwise do unless
prompted first by Paul). Often Paul played a tremolo to accompany
the head shake.
Samantha had a repetitive clap in which she clapped her right first
into her open left hand palm. This clap often matched the rhythm
of the music accurately. This gesture was often terminated with
Samantha clapping her right hand over her mouth.
When Samantha became very excited (squealing, laughing, and
smiling), she tended to bounce up and down on the circle drum
on which she sat, flap her hands (with elbows bent up and hands
shaking at shoulder height), and then slap her thighs. This was a
pattern that was repeated frequently, with some variance, over both
sessions. This “dance” could also accompany negative excitement or
agitation (squealing, crying, screaming, and frowning). Paul often
responded to the dance with a change in tempo, especially a slow
ritardando, or a change in music. Often Samantha immediately
followed this dance with a sudden stillness, shifting her gaze to her
upper left-hand side, and dropping her arms to her sides with her
hands touching the circle drum.
When Paul moved around the room, Samantha followed him with
her gaze and her posture; remaining seated, she would turn her
body to continue visual contact with what Paul was doing.
Samantha frequently leaned in and out with the music, which also
reflected the rhythm of the music being played.
Samantha frequently placed her hands between her knees to touch
the circle drum she sat on, accompanying the end of a song.
Samantha and Paul: Atypical Moments
•
•
•
An unexpected song was played and Samantha moved quickly
backwards, placing her hands on her ears.
Samantha followed a moment of stillness with moving her gaze to
her right. (Typically, Samantha looked either to the left or straight
ahead.)
Paul invented a patty-cake game which kept Samantha in time
with the music and which was later translated into a bell-tapping
intervention.
•
•
•
•
Samantha avoided eye contact with Paul at the beginning of an
intervention involving the choice of three instruments and then
progressively closed up her posture (head down, shoulders curled
inward) when Paul leaned in to attempt to make eye contact.
Samantha guided Paul’s hand back to playing the guitar after he
paused for a moment.
Samantha systematically created variations on her “excited dance”
that involved adding new gestures, taking away gestures, or changing
the tempo of the dance.
Samantha did not respond either to Paul’s prompts or in a way that
was expected:
-
•
•
•
•
•
•
•
•
she did not place her hand on Paul’s chin for the hello song
she did not shake her head on certain tremolos
Samantha made unprompted eye contact with Paul several times.
Samantha’s gaze drifted to the right side at about the same time in
the both sessions.
Paul subtly imitated Samantha’s head shake at the midpoint of the
session.
Paul leaned back after Samantha did so during a song (not as part of
a swaying pattern).
Samantha closed up her posture towards the end of the session,
and this was followed by a dramatic shift in tempo of gestures—the
gestures promptly became slow and had a flowing quality (normally
they have a more jerky quality), but then they suddenly sped up
quickly towards the end of the session.
Paul reflected a moment of stillness for Samantha by creating a
pause in the music.
Samantha had an infrequent hand gesture that may be significant—
her right hand opened in front of her torso, palm inward to the
side, and she opened her fingers wide. This gesture occurred with
Samantha leaning inward and making eye contact, so it may be that
this gesture was an attempt for Samantha to make contact with Paul.
Samantha’s splayed open finger gesture reappeared but took a less
prominent or significant position, appearing only in the midst of the
excited dance.
Jennifer and Korina: Music Listening and Music Playing Postures
Jennifer’s music listening posture included the following gestures:
•
•
•
•
•
•
Her mouth would open and close, often imitating the syllables sung
by Korina.
Her gaze was in the general direction of Korina but moved back and
forth rapidly. At times she would gaze off into the distance, and at
other times her eyes would close.
Her eyebrows were angled upwards, which to some observers would
indicate wistfulness or dreaminess.
Her left foot often rose up in conjunction with significant changes
in the music such as a gradual crescendo, increase in tempo, or an
ascending melody line.
Her left hand was held in front of her chest with her wrist bent and
palm facing upward.
Her right hand was also held in front of her chest, holding a
handkerchief in her fist, the fist angled downward. She used her
right hand to indicate yes during verbal interactions, but she was
still while listening to music.
Korina’s music playing posture included the following gestures:
•
•
•
•
•
In LMA terms, her gestures could be described as direct, free, strong,
and slow.
She sat and strummed the guitar with large gestures (large
downstroke with a quick upstroke).
Her head swayed in time with particularly rhythmic passages of the
music.
Her body leaned in slightly over the guitar towards Jennifer.
Her gaze was directed at all times on Jennifer, and her chin was up
and out while singing.
Tango Improvisation in Music Therapy
L’improvisation de style tango en musicothérapie
Demian Kogutek, BMT, MMT, MTA
PhD Student, Rehabilitation Sciences, University of Western Ontario,
London, ON, Canada
Abstract
Little used in clinical improvisation, tango’s potential implications in music
therapy have not as yet been fully examined. The goal of this exploratory
research study was to incorporate tango music into a clinical improvisational
setting to see how the musical components of tango could expand the level of
musical communication possible in participants and how these components
could affect the therapeutic process. This qualitative research incorporated
both theoretical and practical applications, and the methodology was based
in grounded theory. Three clients from a long-term care centre participated in
tango music during clinical improvisation. They played tenor metallophone
while being accompanied by the researcher on classical guitar. The primary
data collection sources were audio and video recordings. The research
included a microanalysis of the improvisations, the results of which showed
how tango music had effectively altered the melodic contour, dynamics,
and tempo played by each participant. The research sessions also provided
a means for emotional relief and allowed the participants to incorporate
stylistic characteristics of tango into their improvisations. This is shown in a
measurable and quantifiable manner through music notation.
Keywords: music therapy, tango, clinical improvisation, qualitative
research, therapeutic relationship
Résumé
Peu utilisé en improvisation clinique, le potentiel de la musique de style
tango en musicothérapie n’a pas encore été suffisamment étudié. Le but
de cette recherche exploratoire est d’incorporer la musique de style tango
à l’intérieur d’un contexte d’improvisation clinique afin d’observer
comment les composantes musicales du tango peuvent élargir le niveau
de communication musicale possible des participants et comment ces
composantes peuvent influencer le processus thérapeutique. Cette
recherche qualitative incorpore à la fois des applications théoriques et
pratiques et la méthodologie se base sur une théorie empirique. Trois clients
d’un centre de soins de longue durée ont participé à de l’improvisation
clinique utilisant de la musique de style tango. Ils ont joué du métallophone
ténor en étant accompagnés par le chercheur à la guitare classique. Les
sources primaires de collecte de données théoriques et pratiques provenaient
d’enregistrements audio et vidéo. La recherche inclut une microanalyse
des improvisations dont les résultats illustrent comment la musique de
tango a efficacement changé le contour mélodique, les dynamiques et le
tempo dans la musique jouée par chaque participant. Les séances de cette
recherche ont offert un relâchement émotionnel aux participants et leur ont
permis d’incorporer les caractéristiques stylistiques du tango dans leurs
improvisations. Ceci est démontré de façon mesurable et quantifiable par la
notation musicale.
Mots clés : musicothérapie, tango, improvisation clinique,
improvisation clinique, recherche qualitative, relation thérapeutique
The use of clinical improvisation has been extensively researched and
written about (Aigen, 2005; Ansdell, 1995; Bruscia, 1987; Lee, 2003; Lee
& Houde, 2010; Nordoff & Robbins, 1977/2007; Pavlicevic, 1991; Ruud,
1998; Wigram, 2004). However, a less explored research area of clinical
improvisation has been the use of different styles of music. Lee (2003) and
Lee and Houde (2010) posited that music therapists should be knowledgeable
about multicultural styles and the general theoretical makeup of different
music from around the world. According to Aigen (2005), Paul Nordoff
reported a remarkable experience with the first client he worked with in
a music therapy context. He observed that while the boy seemed content
and serene when a Chinese pentatonic scale was played, the boy reportedly
cried when Nordoff altered the tones to a Japanese pentatonic. Nordoff went
back and forth between the two scales, and each time, he observed the same
reaction. If two different musical styles can generate two completely different
emotional responses, what are the implications of using different styles of
music in clinical improvisation? How then, can these implications be utilized
in a therapeutic setting?
Purpose of the Study
While I was growing up and studying music in Buenos Aires, Argentina,
tango music was an integral part of my life. After immigrating to Canada at the
age of 22, my connection to tango diminished somewhat, maybe because the
environmental incentive was not present any more. Many years later, I began
incorporating tango music in clinical improvisation sessions as a master’s
degree student at Wilfrid Laurier University in Waterloo, Ontario, Canada.
During these individual sessions, I noticed clients who had a tendency to play
similar rhythmic and melodic patterns throughout improvisations. My aim
as a student was on incorporating not only tango, but also different styles of
music, instrumental arrangements, and improvisational techniques in order
to expand clients’ musical vocabulary and communication while assessing
the clients’ acquirement of musical patterns and ideas over time.
It was because of my clinical work that I decided to conduct this
research. The purpose of this research study was to incorporate tango music
in improvisational music therapy. The objective was to expand each client’s
level of musical communication by analyzing the qualities of improvised
tango, specifically dynamics, rhythm, melodic patterns, and tempo, ultimately
linking the participant’s musical expansion to the development of the
therapeutic relationship.
In order to understand the implications of tango style during clinical
improvisation sessions, I formulated the following two questions:
•
•
How do the musical components of tango expand the client’s level of
musical communication?
How do the musical components of tango affect the therapeutic
process?
Research Design
Methodology
This qualitative research used a grounded theory approach. The goal of
this research method is to develop interrelated concepts that can describe
reality and at the same time generate new ideas (Amir, 2005; Glaser & Strauss,
1967). Semeijsters (1997) stated that reality is not described by means of an
already existing theory and hypotheses; instead, these can be generated from
and become grounded in the reality of a research study. This process requires
the researcher’s total immersion in the data in order to become intimately
acquainted with the data and develop a detailed knowledge of it.
The research began with the collection of data, and through this process
I was able to identify patterns, relationships, concepts, and categories. This
phase is called open coding. The second step, axial coding, was then done. This
involved procedures for connecting and relating categories and subcategories
found in the open coding (Wheeler, 2005). Most grounded theory research,
including the one described in this article, also incorporates data related to
self-reports, audio recording, and observations (Smeijsters, 1997).
Four clients living in a long-term care home were chosen to experience
tango style during clinical improvisation sessions. I invited the participants
to play the tenor metallophone while I accompanied them on classical guitar,
which is my main instrument. I chose the tenor metallophone for several
reasons: (a) the instrument produces a pleasant and interesting sound;
(b) it is simple to play and requires no previous musical training (Nordoff
& Robbins, 1977/2007); and (c) the instrumental sounds of the guitar and
tenor metallophone complement each other, providing the opportunity to
engage on equal musical terms (Pavlicevic, 1991), ultimately allowing me
through musical notation to explore not only rhythmic but also melodic
characteristics of the client’s response to tango improvisation.
For the purpose of the research, a reflective improvisation technique
was used (Wigram, 2004). This technique required me as therapist to begin
the improvisation with music that was reflective of the client’s mood at that
time. Grounding techniques were also incorporated to create a stable musical
environment by including music that acts as the anchor for the client’s music.
The similar techniques of holding and containing were employed, acting as
the musical anchor for a client who was ungrounded in his or her playing
and whose music was random and without direction (Bruscia, 1987).
Approximately five to ten minutes of improvisation, I transitioned into tango
style. After approximately two to five minutes of tango improvisation, I
transitioned back to the original style of improvisation and then continued
with the clinical improvisation intervention. I used an overlap transition
technique (Wigram, 2004), where the musical style was introduced while
continuing with the existing way of playing by using legato or smooth tango
arpeggios.
Participants
A total of four participants ranging in age from 46 to 87 years old each
attended one individual music therapy session per week for a period of eight
weeks. Three participants were female and one was male. All had different
diagnoses, which included Alzheimer’s disease, dissociative identity disorder,
and chronic obstructive pulmonary disease. Sessions lasted between 20 and
40 minutes, depending on the length of the improvisation.
In order to have greater transferability, which refers to a generalizability
of the research findings to broader populations and settings (Pomerantz,
2008), three out of the four participants were selected on the basis of their
different ages and diagnoses. A university research ethics board approved
this research, and informed consent was obtained from all participants
involved in the research.
A music therapy assessment was conducted in order to evaluate whether
potential participants were capable of playing the tenor metallophone. In
addition, clinical goals and interventions were established to address specific
needs of participants in order to maintain a therapeutic focus throughout the
research process. Table 1 presents the most relevant information gathered
during the clients’ assessments.
Data Collection Procedures
Audio and video recordings were the primary sources of data collection.
In each session, the participant sat across from me, and a digital video camera
was placed two metres from the participant and set at an angle that captured
both the participant’s and my profile. Two microphones were used; these
recorded the audio portion of the session to ensure a high quality of sound.
Data Analysis
For each participant, the tango portion of an improvisation was
selected and transcribed from the audio recording using Finale software. I
also selected and transcribed 30 seconds before and after the tango portion.
These two 30-second portions were used to compare the tango portion with
the surrounding musical style of the improvisation that was based on the
client’s mood. After printing the notation of the improvisation portion to be
analyzed, I employed three methods for data analysis.
The first method I used was Holck’s (2007) ethnographic descriptive
approach to video microanalysis. This is an informed approach to observational
research that studies everyday settings and seeks to understand actions and
their meanings in a social context. Using this method of recording interactions
for analysis, I began with standard music notation and then added gestures
and facial movements over the notation line, a technique described by Wosch
and Wigram (2007).
The second method I used was De Backer and Wigram’s (2007) analysis
of music notation examples. I analyzed the musical score of the selected
improvisation, and I notated figures in a structured way to identify relevant
sections and points in the score. I marked major sections with letters and
indicated details such as accents and dynamics in standard musical notation.
Having used these two methods to transcribe the music and add printed
notations, I then did a simultaneous analysis of both methods horizontally
and vertically. The horizontal analysis allowed for interpreting music and
meaning of action independently across time, while the vertical analysis
allowed comparison between music and action at specific points in time.
Table 1
Client Assessments
Participant
Client A
Gender/age
Male/85
Alzheimer’s disease
Diagnoses
Client B
Female/63
Client C
Female/47
Chronic obstructive
pulmonary disease
Dissociative
identity
disorder as a
result of herpes
encephalitis
Assessment
Client tended to
become stuck in
repeating rhythmic
and melodic patterns.
He played up and
down the scale
with both hands
alternatively, leaving
a tone or semitone
in between. He
demonstrated rigid
and perseverative
patterns in his
improvisation.
Client thrived in the
palliative care unit,
becoming ambulatory and
virtually independent, but
still required oxygen therapy.
Neurologically, she remained
intact. From an early age,
client was obligated by her
mother to take piano lessons.
She stopped studying music
after completing several
grades at the conservatory
of music. Her mother was
displeased with her decision.
Client felt her learning
process was too forceful
and was not an enjoyable
experience for her.
Client presented
negative
behaviours such
as entering other
patient’s rooms,
agitation, verbal
aggression,
non-compliance
to requests,
and socially
inappropriate
behaviors. These
behaviours were
difficult to manage
on the unit.
Clinical Goal
To provide client
with meaningful
social interaction
through the
use of clinical
improvisation.
To reconnect client
with music-making in a
nonthreatening way. Clinical
improvisation intervention
suited her needs.
Intervention
Attempts were made
to change the client’s
rhythmic, melodic,
and dynamic patterns
by encouraging
different rhythms,
chord progressions,
and the use of
different musical
styles.
A decision was made not
to encourage her to play
the piano, which the client
disclosed intimidated her,
and instead decided that her
playing the metallophone
would be a more positive
experience.
To increase
client’s ability to
remain on task by
maintaining goaldirected behaviors
through clinical
improvisation.
This provided
her with social
interaction skills
and furthered her
communication
through musical
dialoguing.
Provided
client with the
opportunity to
improvise on
instrument of
choice with
prompting and
encouragement
with a minimum
amount of verbal
interaction.
The third method I used was an indexed account of each session in its
entirety. The process of sessions was described, which led to interpretations
of the therapeutic process. This included a component where I engaged in
ongoing self-reflection. A critical component of the research process was
documenting the intrapersonal–interpersonal experiences and physical
sensations not visible on the video recording. Finally, any particular
interpretation of the data from the first two methods was compared to the
indexing of the entire session.
The use of these three methods of analysis made it possible to
understand the implications of tango from three different perspectives. The
music notation analysis provided a closer look at the improvisation, while
the recording of the participants’ actions provided a visual understanding of
the phenomenon. Finally, through analysis of the indexing of the session, an
even greater understanding of tango’s implications was gained. Throughout
this process of data analysis (axial coding), I was able to formulate categories
and sub-categories based on open coding.
Results
Categories
Three categories, each with subcategories, were developed from
the musical analyses: music qualities (phrase contour, tempo, dynamics);
emotional relief (sing, sigh); and incorporation of stylistic components
(glissando, syncopation).
Examples of Clinical Music Analysis
Example 1 (Phrase Contour). In the category of music qualities, the
tango style showed certain implications in all three participants’ musical
responses. This was expressed as shortening phrase contouring and
increasing dynamics and tempo. Phrase contour denotes the gross motion of
pitch, which contains the balance between steps and skips, and the role of the
melodic range over time (Müllensiefen & Wiggins, 2011).
An example of shortening phrase contour could be seen with Client
A, who tended to become stuck, repeating rhythmic and melodic patterns.
He played up and down the scale on the metallophone with both hands
alternatively, leaving a tone or semitone in between scale notes. Baker and
Tamplin (2006) describes this as perseverative playing, a tendency of some
people with cerebral lesions to persistently repeat the same note, movement,
or word.
Although Client A’s rhythmic pattern appeared to be triplets, this was
not obvious due to his lack of accentuation of down beats. I supported his
playing by introducing a tremolo accompaniment in a romantic classical
style on my guitar. In the following example, the notation of the client’s music
is located in the upper staff. The client’s repetitive motion was evident in
measures 16 to 20, among other measures in the excerpt:
Figure 1‐1 Figure 1‐1 Figure 1‐1 I introduced the rhythmic section of the tango style in measure 59.
Instead
of maintaining the repetitive motion, the client began changing this
motion to only one or two measures during the rhythmic part of the tango.
Figure 1‐2 By
measure 81, his melodic shape had a clear contour of an ascending and
descending
line:
Figure 1‐2 Figure 1‐2 Figure 1‐3 When I transitioned back to tremolo accompaniment in a romantic style
in
measure 169, once again the client’s repetitive motion lacked melodic
contour:
Figure 1‐3 Figure 1‐3 Canadian Journal of Music Therapy ∞ Revue canadienne de musicothérapie, 20(2), 173
Example 2 (Increase in Tempo and Dynamics). Before the
introduction of the tango section, Client B was playing mezzo piano in a slow
tempo as I improvised in a 20th-century musical style with arpeggios in the
lower register of the guitar:
Figure 2‐1 Figure 2‐1 With the introduction of tango, the rhythm intensified the dynamics and
tempo
of the improvisation. Client B’s dynamics changed from mezzo piano
to mezzo forte, and her tempo also sped up, resulting in shorter melodic
Figure 2‐2 phrases:
Figure 2‐2 Figure 3‐1 Example 3 (Incorporation of Stylistic Components). Two participants
incorporated stylistic characteristics of tango with the addition of rhythmic
cells,
adding glissandos and syncopations to their playing. Rhythmic cells are
Figure 3‐1 defined as a small rhythmic design that can be isolated or can make up part
of a thematic context (Nattiez, 1990). Before entering into the tango portion
of the excerpt, I matched Client C’s rhythm in a classical style using a simple
melody with an Alberti bass accompaniment. The rhythm contained eighth
notes that imitated the client’s musical style. She played eighth-note and
quarter-note rhythms with phrases that extended over several measures:
Figure 3‐1 When the tango syncopation with glissando was introduced, Client C
used syncopation for the first time in measure 36:
Figure 3‐2 Figure 3‐2 At measure 105, Client C played several glissandos:
Figure 3‐3 Figure 3‐3 Once again, Client C acquired the two most noticeable stylistic
components of tango—syncopation and glissando—and incorporated them
into her improvisation. She also used the syncopated cell and glissando after
the
Figure 4‐1 tango section was no longer present.
Figure 4‐1 Canadian Journal of Music Therapy ∞ Revue canadienne de musicothérapie, 20(2), 175
Example 4 (Emotional Relief). The use of the tango seemed to provide
emotional relief to all three participants. This was seen as singing or sighing
after the rhythmic portion of tango ended. The intensity of the tango rhythm
provided Client B and Client C with emotional relief, as the syncopated
rhythmic
sections transitioned to simple tango arpeggios. It was in measure
119
where
Client B expressed a deep sigh:
Figure 4‐1 Client A reacted in a similar manner, but instead of sighing, he simply
stopped
playing the metallophone and began to sing in measure 179, just
before
the
end of the analyzed example:
Figure 4‐2 Conclusions and Self-Reflection
Most resources that relate to clinical improvisation focus on techniques
that support the client’s musical intention (Bruscia, 1987; Lee, 2003; Ruud,
1998). As well, to meet and match the client’s musical intensity is an essential
starting point in clinical improvisation (Ansdell, 1995). The question that
arises is whether or not the therapist should establish music that challenges
the client. Pavlicevic (1997) stated that it is not always helpful to the client for
the therapist to match and meet the client’s music. In order to assist clients to
begin exploring and growing into the full potential of their dynamic form, the
therapist needs to alter the musical form, offering something new.
Within the context of this study, the tango portion of the improvisation
had two distinct moods. First, the tango arpeggios, which were used as
musical transitions from the client’s initial musical idea to tango and
vice versa, depicted the typical melancholic characteristics of the genre,
and a descending bass line with eight notes created an inviting musical
environment that supported the client’s musical intent. During the tango
arpeggios section, all three clients maintained the role of soloist. During the
rhythmic portions, the syncopation and upbeat marcato dance-like rhythm of
tango style contributed intensification and excitement to the improvisation.
These dance-like qualities of tango and its rhythms contain strong accents,
which can be interpreted as the rhythmic force that encourages movement
in dancers.
Thus, participants seemed to encounter some of this rhythmic force
during the improvisation, and the rhythmic qualities of tango created a
switch in the clinical improvisation. Within the musical structure of tango
style, participants were able to play more freely. The rhythmic portion of
tango created a middle ground in the improvisation where participants were
able to change their style of playing in response to the tango music. This
change process was most evident in the participants’ incorporation and use
of syncopation and their louder dynamics and faster tempos.
Musical intensification can also generate emotional relief. This was
manifested through a participant’s singing and sighing at the end of the
rhythmic portion of tango. Although this finding was the most interpretative
and was not clearly evident in the musical notation, I do believe that it was as
a result of the intensification of the musical style.
The structure of tango served as a means for musical dialogue where
participants expanded their musical communication by incorporating
stylistic characteristics into their own improvisation. This can be interpreted
as empowering clients within the therapeutic relationship through musical
equality during improvisation. The use of a musical style such as tango
can be fundamental to the therapeutic relationship, where the therapist
aims to empower their clients through music. If we consider that clinical
improvisation mirrors the therapeutic relationship, what then are the
implications of musically challenging our clients? If clients are asked to
musically match the intensity of a certain musical style, what then might the
benefits of that intervention be and in what context?
As clients develop their musical communication, the therapeutic
relationship may also gain equality. Sharing a social system with equal power
(e.g., improvisation) is the foundation for growth (Pavlicevic, 1991). The use
of tango in the clinical improvisation process can offer a similar exchange of
support and challenge found in relationships by incorporating its rhythmic
qualities of musical intensity.
References
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students. London, England: Jessica Kingsley.
Jungian Music Therapy: A Method for Exploring the Psyche
through Musical Symbols
Musicothérapie jungienne : une méthode d’exploration de
la psyché à travers les symboles musicaux
Joel Kroeker, MA, MMT, RCC, MTA
Registered Clinical Counsellor/Music Therapist, Victoria, BC, Canada
Psychoanalytic Training Candidate, CG Jung Institute Zurich
Abstract
The purpose of this qualitative heuristic investigation was to articulate the
interface between Jungian depth psychology and sound-based therapeutic
expressive processes. Through a phenomenological exploration of Jung’s
active imagination framework, I offer an improvisation-based mode of inquiry
for exploring human meaning-making capacity through the amplification
of emergent images from the psyche. Jung (1966b) theorized the existence
of energy residing in the unconscious realm and posited that individuals
can release this energy for conscious use by creatively manifesting it into
conscious symbols. Through the description of an original psychodynamic
method entitled archetypal music psychotherapy (AMP), a brief literature
survey, and data collected from 30 heuristic explorative self-trials, I
investigate how music-based symbolic processes can constellate conflicting
polarities towards a reconciling third way (i.e., tertium non datur) that leads
to integration and, possibly, the resolution of oppositional tensions.
Keywords: Jung, music therapy, psychotherapy, archetypal, psyche,
improvisation, self-care
Résumé
Le but de cette recherche qualitative heuristique est d’articuler
l’interface entre la psychologie des profondeurs jungienne et les
processus thérapeutiques expressifs basés sur le son. Par une exploration
phénoménologique du concept de l’imagination active de Jung, j’offre
un type de recherche basé sur l’improvisation afin d’explorer la capacité
de l’homme à rechercher la signification par l’amplification d’images
émergentes de la psyché. Jung (1966b) a conçu la théorie de l’existence de
l’énergie résidant dans l’inconscient et a avancé que les individus peuvent
libérer cette énergie pour un usage délibéré en la manifestant créativement
en symboles conscients. À travers la description d’une méthode originale
psychodynamique appelée psychothérapie archétypale de la musique (AMP),
un court survol de la littérature ainsi que des données colligées à partir
de 30 essais heuristiques personnels d’exploration, j’examine comment
les processus symboliques basés sur la musique peuvent s’organiser en
polarités contradictoires vers une troisième voie de réconciliation (c.-à-d.,
tertium non datur) laquelle conduit à l’intégration et, possiblement, à la
résolution de tensions oppositionnelles.
Mots-clés : Jung, musicothérapie, psychothérapie, archétypique,
psyché, improvisation, santé personnelle
As a training candidate in analytical psychology at the C. G. Jung
Institute in Küsnacht, Switzerland, I had the good fortune to speak with Carl
Jung’s grandson, Dieter Baumann, about Jung’s personal experiences with
music. It was interesting to hear firsthand accounts of Jung’s tremendous
sensitivity to musical material. His subtle level of responsiveness, which of
course influenced his development of analytical psychology, has also had a
profound and lasting effect on the evolution of all the creative arts therapies
(Marshman, 2003). In fact, Chodorow (1997) suggested that creative
arts psychotherapies (which include art, dance, music, drama, poetry,
and sandplay) can be traced to Jung’s early contribution. I undertook this
qualitative heuristic investigation to further articulate this interface between
Jungian depth psychology and therapeutic musical processes.
In 1913 Jung began to describe a process, which he eventually called
“active imagination,” that involved the amplification, interpretation, and
integration of affect-laden images (Jung, 1961). Jung’s process resulted
in an extensive document that came to be known as The Red Book and was
published in 2009. Exploring Jung’s framework phenomenologically, I used an
improvisation-based mode of inquiry for exploring meaning-making capacity
through the sound-based amplification of emergent images from the psyche.
Jung (1966b) theorized the existence of energy that resides within the
unconscious realm and posited that individuals can release this energy for
conscious use by creatively manifesting it into conscious symbols. Through
the description of an original psychodynamic method, archetypal music
psychotherapy (AMP), and a brief survey of literature, herein I investigate
how music-based symbolic processes can assist in constellating conflicting
polarities towards a reconciling third way (i.e., tertium non datur) that leads
to the integration and possibly the resolution of oppositional tensions.
Literature Review
Despite Jung’s tremendous impact on the understanding and use of the
creative expressive arts, his collected works explicitly mention music only
a few times. His only documented interaction with music therapy occurred
in 1956, when he requested a session with Margaret Tilly, chief music
therapist at the Langley Porter Clinic in San Francisco. According to Tilly
(1956/1977), Jung initially stated, “I have read and heard a great deal about
music therapy . . . but I never listen to music any more . . . because music is
dealing with such deep archetypal material, and those who play don’t realize
this” (p. 274). Tilly described their two-hour meeting as follows:
[Jung stated,] “I want you to treat me exactly as though I were one
of your patients.” I began to play. When I turned round, he was
obviously very moved . . . saying, “I don’t know what is happening to
me—what are you doing?” And we started to talk. He fired question
after question at me. “In such and such a case what would you try to
accomplish—where would you expect to get—what would you do?
Don’t just tell me, show me”; and gradually as we worked he said, “I
begin to see what you are doing—show me more.” I told him many
case histories . . . He was very excited and as easy and naive as a
child to work with. Finally he burst out with “This opens up whole
new avenues of research I’d never even dreamed of. Because of
what you’ve shown me this afternoon—not just what you’ve said,
but what I have actually felt and experienced—I feel that from now
on music should be an essential part of every analysis. This reaches
the deep archetypal material that we can only sometimes reach in
our analytical work with patients. This is most remarkable.” (pp.
274–75)
Watts (1972) referred to this meeting in his autobiography:
Shortly afterwards, Jung’s (musician) daughter (Marianne) said to
Margaret, “Perhaps you don’t realize that you did something very
important for me and my father. I have always loved music, but he
has never understood it, and this was a barrier between us. Your
coming has changed all that, and I don’t know how to thank you.”
(p. 394)
Despite Jung’s recognition of the potential significance of music in
psychoanalysis, a dearth of musical applications within Jungian and postJungian discourse has left a gap in the literature; and despite the many reviews
of Jungian approaches to psychodynamic depth psychology (Hillman, 2004;
Hollis, 2000; Johnson, 1986; von Franz, 1986), much of the literature relating
the creative expressive arts to Jungian clinical aims focuses on art therapy
(Furth, 2002; Mazloomian, 2006; McNiff, 1992 ), psychodrama (Gasseau
& Scategni, 2007), and dance therapy (Pallaro, 2007). There is also some
Jungian-inflected literature on music and therapy, which includes the guided
imagery and music research of Clark (1991), Merritt (1994), Short (1996),
Wesley (1998), Ward (2002), and Wärja (1994). In addition, Ammann (1998)
worked with concepts of Marsilio Ficino, and Ahonen-Eerikäinen (2007)
used Jungian imagery techniques in her group analytic music therapy model.
Still, aside from Kittelson’s (1996) phenomenological account of the role of
acoustic imagination in therapy and Hitchcock’s (1987) explication of the
influence of Jung’s psychology on the therapeutic use of music in relation to
the analytical music therapy work of Mary Priestley, scant literature exists on
the relationship between Jungian depth psychology and music.
Some of the work on Jung and creativity focuses on Jung’s proposition
that creativity can engage a healing power that resides in the unconscious
(Salmon, 2008), whereas other publications concentrate on Jung’s
differentiation between creative work produced for therapeutic purposes and
what he referred to as “art” (Marshman, 2003). McClure (1999) suggested
that connecting with the unconscious within a healing framework such as
psychotherapy can facilitate deeper knowledge of self and that creative media
such as music, movement, or art supply an avenue for connection to deeper
levels of psyche (p. 15). Csíkszentmihályi’s (1996) description of flow states,
which are characterized by feelings of energized and inspired full immersion
in creative activity, has achieved relevance to discussions of creativity and
psychological healing due to its widespread use in the positive psychology
literature.
The relationship between therapy (which often involves a therapist
and a client) and self-care (which may involve a self-administered therapeutic
method) is significant in regard to this current study. Aside from Ruud’s
chapter on musicking as self-care (2010), Bruser’s (1997) work on how to
avoid injury as a practicing musician, and Lamont’s (2003) master’s thesis
on burnout, there seems to be little literature on self-care within the field
of music therapy. However, some literature about creative expressive arts
therapies does draw on specific Jungian terminology in order to articulate
the subtle relationship between unconscious material and therapeutic
healing. Two examples are the article by Brooks (2000) on the anima imagery
expressed by men using guided imagery and music and Priestley’s (1987)
work on music and shadow. Barba’s (2005) work on songwriting for selfdiscovery and Skar’s (2002) writing about music and the search for self are
rare examples of direct focus on music creation from a Jungian perspective.
Core Jungian Concepts
In order to apply Jung’s contributions effectively within a music
therapy framework, it is important to clarify some of the subtleties of the
terms he developed. Some essential terminology includes the following:
Psyche. This term most often refers to the entire feeling and thinking
mechanism of an individual (Maude, 1999). Jung (1964) described
psyche as limitless and indefinable and as consisting essentially of images
(1960/1972). He envisioned the psyche in three levels: ego consciousness,
personal unconscious, and collective unconscious.
Archetype. Jung (1959/1981) described archetypes as primordial
patterns of psychic energy, originating in the collective unconscious and
primarily manifested in dreams. Jung considered both the ego and the self to
be archetypes in their own right (Barba, 2005). Ahonen-Eerikäinen (2007)
introduced the similarity between dream material and archetypal images
that emerge during music listening or improvisation.
Anima/animus. Jung (1917/1973) depicted the anima (or feminine
soul) as an archetypal quality within a man that could be considered the
totality of the unconscious feminine psychological qualities that he possesses
and the animus (or masculine soul) as the correlating set of contrasexual
masculine psychological qualities within a woman. He also suggested that
the anima or animus can show up in dream characters whose genders differ
from that of the dreamer.
The collective unconscious. Jung suggested (1959/1981) that our
immediate consciousness is of a personal nature and that there also exists
a second psychic system involving archetypal forms, which is of a more
collective, universal, and impersonal nature. He considered this second
system to be identical in all individuals and to be inherited rather than being
developed individually.
Archetypal psychology. Unlike classic or developmental Jungian
perspectives, archetypal psychology focuses on images or characters that
emerge from the psyche and how they can strengthen the individual when
given a voice (McClure, 1999). Archetypal psychology has been developed
further by the works of Hillman (1983), Campbell (1988), Moore (1993), and
Guggenbühl-Craig (1995).
Active imagination. This concept, developed by Jung, involves
the amplification and personification of archetypal dream images and
unconscious material while, in a waking state, initiating a dialogue with one’s
inner characters. Jung (as cited in Chodorow, 1997) suggested that this active
imagination process can lead to a voyage of discovery, which requires an
immersion in the creative imagination and its “uncertain path” (p. 3).
Complex. A complex is understood as a collection of ideas and images
orbiting around a core made up of one or more archetypes and characterized
by an emotional affect. Jung (1960/1972) suggested that complexes are
like splinter psyches, behaving like independent beings and that there is no
difference in principle between a fragmentary personality and a complex.
Compensatory images. Images that arise from the unconscious (such
as in dreams) often serve to compensate for the one-sided attitudes of the
ego in order to offset perspectives that are “not truly adaptive” (Beebe, 1993).
Sometimes the ego experiences these compensatory images as a threat, but
if one can respond receptively to them and manage to integrate them, this
compensation can help individual consciousness evolve towards greater
wholeness.
Individuation. Jung supplied two central definitions of this process.
In the first (1956/1967) he noted that it involves integrating the conscious
with the personal and collective unconscious towards the ultimate purpose
of achieving wholeness. In the second (1960/1968b) he declared it to be the
central aim and purpose of psychological development.
Jacobi (1942/1973) proposed four main guidelines for Jung’s conception
of the individuation journey:
1.
2.
3.
4.
Becoming conscious of the Shadow through confronting and
accepting those aspects of ourselves that we have repressed or
ignored;
Becoming conscious of the anima or animus (the contrasexual
souls in men and women), through which the contents of the
collective unconscious are filtered into the conscious mind;
Becoming conscious of the archetypal spirit by recognizing the
interrelationship of archetypal opposites (e.g., the realization
that we are capable of both good and evil);
Becoming conscious of the self, which Jung called “selfawareness,” which results in a psychic shift away from the fixated
perspective of the ego into a transformed attitude toward life.
Methodology
Because the activity of the psyche is too broad and far-reaching to
be definitively quantified, I have chosen to use Guba and Lincoln’s (1989)
non-positivist qualitative research paradigm that focuses on why and
how rather than on what, where, and when. My prior familiarity with the
phenomenological theme (Husserl in Alvesson & Skölberg, 2000) of this
project (i.e., Jungian depth psychology) renders this study, epistemologically,
as an emergent abductive study (Burks, 1946).
Jung (1960/1972) considered image and meaning to be identical and
suggested that as one takes shape, the latter also can become clear. I have
assumed throughout this study that this process can be observed through
changes in somatic sensations or mental/psychological states and through
the awareness of transformations of energy; I have also assumed that these
changes can be identified, articulated, and communicated. The framework I
have chosen for working with all emergent material (music, dreams, insights,
and images) is that of Jungian depth psychology (Jung, 1966a). I also employ
elements of music therapy theory (Ahonen-Eerikäinen, 2007; Bonny, 1993;
Bruscia, 1987; Priestley 1987; Stige, 2005) and expressive arts therapies
theory (Furth, 2002; Gasseau & Scategni , 2007; Knapp, 1988; Malchiodi,
2003; Mazloomian, 2006; Pallaro, 2007). These elements assume the
usefulness of creativity for therapeutic change.
The field of music therapy covers a wide range of psychological
perspectives ranging from behavioural models involving reward systems
(Madsen, Cotter, & Madsen, 1968) to exclusively music-centred models
focusing on music itself as therapy (Aigen, 2005; Garred, 2006; Lee, 2003),
to psychodynamic analytical models that combine words and music in a
therapeutic context for working with unconscious material (Priestley, 1975;
Scheiby, 2001). I have focused exclusively on psychodynamic models, since
this perspective most closely relates to Jung’s own clinical work.
My three research questions resulted from applying salient aspects of
Jung’s psychological theories to psychodynamic music therapy:
1.
2.
3.
What compensatory images emerge from the unconscious when
one integrates musical improvisation into Jung’s active imagination
process?
How do these images lead to meaningful therapeutic change?
How does this change contribute to the individuation journey?
Research Design
Influenced by Stige (2005), I undertook an emic first-person study
whereby I attempted to chart my own encounters with unconscious
material with a step-by-step process I developed. This was an expressive
arts-based process (Hervey, 2000) similar to Geertz’s (1973) descriptive
ethnomusicological case study that involved gathering and analyzing data
while taking into account the direct observations of the unconscious material
that emerged throughout the process. Moustakas’s (1990) heuristic research
methodology further informed my attempts to independently analyze and
interpret the data.
Within this ethnographic and philosophical inquiry (Wheeler, 2005),
I aspired towards “thick description” (Geertz, 1973) in order to describe
behaviour and context simultaneously. This work is ethnomusicological in
that the music and data are not only seen from a sonic perspective but are also
observed and analyzed from social, perceptual, cultural, and psychological
perspectives. As Stige (2005) suggested, ethnographic research can be more
than simply a research method: rather, it can be seen as an orientation to
research, both in self-reflective studies and in studies of others in which the
cultural is viewed as an inherent analytic and interpretive resource.
Using basic foundational research as described by Wheeler (2005), this
study was intended to increase knowledge on the fundamental relationship
between the practice of music psychotherapy and Jungian psychology. To this
end I used Kenny’s holistic paradigm (cited in Wheeler, 2005), which includes
a hermeneutic circle model in which symbolic representations of psyche are
viewed within a larger complex holistic system that is greater than the sum of
its parts (Patton, 2002); this process thus leads the researcher through a cycle
of experiences, contextualizations, separation into parts, and re-integrations
that in turn lead to new experiences (Wheeler, 2005). Interpretation and
meaning within this AMP method relied on a constant interaction between
the whole (i.e., everything that emerged from each session) and its parts (e.g.,
the individual archetypal characters that arose).
Trustworthiness of this Study
Researcher bias, which is always a potential issue with human participant
research, may be more possible within a heuristic qualitative case study
because the researcher is also the research instrument. As with any emic
study (i.e., one conducted by an individual who is a member of the culture
under scrutiny), positive results could be partly correlated with my belief
in the underlying value of Jungian psychological concepts as well as my own
significant history with Jungian psychodynamic work. To explore this aspect
of trustworthiness, participants at an AMP data analysis workshop were taken
through the various steps of this same AMP method and were then presented
with the data from this study. These participants’ valuable feedback revealed
correlations between their personal experiences with the emergence of
compensatory images and the results of this study. Similar experiential
correlations later received from participants at presentations given in Brazil,
Santa Cruz, Vancouver, Winnipeg, Halifax, and New York contributed to the
credibility, transferability, dependability, and confirmability (Lincoln & Guba,
1985) of this project and the efficacy and relevance of its methodology and
core categories.
Data Collection Procedure and Interpretive Analysis
The data were collected and analyzed through a four-phase process
that included conscious experience (e.g., musical improvisation); conscious
analysis (e.g., analyzing the musical data); unconscious processing (e.g.,
dreaming); and meta-analysis (e.g., analyzing and reflecting on my analysis
process). I employed elements of grounded theory (Strauss & Corbin, 1990)
in working with the data, including an open coding process using through
NVivo 8.
Phase 1. I created a self-administered multimedia process through
improvising with various artistic media including musical improvisation,
sculpture, spontaneous poetry, free- associative journaling, visual art,
improvisational gesture, improvisational film-making, and editing with
iMovie. Once this format was established, I underwent 30 sessions during
which I took myself through this archetypal music psychotherapy (AMP)
process. The step-by-step method is as follows:
1) Silence. Observe one minute of silence with eyes closed, to clear
mental space. This silent intentional space creates an objective
starting point to launch the session.
2) The question. Write down a question that is psychologically or
emotionally relevant in your life right now. This step sets an initial
intention that aligns the therapeutic process with current life
experience and situation.
3) Mini self-assessment (pre-treatment). Briefly summarize a state
you are currently experiencing physically/somatically, mentally,
emotionally, or spiritually. This step establishes a baseline from
which to observe possible changes at the end of the session.
4) The dream. Write down, with images or in prose, a potent image
from your most recent dream. This step gives a snapshot of the
current psyche state because the images that emerge in dreaming
are not chosen consciously or intentionally, but instead arise directly
from the unconscious (Jung, 1958/1970).
4a) Free associations. Highlight the most relevant aspects of the
dream and then make three free-associative links for each aspect.
This sub-step brings the dream image you have chosen more
concretely into consciousness while amplifying the unconscious
material and expanding your personal connections to it.
5) The aim. Write down one therapeutic aim for this session that
clearly pinpoints an obstacle you wish to transcend or integrate in
order to experience a greater sense of well-being. Have this aim
visible in front of you for the rest of the session.
6) The improvisation. Using any instrument or the voice, record a
short improvisation (5 minutes) that musically personifies the most
potent aspect of your chosen dream image or aim.
7) Amplifying the theme. While listening to the recording of the
improvisation, with eyes closed and using both hands (i.e., holding
one drawing utensil in each hand), draw a visual representation
of the musical dream image. Jung suggested that this art-making
process can contain or even alleviate feelings of trauma, fear, or
anxiety and can also repair, restore, and heal (Malchiodi, 2003).
8) Return to silence. Take four breaths in silence to allow integration
after this flow of activity.
9) Processing journal. While listening three times to the
improvisation recording, journal about the most significant images
or themes using free association, keeping in mind the aim from Step
5. This step could be treated like an adapted form of Bonny’s guided
imagery and music (Ward, 2002); in other words, you may treat this
recorded improvisation as your own personal “music program.”
10) The title. Write down a title for this session that symbolically
encapsulates the quality and experience of what has arisen.
11) Meta-analysis. Using free journaling, identify insights about and
significant elements of this particular process, focusing on anything
that was surprising or helpful in terms of the aim (Step 5). This step
allows you to index the experience at conscious intellectual, sensory,
and intuitive levels of awareness.
12) Mini self-assessment (post-treatment). To document any
changes that may have occurred, briefly summarize your current
state physically/somatically, mentally, emotionally, or spiritually.
Phase 2. I created a system for collecting and recording the material
that emerged from the 30 sessions of Phase 1. The collection and recording
process included working with software such as Garage Band, iMovie, Photo
Booth, and iPhoto. Working with these programs then became part of the
creative process during Step 6 (the improvisation) in the form of a musical
improvisation with visual aspects (i.e., pictures and video images) as per the
material that emerged from the unconscious during the AMP process.
Phase 3. I analyzed the emergent material according to Jungian
principles, using the following questions:
•
•
•
•
•
•
•
What symbols, characters, or energies emerged?
What compensatory aspects arose?
What role did music play in this session?
What recurrent archetypal theme(s) emerged?
How was this theme (or themes) reflected in the musical elements
(melody, harmony, rhythm, timbre, texture, dissonance, consonance,
or any other musical aspects) that emerged?
What change(s) occurred?
What short final personal suggestion or practice emerged from this
process?
Regarding the interpretation of musical data through improvisationassessment profiles, Bruscia (1987) stated that a psychoanalytic perspective
of musical assessment assumes that the elements of one’s music (e.g., pulse,
timbre, harmony, melody, modality, phrasing, texture, volume) are a symbolic
projection of unconscious aspects of the self (p. 450). Therefore, a change in
musical texture could reflect a correlating change in an individual’s internal
psychological state. In this way, music can serve as a consciously manifested
mirror that reflects an individual’s internal dynamics so that they can see (and
hear) these shifts more clearly. This process, in turn, can lead to significant
personal insights and therapeutic change.
Phase 4. The final phase involved formal written articulation of the
process and the resultant findings.
Results
Each of the 30 sessions produced a specific psychological issue, a
therapeutic aim, and an antidote in the form of a compensatory image;
the latter was then amplified through the archetypal music psychotherapy
process. I discuss the archetypes that emerged in the following sections.
The Shadow
One of the most striking types of symbolic archetypal characters
was called the Shadow by Jung (1959/1968c), who characterized it as
consisting of repressed weaknesses, shortcomings, and instincts, and stated
that everyone carries at least one; the less it is embodied in the individual’s
conscious life, the more dense and powerful it becomes. However, by also
identifying the Shadow as a central point of creativity (1959/1968c), he
indicated that these disowned aspects of self can yield great wealth and
healing in spite of their initially grotesque appearance. Numerous symbolic
shadow characters emerged by name within my data, including (session
number in parentheses):
•
•
•
•
•
•
•
•
•
Huge Black Spider (2)
Tall, Thin, Red-Haired Dogs (3)
Nine-Foot-Tall Green Witch (3)
External Animus Shadow Projection (9)
Oily Cloud of Dark Shadowy Negativity (10)
Inky Blackness (11)
Dark Poison (11)
Black, Oily Blob (12)
Slime and Muck (20)
Some liminal (i.e., transitional) characters also emerged from the
shadow aspects that seemed to carry both positive and negative connotations.
One was Lakehead Osho in Session 4, who was unhygienic, antisocial, and
somewhat dangerous but also offered the healing potential for “strength in
solitude,” which was the antidote for my psychological issue from that session
(i.e., feeling unwanted and rejected). Another liminal shadow character,
Mahakala the Wrathful Protector Energy That Cuts All Projection (Session 5
and 9), was uncompromisingly wrathful yet also compassionate in his wrath.
He activated the antidote to the feelings of “possession by the negative anima”
by skillfully and swiftly cutting away the misguided projection in a powerful
symbolic ritual act, which eventually led to the liberation of the True Inner
Anima. In Session 9, the external animus shadow projection, represented by
the Inky Black Shadow, actually transformed into Mahakala, who “focuses all
activity towards waking up and clarifying confusion.”
The Anima
Another major Jungian archetypal figure that emerged during these
AMP sessions was the anima, or feminine soul. She manifested in various
symbolic guises including the Dignified Ruling Queen, the Wild Red Woman
With Green Eyes, and the Great Earth Mother.
Jung (1917/1973) suggested that anima development in men is about
opening up to a broader spirituality and a new conscious paradigm through
connecting with the emotional world, including relational aspects of intuition,
creativity, and imagination. He identified four distinct levels of anima
development: Eve (the feminine as object of desire), Helen (the feminine as
self-reliant, intelligent, and insightful, but not necessarily virtuous), Mary
(the feminine as bearer of spiritual purity), and Sophia (the feminine as the
fully integrated personification of wisdom). By this final stage of integration,
he stated that the anima is too multifaceted for any single symbol to fully and
permanently contain.
Other Archetypes
Other archetypes that emerged throughout the data collection phase
included:
•
•
•
•
•
•
•
•
•
Wise Old Man/Woman (e.g., Old Gurdjieff in the Beautiful Spacious
Desert, Earth Mother, Four-Sided Triangle as King in His Court)
Syzygy (e.g., Balanced Older Couple)
Magician Shaman Healer (e.g., Dusty Snake Charmers)
Archetype of Resurrection (e.g., Phoenix in Magic Hour Light)
Divine Masculine/Feminine (e.g., Deep Masculine Voice That
Emerges in the Improvisation, Great Man, Regal King and Queen
Balanced Ruling Dyad)
Trickster (e.g., Slippery Dolphin Who Represents Playfulness Even
in Dangerous Waters)
Home (e.g., Source, Return to the Welcoming Home Village)
Hero (e.g., Desertscape Samurai, Black Shambhala Samurai, Heroic
Indigenous Masculine Voice of Strength)
Protector (e.g., Mahakala)
•
•
Nature and the Natural Elements (e.g., Great Eastern Sun,
Strengthening Fire, Orange Wind, Emptiness, Blue Triangle,
Orange Coiled Snake, Green Swan, Open Blue Sky Mind)
Artist (e.g., Henry Miller Who Plays Through Hoki, His Fifth and
Last Wife)
Music as Archetype
The recorded improvisational music that emerged through these 30
sessions could also be considered archetypal material (Lee, 2003; Nordoff &
Robbins, 1977/2007; Palmer, 1997). As Palmer suggested, music has been a
part of human existence for tens of thousands of years and thus has earned
its place, in and of itself, as an archetype within the collective unconscious.
In order to explore the archetypal significance of the improvised musical
elements within these sessions, I employed some aspects of Bruscia’s
(1987) improvisational assessment profiles. This involved analyzing musical
elements from the perspective of Jungian principles (i.e., personifying musical
elements such as melody, harmony, rhythm, timbre, texture, and dissonance/
consonance, and then engaging in dialogue with the most significant musical
characters).
In Session 16, for example, as the polarities within the Aphrodite
paradox became clear, my right hand on the piano personified one character
through angular light-hearted consonant melodic movement and my left
hand represented the opposing viewpoint in plodding (“heavy-handed”)
dissonant clusters. As the two hands encroached on each other’s territory
and crossed over in physical space, “a surge of electric energy shot through
my body and pinned me to this electric shocking fizz” (meta-analysis
journal entry). The improvisation itself became a musically rendered active
imagination dialogue between the two polarities, via my right and left hands,
which resulted in the two energies “finding their way back to the middle,
playing something somewhat consonant together, and then ending on a midrange neutral minor-ish chord . . . as if these warring energies found some
sort of resolution within me” (meta-analysis journal entry).
During my analysis of the various elements of this improvisation, the
final insight emerged in words: “Engage the strength of this transformed
mid-range music to break the spell of possession and polarization” (metaanalysis journal entry). The resultant quality of liberation emerged directly
from the archetypal musical experience itself, which I then further clarified
and integrated into my consciousness through words.
Compensatory Transcendent Function
From the results of this study, it appears that this AMP method provides
a way to constellate the opposites through artistic expression, as Jung (1966a)
recommended. It also seems that this constellation of the opposites engages
the psyche’s self-regulating function, as expressed through the consistent
emergence of unifying compensatory symbols and archetypal characters.
These images were translated into a meaningful antidote (a third way in
relation to the pair of opposites) to the psychological issue (i.e., the aim in
Step 5) through reflection and free-associative journaling, which resulted in
a direct relationship to the larger individuation journey.
Each of the 30 AMP sessions produced at least one significant
compensatory symbol, each of which led to a potent and relevant antidote.
Four main categories emerged:
•
•
•
•
issues relating to redeeming the negative anima (12 sessions)
issues relating to accessing and accepting inner resources
(7 sessions)
issues relating to energy level (5 sessions)
issues relating to personal life direction (4 sessions)
In each case the transcendent function (Jung, 1966a) was engaged
through a creative expressive modality, which resulted in clearly identifiable
therapeutic change. For example, in Session 1, “loneliness” was transformed
through the AMP process into “strength in solitude.” In Session 2, “unsettled
relational discord” resulted in the emergence of “the Balanced Older Couple.”
Individuation
According to Jungian theory, through observing the symbolic images
that arise via creative processes we can reintegrate the neglected and lost
parts of ourselves. By doing so we give them harmonious expression through
the unification of opposites in order to return to our natural state of inner
wholeness. Through the development of this AMP method and through
undergoing 30 sessions, the material that emerged revealed a correlation to
Jung’s four-stage individuation formulation. I have placed the aspects that
emerged (below) into their particular stages.
Stage 1: Becoming conscious of the Shadow. Shadow material
emerged in Session 1 and continued to appear in various manifestations
throughout the 30 sessions. At times the shadow aspects resulted in negative
physical sensations (e.g., tight stomach, constricted breath, compression
in back of head); adverse mental associations (e.g., enraged, overloaded,
worried); and unfavorable musical representations. For example, in Session 5,
I wrote, “The harmony was like big migraine piles of dissonant metal bowling
balls dropped on a metal floor in a racquetball court,” and in Session 9 I wrote,
“Aggressive sharp staccato texture like a dangerous pecking carnivorous
man-eating dinosaur bird.” Some shadow aspects underwent tremendous
symbolic transformations over the course of the sessions; through analysis
and reflection, these led to a greater acceptance of the multifaceted nature of
my personality.
The transformation of this shadow material also revealed itself
musically within the improvisations, which made me think that individuation
and shadow-integration can be expressed through sound. For example, in
Session 3 the “low clustered jabbed mucky keyboard chords . . . grab onto my
vocal notes and pull them down,” is shadow activity, but then at 2:59 in the
same improvisation I wrote, “Some change happens” during which “I lock in
melodically with the harmony.” This shift was experienced as a moment of
transformation in which “this . . . musical groove restores my own access to
my . . . energy.” This renewal of vitality led to the emergence of a compensatory
archetypal hero, Lakehead Osho, who “restores personal agency.” This
transformation resulted in the physical experience of “being able to breathe
again now . . . feels good . . . huge deep breath.” In short, the shadow material
manifested in the musical elements, which were then worked through
musically between the contrasting elements (e.g., dissonance vs. consonance
or clusters vs. angular melody) until emotional harmony was re-established.
Stage 2: Becoming conscious of the anima/animus. Twelve of the
sessions dealt specifically with issues relating to redeeming the negative
anima; in fact, this was the largest single issue that arose over the entire
project. Although hints of the full cycle of Jung’s (1917/1973) four-stage
anima development (Eve, Helen, Mary, Sophia) emerged within the data, the
most striking aspect of this development was how these anima images (along
with their interrelationship with the shadow material) transformed and
evolved on their own from one session to the next. For example, the shadow
aspect of the Terrifying Tall Red-Haired Dogs (Session 3) eventually became a
developed anima image of the Wild Red Anima With Green Eyes Spinning Silk
(Session 25). Both images shared common associations, except the first was a
more primitive, terrifying, detached energy and the second was an elaborate
relational image of the feminine soul.
The Session 25 improvisation resulted in a profound experience of
“knowing where I am in the music” and “being able to match the pace of
the notes with my feelings in real time (without fixation or editing),” which
led to an experience of “non-attached observation of external phenomena.”
This internal experience of letting go of my inner “Wild Red Anima” led to
an external experience of “letting go” of a painful external anima projection.
This direct relationship between inner symbolic work and an increase in
external wellness is precisely the sort of therapeutic change for which I
created this AMP method. My experience here indicates that these potent
internal experiences of symbolic surrender can sometimes be generalized
out into the external “real” world towards a positive aim (e.g., letting go of
old, outdated wounds or repairing broken relationships).
Stage 3: Becoming conscious of the archetypal spirit. Jung
(1959/1968c) suggested that the phenomenon of spirit is an autonomous
psychic complex that, like other complexes, manifests in consciousness as a
personal being (e.g., in personified symbols). Jung described archetypal spirit
as a dynamic principle with a revelatory character and suggests that embracing
such examples of wider consciousness can give life a sense of meaning that
makes ego-based existence seem dull in comparison (1959/1968c). Jung
(1959/1968c) suggested that Spirit typically appears in the symbolic form
of the Wise Old Man archetype (e.g., Wise Old Gurdjieff from Session 1), the
Magna Mater Great Earth Mother (e.g., the Earth Mother from Session 9)
and the Superior Master and Teacher (e.g., the Desertscape Samurai from
Session 8). According to Jacobi (1942/1973), Jung’s individuation process is
primarily one of uniting opposites: matter and spirit, form and formlessness,
body and psyche.
Jung (1934/1968a) suggested that the process of integration involves
the gathering of many into a singularity. One example of this unification and
the subsequent compensatory emergence within the AMP process occurred
in Session 1 when Old Gurdjieff in the Beautiful Spacious Desert gave rise to
“an inner resource of strength in solitude” in response to the “overwhelming
weakness of loneliness.” This renewed quality of strength was reflected
musically in “the resilient authority of the vocal quality in the improvisation,”
resulting in a constellated “unified theory as source of psyche.”
Another example of therapeutic change through the emergence of a
symbolic reflection of an archetypal spirit occurred in Session 8 when The
Desertscape Samurai introduced a therapeutic ritual (i.e., shaving my head)
in order to achieve the aim of “becoming free from an old persona that is now
too small.” The Samurai presented an internal image of “mercifully destroying
all that is extra” in order to “cut me free from this irrelevant and diminishing
self-image” which, when completed by the external ritual of shaving my head,
led to “renewed vitality and inner resources.” This change, from “feeling
trapped by an old worn-out identity” to “a feeling of liberation and renewal,”
was reflected in a stark change in texture in the music. At 6 minutes into
the improvisation the texture becomes “peaceful and beautiful, which is a
change from the dark brooding beginning. . . . Some dynamic equilibrium
was reached here, as shown in the suddenly gentle parasympathetic voice
quality.”
Stage 4: Becoming conscious of the self. Jung considered the
self, the primary archetype of unified wholeness, to be the ideal product
of the individuation journey. The self is both the whole and the center
(Zweig & Abrams, 1991). Some symbolic reflections of wholeness within
my data include the “rectangular square cement shallow pool” of Session
3, the “beautiful Shambhala painting of a Samurai spreading a sheet of
shambhala light all around to the four corners” from Session 12, and the four
symmetrically spaced characters in Session 16 (i.e., Blue Triangle, Yellow
Great Eastern Sun, Orange Coiled Snake, and Green Swan).
After decades of analyzing the dream images of his analysands, in
regard to the symbolic significance of the square and the number four, Jung
(1934/1968c) stated that “[mandalas] are all based on the squaring of a circle
. . . a kind of central point within the psyche, to which everything is related,
by which everything is arranged, and which is itself a source of energy” (p.
322). For me, these symbolic aspects of wholeness were accompanied by a
tremendous sense of balance and stability, physically and psychologically; it
even seemed as if the final insights gained from each of the 30 sessions came
from this same sense of grounded composure and equanimity. By combining
the final insights from each of the AMP sessions, I was able to recognize a
more complete personal individuation story.
Discussion
Given the diverse imagery that emerged and the consistent results of
these 30 AMP sessions, I believe that this method can be a way to engage
and amplify the inner symbolic world of the participant that is effective and
results in greater clarity about inner dynamics and polarities. The most
effective elements of the method include the identification of a personal
issue, emotion, or therapeutic focus, as well as the willingness to express this
aspect symbolically through creative means in order to apply any emergent
insight to one’s external life experience.
The increases in energy I documented after each AMP session
reminded me of Hillman’s (1979/1989) statement that engaging with the
deepest patterns of psychic functioning can lead to a fundamental animating
quality of vitality (p. 41). The renewed sense of life energy and wholeness
that emerged for me through the creative aspects of this AMP method
seemed to confirm the Jungian proposition that creativity can engage a
healing power that resides in the unconscious (Salmon, 2008). As previously
noted by McClure (1999), the archetypal characters that emerged within
this AMP process tended to lead the way to experiences of personal strength
when intentionally given expressive voice (p. 17). My experience here echoed
Jung’s statement that surrendering oneself to become immersed in the
creative imagination and its “uncertain path” (1968/1997, p. 91) can lead to
a voyage of personal discovery.
Due to the self-administered aspect of this therapeutic work, its use is
in some ways contraindicated. Participants would do well to have a trusted
friend or colleague in mind—or a therapist—to contact if they should find
themselves overwhelmed by the unconscious material that arises (Johnson,
1986). Participants who tend to disassociate during creative flow experiences
or in the presence of extended spans of music, or anyone who is taking
psychoactive medication, should undergo this process only in the presence
of a trained therapist.
For me, many of the strong energies that arose via these archetypal
symbols served to compensate for one-sided attitudes of the ego, and thereby
offset perspectives that were “not truly adaptive” (Beebe, 1993). This shift
in perspective, which occurred many times within these sessions, resulted
in the transformation of internal feeling states and external behaviours. For
example, emotional states such as isolation (Session 4), anxiety (Session 5),
and aggression (Session 9) were transformed through this AMP process into
“inner confidence,” “playful curiosity,” and “re-integrated energy towards a
positive vision.” It seems that the intentional identification of a particular
therapeutic aim and the adherence to this aim throughout this AMP process
can provide a way for the conscious mind to contribute to the profound
compensatory function that is naturally served by unconscious symbols.
At times within the sessions, my ego experienced these compensatory
images as a threat (e.g., the Inky Black Blob). But when I managed to
respond receptively to them, transformation became possible (e.g., the Blob
transformed into the Engine of Consciousness). At this point, one might
manage to move past the fear (as I did) in order to integrate these energies
and redirect them towards a greater sense of wholeness.
In light of Jung’s suggestion that the central aim of psychological
development is individuation through integrating conscious and unconscious
aspects (1934/1968a), it is interesting to note that all four of Jung’s main
guidelines for the individuation journey (becoming conscious of the Shadow,
anima/animus, archetypal spirit, and self) as described by Jacobi appeared
within these sessions. Their appearance seems to affirm that the stages of
individuation are indeed closely linked with symbolic inner processes and
that the act of intentional creativity, as suggested by Stein (1995), can open
the self to the potential for transformation from a fixated ego-consciousness
to a wider psychological wholeness. This move from a one-sided view to
a perspective that is expansive enough to include various contradictory
elements well describes the experience of personal therapeutic change and
liberation.
Such change is often achieved through an intensive therapeutic
relationship with a therapist. Jung suggested that the role of therapist is
to mediate the transcendent function for patients by helping them bring
the conscious and the unconscious together and thereby to arrive at new
attitudes (Campbell, 1971). It is interesting to note that AMP offers a selfadministered path to this experience of personal liberation. During AMP
sessions, participants are empowered to take on the role of self-guide (i.e., to
become their own therapists) as they negotiate between their own conscious
and unconscious worlds while staying true to their own chosen therapeutic
aims. Crossing this threshold between consciousness and the personal
unconscious by constellating the opposites through artistic expression seems
to engage the psyche’s natural self-regulating function, as displayed by many
of the potent inner and outer transformations that occur within this process.
Finding lasting psychological resolution through this solo restorative work
could be experienced as a major therapeutic achievement.
Further Study
Exploration of these results from the perspective of other Jungian
categories such as psychological typology (e.g., the Myers Briggs Personality
Inventory, Myers, 1980), complex theory (Jung, 1958/1971), or synchronicity
(the acausal connection between two or more psychological or physical
phenomena; Jung, 1972), could be beneficial. For example, an individuals
could use AMP to help identify and develop their ego dystonic (i.e., inferior)
personality functions instead of continuing to default to their usual personality
patterns. Or one could use AMP to explore the therapeutic efficacy of creative
processes while in a “complexed state” or the synchronistic relationship
between internal symbols and external events.
Reflections
Along with providing an effective self-care modality, the material
that arose during these sessions also had a significant impact on my own
clinical work with adults, teens, and seniors. Working with issues through
the amplification of this emerging inner material led me to a greater personal
understanding of the relationship between external conflicts and internal
dynamics. Clarity about these intrapersonal relationships then generalized
to interpersonal clinical situations, leading to significant insights regarding
key therapeutic aspects such as transference, countertransference, projective
identification, and parallel process. Through AMP, personal insights gained
from directly confronting and exploring one’s inner world can correlate
directly with one’s clinical choices within a session as a therapist, and thus
can increase one’s effectiveness as a therapist.
For me, the vulnerable experience of coming into contact with my own
inner polarities has led to greater flexibility and empathy in my work with
music therapy populations whose aims include increasing flexibility and
decreasing oppositional black-and-white thinking. The deeply emotional
experience of discovering a “third way” to negotiate a seemingly impossible
ego stance, which occurred in the AMP sessions through dialogue with
compensatory images, has not only increased my ability to integrate
difficult emotions but has also enriched my relational abilities in a clinical
setting. Forging such links between inner experience and external relational
behaviour lies at the heart of this AMP work.
In conclusion, I feel that the ultimate aim of this restorative AMP work
is to move towards a unitive state of awareness. In turn, this state not only
brings unconscious elements to consciousness through amplifying inner
symbols but also opens the door to ongoing dialogue between the inner
and outer aspects of the human experience. The process of creating and
experiencing this AMP process, and analyzing its results, has shown me that
creatively reconnecting with these inner characters who are often disowned
through trauma or neglect can significantly contribute to re-establishing a
greater sense of well-being.
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Création d’un programme de musicothérapie pour
les proches aidants de personnes ayant la maladie
d’Alzheimer
Christelle Laforme, MMT – MTA
CHSLD Groupe Champlain de la Montérégie, Varennes, Québec, Canada
Résumé
Les proches aidants peuvent présenter plusieurs signes de détresse (stress,
émotions difficiles, symptômes physiques, isolement, dépression, etc.)
lorsqu’ils accompagnent leur proche qui est atteint d’une maladie. Cette
recherche décrit une étude qualitative qui explore comment un programme
de musicothérapie pourrait soutenir les proches aidants de parents étant aux
stades modérés de la maladie d’Alzheimer. Le programme s’inspire de la revue
de la littérature ainsi que d’une entrevue auprès d’une musicothérapeute.
Les résultats montrent que les techniques les plus utilisées avec les proches
aidants sont la composition de chansons, la poésie et l’improvisation musicale.
Cette recherche théorique propose un programme de douze semaines pour
un groupe d’aidants naturels et recommande que la recherche se poursuive
pour ainsi mieux répondre aux besoins de cette clientèle grandissante vu le
vieillissement de la population et une augmentation des cas de la maladie
d’Alzheimer.
Mots-clés : musicothérapie, programme de musicothérapie, proche
aidant, Alzheimer, étude de cas
Abstract
While accompanying their relative suffering from a disease, the family
caregivers may show various signs of distress (stress, difficult emotions,
physical symptoms, isolation, depression, and etc.). This study describes a
qualitative study through the exploration of a music therapy program aiming
the possibility of supporting family caregivers of parents in moderate levels of
Alzheimer disease. The program draws its inspiration from literature survey
and from a music therapist interview. The findings demonstrate that the most
efficient techniques used with caregivers are song writing, poetry and music
improvisation. This theoretical research is inviting a group of caregivers
to a twelve-week program and recommends the research continuity for
consequently better serve the needs of this growing population given the
ageing population and an increase of cases of Alzheimer disease.
Keywords: music therapy, music therapy program, family caregiver,
Alzheimer, case study
La maladie d’Alzheimer est la forme la plus répandue d’une grande
catégorie de troubles cliniquement qualifiés de « démence » ou de maladie
neurodégénérative (Diamond, 2006). Selon la Société Alzheimer du Canada,
cette maladie du cerveau se caractérise principalement par la détérioration
progressive de la pensée et de la mémoire. Les cellules nerveuses du
cerveau meurent en raison d’activités « anormales », les principales étant
le développement de « plaques et d’écheveaux » que le Dr Alzheimer a été
le premier à décrire il y a 100 ans (Diamond, 2006). Les symptômes sont
accompagnés de pertes dans d’autres sphères comme les habiletés sociales ou
le langage (Clair & Davis, 2008), allant de brèves pertes de mémoire à la perte
du langage et du fonctionnement (Diamond, 2006). De ce fait, les proches
aidants voient leur vie modifiée lorsqu’une personne de leur entourage est
atteinte de la maladie : « Caring for an elderly person with dementia is no
easy task and it implies an emotional, physical, social and in the long run
also financial burden » (Dröes et al., 2004, p. 214). Selon la Société Alzheimer
du Canada, plus de quatre millions d’individus seront atteints de la maladie
d’Alzheimer ou d’une maladie connexe au Canada durant les 25 prochaines
années s’il n’y a pas d’avancées médicales significatives (Société Alzheimer
du Canada, 2011). Il y aura ainsi plus de proches aidants et on peut croire que
les établissements de santé auront de la difficulté à répondre à la demande.
Il existe déjà des programmes de soutien pour les proches aidants, soit
des groupes de soutien d’éducation, d’autres qui utilisent des techniques
de gestion du stress, des programmes de stimulation cognitive, du soutien
individuel à la maison, etc. (Dröes et al., 2004). Pour sa part, Clair (1996)
traite de l’utilisation de la musicothérapie auprès des proches aidants de
personnes ayant la maladie d’Alzheimer, mais elle porte son attention sur ce
qu’ils peuvent faire avec les proches plutôt que de mettre l’accent sur le proche
aidant uniquement. Bien que ce type de thérapie procure des bénéfices pour
les proches aidants, il serait intéressant d’offrir à ceux-ci un soutien externe
qui puisse répondre à leurs propres besoins. Si on considère que la musique
touche plusieurs domaines de l’être humain aux niveaux émotionnel, cognitif,
physique et spirituel, on peut supposer que la musicothérapie pourrait aider
les proches aidants à répondre à leurs besoins au moyen d’un groupe de
soutien. La présente étude explore la possibilité d’offrir la musicothérapie à
l’intérieur d’un programme de soutien pour les proches aidants de personnes
atteintes de la maladie d’Alzheimer. Aux fins de cette étude, l’accent est mis
sur les enfants adultes proches aidants de parents atteints de la maladie
d’Alzheimer ainsi que les personnes atteintes de la maladie au stade modéré,
et ce, afin de délimiter l’étude et de cibler la population à laquelle s’adressera
le programme de musicothérapie. La recherche veut donc répondre à la
question suivante : « Comment un programme de soutien en musicothérapie
pourrait-il répondre aux besoins de proches aidants dont les parents sont
atteints de la maladie à un stade modéré? » Plus spécifiquement, les questions
de réflexion seront les suivantes : (a) Quelles seraient les approches en
musicothérapie qui pourraient répondre aux besoins des proches aidants
à ce stade précis de la maladie?, (b) Qu’est-ce que la musicothérapie
pourrait apporter dans le soutien des proches aidants?, (c) Serait-il possible
d’intégrer une approche multimodale (utilisant plusieurs modalités) dans un
programme de musicothérapie pour les proches aidants? Concernant le peu
de recherches effectuées en musicothérapie auprès des proches aidants, il
est espéré que cette étude contribuera à offrir davantage de services à cette
clientèle.
Élements théoriques : regard sur la maladie
La maladie d’Alzheimer
Morrison (1995) définit la démence dans le DSM-IV Made Easy comme
une régression d’un niveau de fonctionnement antérieur incluant des pertes
de mémoire et au moins un déficit cognitif parmi les suivants : agnosie,
aphasie, apraxie et perte de la fonction exécutive. Les symptômes doivent
avoir un impact important sur la vie des patients. La maladie d’Alzheimer
est la forme la plus courante de démence et constitue 50 à 80 % des cas
(Alzheimer’s Association, 2011). Cette maladie neurodégénérative cause
la mort des cellules du cerveau due au développement de plaques et
d’écheveaux. Fréchette (2011) mentionne que cette maladie est la deuxième
en ordre d’importance que les Canadiens redoutent le plus en vieillissant.
On peut comprendre cette réaction lorsqu’on regarde les statistiques de plus
près. Selon Diamond (2006), un Canadien sur 20 âgé de plus de 65 ans est
atteint de la maladie d’Alzheimer, mais à partir de 85 ans, on peut compter
une personne sur quatre qui en est atteinte, ce qui est plutôt inquiétant.
En outre, la maladie d’Alzheimer est diagnostiquée chez de plus en plus de
jeunes à cause de facteurs tels que les nouvelles méthodes de diagnostic et
l’augmentation des facteurs de risque de la maladie, dont le vieillissement et
l’hérédité (Diamond, 2006). Une fois diagnostiquée, on sait que la maladie
d’Alzheimer évolue généralement lentement et se développe en plusieurs
stades.
Bien que la maladie d’Alzheimer agisse différemment sur les individus,
on retrouve des symptômes récurrents. Reisberg (Alzheimer’s Association,
n.d.) décrit sept stades de la maladie d’Alzheimer. Au premier stade, la
personne démontre un fonctionnement normal. Au deuxième stade, les
premiers symptômes de la maladie d’Alzheimer peuvent apparaître sous
forme de quelques pertes de mémoire. Ce n’est qu’au troisième stade, stade
de déclin cognitif léger, que les médecins peuvent diagnostiquer la maladie
d’Alzheimer. Le déclin cognitif modéré apparaît au quatrième stade, où une
entrevue peut clairement détecter des problèmes dans plusieurs domaines.
Par exemple, l’individu oublie des événements récents et peut même oublier
des parties de son histoire personnelle. Au cinquième stade, le stade léger
à modéré, l’individu a des problèmes de mémoire évidents, des problèmes
d’orientation (date, endroit) et a besoin d’aide pour choisir les vêtements
appropriés pour la saison ou un événement. Le stade modéré à sévère
constitue le sixième stade qui se caractérise par des changements dans la
personnalité de l’individu, comme de l’illusion et de la méfiance, ainsi qu’un
grand besoin d’aide pour les activités quotidiennes. Dans le dernier stade
de la maladie, qui correspond à un déclin cognitif sévère, les individus
perdent la capacité à répondre à leur environnement, à maintenir une
conversation et, avec le temps, à contrôler leurs mouvements. À cet égard,
dans le rapport de l’Association d’Alzheimer (2011), l’incapacité de pouvoir
bouger et se déplacer peut rendre l’individu plus vulnérable aux infections,
donc susceptible d’attraper une pneumonie. Selon Voisin et Vellas (2009), la
détérioration fonctionnelle et les problèmes de type neuropsychiatrique sont
plus proéminents que les pertes cognitives au dernier stade de la maladie.
Cela entraîne un plus grand fardeau chez le proche aidant et mène souvent à
l’institutionnalisation du proche. En général, la maladie dure de 7 à 10 ans,
après quoi les personnes décèdent (Diamond, 2006).
Proches aidants – les défis
Le Center on an Aging Society (2005) définit le terme « proche aidant »
comme suit : « the primary, unpaid helper of people age 65 or older residing
in the community who need assistance with one or more basic everyday
activities » (p. 1). En général, ce sont les membres de la famille ou les amis
qui s’occupent des personnes âgées qui ont besoin d’aide pour les activités
quotidiennes, qu’ils aient des pertes cognitives ou non. À cet égard, les
conjoints et les enfants adultes constituent la majorité des proches aidants,
bien que ces derniers soient de plus en plus enclins à s’occuper de leurs
parents. De nos jours, la proportion d’hommes proches aidants est plus élevée
qu’en 1995, mais les femmes demeurent les plus nombreuses à prendre soin
de leurs proches (Center on an Aging Society, 2005). Même si l’âge ou le rôle
dans la famille du proche aidant diffère, les problèmes auxquels ils ont à faire
face sont similaires.
Plusieurs recherches démontrent que les proches aidants se voient
confrontés à de nombreux défis et problèmes au cours de l’évolution de la
maladie. Koerner et Kenyon (2007) ont analysé les changements dans le
bien-être de proches aidants au quotidien. Un groupe de 63 proches aidants
ont été observés pendant huit jours consécutifs. Les résultats ont démontré
que les proches aidants avaient plus de symptômes négatifs tels que de la
dépression, des symptômes physiques et un sentiment de grand fardeau
lorsqu’il y avait plus d’éléments stressants; plus de tâches, plus de problèmes
de comportement de la part du proche et plus de mécontentements face
aux services de soins donnés au patient. Pour leur part, Papastavrou,
Kalokerinoua, Papacostas, Tsangari, et Sourtzi (2007) ont découvert
qu’environ 68 % des 172 proches aidants participant à leur recherche
portaient un grand fardeau relié à la maladie du patient et que ce fardeau
différait selon leur sexe, leurs revenus et leur niveau d’éducation. Dans leur
recherche, Etters, Goodall, et Harrison (2008) ont démontré que le fardeau
du proche aidant est également accentué selon que l’on est une femme ou
un homme, mais aussi en fonction d’autres facteurs tels la relation avec le
patient, sa culture et sa personnalité. On a découvert que des interventions
individualisées comportant plusieurs composantes diminuaient le fardeau et
augmentaient la qualité de vie du proche aidant. Ainsi, un meilleur bien-être
permettra au proche aidant de prolonger les soins donnés à la maison. Quant
à Machnicki, Allegri, Dillon, Serrano, et Taragano (2009), leur recherche se
limite aux facteurs comportementaux, cognitifs et fonctionnels. D’une part,
les résultats ont montré que les symptômes comportementaux chez les
personnes ayant un trouble cognitif, une démence ou une dépression sont
fortement reliés au fardeau du proche aidant qui s’occupe d’eux. D’autre
part, les facteurs fonctionnels et cognitifs ont aussi un impact sur le fardeau des
proches aidants qui s’occupent de patients ayant uniquement un trouble cognitif.
En conclusion, prendre soin d’une personne ayant la maladie d’Alzheimer
peut entraîner un fardeau considérable et des symptômes négatifs. Bien que
les proches aidants diffèrent les uns des autres, ils vivent des symptômes
similaires tels que la dépression, le stress, l’isolation, la fatigue, des émotions
difficiles et des symptômes physiques (Wayne & Segal, n.d.). De plus, ils vivent
un deuil à cause entre autres de la dégénérescence de la maladie de leur
bien-aimé (Lindgren, Connelly, & Gaspar, 1999). Étant donné la lourdeur de
la tâche, on peut se questionner sur le soutien offert aux proches aidants qui
ont plusieurs besoins tels que maintenir leur santé émotionnelle et physique,
se préparer à la maladie et prendre soin de soi (Wayne & Segal, n.d.).
Proches aidants – aspects positifs
De nos jours, on entend davantage parler des aspects négatifs d’être
proche aidant aux dépens des aspects positifs. Il faut dire que la recherche
sur les proches aidants est plus axée sur les aspects négatifs. Pourtant,
Cohen, Colantonio, et Vernich (2002) concluent avec leur recherche qu’il
est important que les professionnels soient renseignés sur les aspects
positifs d’être proche aidant pour bien comprendre leur expérience et avoir
une meilleure capacité à identifier les facteurs de risque. Au moyen d’un
échantillon provenant du Canadian Study of Health and Aging, 289 proches
aidants ont été interviewés sur leur rôle et les aspects positifs de leur
situation. Les résultats montrent que 211 proches aidants ont été capables
d’identifier au moins un aspect positif. D’autre part, 20 autres personnes
ont pu trouver plus d’un aspect positif à leur rôle d’aidant. L’étude a aussi
démontré que les niveaux de dépression et de fardeau étaient moins élevés
et que les scores à un test d’auto-évaluation de la santé étaient meilleurs
chez ces derniers. Il y a donc une corrélation entre la façon dont les proches
aidants perçoivent leur rôle et le bien-être de ceux-ci.
Loboprabhu (2006) rapporte que les proches aidants peuvent trouver
une source de réconfort dans leur rôle : « Sensing the pleasure of the loved
one may be a source of comfort to caregivers » (p. 92). Parallèlement, les
aspects positifs de leur rôle, comme les occasions d’exprimer leur amour
à travers les soins prodigués, peuvent contribuer à apporter un certain
équilibre en dépit de la charge qu’ils ressentent. Cette prise en charge peut
également augmenter le niveau d’estime de soi des proches aidants (Grbich,
Parker, & Maddocks, 2001). D’ailleurs, quelques chercheurs (Miller, 1989;
Mindel & Wright, 1982; Moss, Lawton, Dean, Goodman, & Schneider, 1987)
ont étudié le niveau de satisfaction du proche aidant. Dans le cas de Miller
(1989), il a analysé la corrélation entre le niveau de stress et le niveau de
satisfaction de proches aidants, spécifiquement des enfants adultes. Les
résultats ont montré que les caractéristiques démographiques des proches
aidants, le niveau de déficience des parents, le niveau de soins donnés et les
problèmes de prendre soin d’une personne expliquent 25 % du niveau de
stress, alors que ces caractéristiques expliquent seulement 5 % du niveau de
satisfaction des proches aidants. Le niveau de satisfaction est alors peu relié
aux défis que rencontre l’aidant. La recherche conclut que les enfants adultes
reportent de hauts niveaux de stress, mais également de hauts niveaux de
satisfaction, contrairement à ce qu’on pourrait penser.
En résumé, les aspects positifs d’être des proches aidants sont beaucoup
plus nombreux que l’on pense et il est important de ne pas les négliger pour
avoir une bonne compréhension de ce qu’ils vivent. Par exemple, certains
racontent qu’ils se sentent utiles, qu’ils ressentent de la fierté lorsqu’ils
sont capables de bien gérer les crises et qu’ils apprécient la proximité dans
le contact avec la personne dont ils prennent soin (Farran, Miller, Kaufman,
Donner, & Fogg, 1999; Kinney, Stephens, Franks, & Norris, 1995; Kramer, 1997).
Proches aidants – enfants adultes vs conjoints
Silverman (2008) démontre que les enfants adultes vivent des
conséquences différentes de leur rôle que celles que vivent les conjoints.
En effet, les enfants adultes aidants vivent ce qu’on appelle le renversement
des rôles; normalement, c’est le parent qui s’occupe de son enfant et les
parents gardent ce rôle jusqu’à l’âge adulte. Toutefois, lorsqu’il est rendu
impossible pour le parent de s’occuper de soi-même, l’enfant doit prendre le
rôle de parent. Il doit, entre autres, prendre des décisions pour ses parents
et s’occuper d’eux au quotidien. Il ne ressent plus alors le rôle de réconfort
et de sécurité du parent. D’autant plus que si la relation parent-enfant était
difficile, cela complique les choses pour le proche aidant qui s’occupe d’un
parent. Puis, les enfants adultes aidants doivent s’occuper non seulement de
leurs parents, mais aussi de leurs enfants, phénomène communément appelé
la « génération sandwich ». Ils ont peu de temps pour eux-mêmes. À cela
s’ajoute aussi la conciliation avec le travail, ce qui n’est pas toujours évident.
Les conjoints aidants, quant à eux, font face à des problèmes différents, soit
la perte de leur partenaire de vie, la perte d’une vision pour l’avenir ainsi que
leur perte d’autonomie.
Groupes de soutien
En observant tout ce que peuvent vivre les proches aidants, on aurait
tendance à croire qu’ils vont chercher de l’aide et du soutien. Pourtant, Tebb
et Jivanjee (2000) ont examiné les expériences d’isolement dans la vie de
proches aidants de personnes ayant la maladie d’Alzheimer et ont révélé
des résultats alarmants. Huit conjointes, donnant des soins à leurs conjoints
depuis au moins trois ans, ont été rencontrées en entrevues semi-structurées.
On a observé que les participantes n’allaient pas chercher de soutien parce
qu’elles n’étaient pas conscientes de leur isolement, elles manquaient
d’informations sur le soutien disponible et n’étaient pas identifiées par
des services médicaux ou sociaux. De plus, une autre recherche (Bruce &
Paterson, 2000) portant sur 24 proches aidants de personnes ayant une
démence appuie ces résultats. Les chercheurs concluent que les problèmes
de communication entre les proches aidants et le praticien général semblent
avoir un effet important sur l’accès au soutien et à l’information. Également,
il est probable que les conjoints qui prennent soin de leur bien-aimé
aient recours à moins d’aide dans les cas qui sont déjà allés chercher de
l’information lorsqu’ils prenaient soin de leurs parents. D’ailleurs, Sörensen,
Pinquart, et Duberstein (2002) ainsi que Gitlin et al. (2003) rapportent
que les enfants adultes bénéficient souvent plus des interventions que les
conjoints, car ils sont moins préparés pour le rôle d’aidant.
Même si les proches aidants ne profitent pas toujours du soutien, il
existe toutefois plusieurs types de groupes de soutien. Gaugler, Roth, Haley, et
Mittelman (2008) se sont questionnés à savoir si le counseling et du soutien
peuvent réduire le fardeau et la dépression des proches aidants, conjoints
de personnes ayant la maladie d’Alzheimer, durant le passage de la maison à
l’institution. Leurs résultats ont démontré que le sentiment de fardeau et de
dépression était beaucoup plus bas pour les proches aidants dans le groupe
de soutien, comparé au groupe contrôle qui recevait les soins généralement
donnés. Les proches aidants du groupe contrôle pouvaient utiliser par euxmêmes les services disponibles et ils pouvaient contacter les chercheurs pour
de l’information ou des références. Leur recherche a également soulevé que
le fait d’institutionnaliser le proche agit en soi-même en réduisant le fardeau
et le niveau de dépression dans les deux groupes. Bien souvent, le niveau de
fardeau et le niveau de stress évoluent ensemble (Miller, 1989). Certaines
interventions de groupe se centrent sur les moyens de gérer le stress (Haigler,
Mims, & Nottingham, 1998; Schmall et al., 2000). Par exemple, Lévesque et al.
(2002) ont fait une recherche axée sur la théorie transactionnelle du stress et
de stratégies d’adaptation de Lazarus & Folkman (1984) et également sur le
programme de formation pour faire face aux problèmes de manière efficace
(Coping Effectiveness Training Program) (Folkman et al., 1991). Le but du
programme était d’augmenter la capacité pour les proches aidants à vivre
avec les demandes stressantes lorsqu’ils prennent soin d’une personne ayant
une démence.
Certains chercheurs ont trouvé que des interventions psychosociales
donnaient de bons résultats auprès des proches aidants (Martín-Carrasco et
al., 2009; Van Mierlo, Meiland, Van der Roest, & Dröes, 2012). De son côté, la
recherche de Martín-Carrasco et al. (2009) auprès de proches aidants conclut
qu’une intervention psychosociale peut diminuer la détresse de ces derniers
et les aider à trouver des stratégies de résolution de problèmes. Un autre
programme psychoéducationnel de 12 semaines, avec l’utilisation d’un DVD
auprès de proches aidants chinois américains qui s’occupent de personnes
ayant une démence, a donné des résultats positifs (Gallagher-Thompson et
al., 2010). En effet, l’état émotionnel positif des proches aidants était plus
élevé après l’intervention. Également, les proches aidants trouvaient que les
comportements de ceux qui recevaient les soins étaient moins stressants
pour eux.
Il existe également du soutien pour les proches aidants qui s’occupent de
leurs proches à la maison : soins de répit, programme de stimulation cognitive,
information et soutien émotionnel combiné avec des exercices de relaxation,
des interventions téléphoniques, etc. (Dröes et al., 2004). Ashworth & Baker
(2000) ont réalisé des entrevues avec 23 proches aidants pour connaître
leurs expériences des soins de répit. Ceux-ci ont considéré les soins de répit
comme un service qui les aide à s’occuper de leurs proches et à maintenir les
soins à la maison pour une plus longue durée. Harding et Higginson (2003)
suggèrent quant à eux qu’une variété de modèles est appropriée auprès des
proches aidants, car il est clair que ceux-ci ont plusieurs besoins et qu’un
seul modèle de soins ne peut tous les rencontrer. Ils en sont venus à cette
conclusion après avoir effectué une revue systématique de 22 interventions
telles que les soins de répit et les soins infirmiers à domicile.
Bien qu’il existe de plus en plus d’interventions avec les proches
aidants, Pinquart et Sörensen (2002) rapportent que les interventions avec
les proches aidants de personnes ayant une démence sont souvent moins
réussies qu’avec d’autres proches aidants, car ces premiers (proches aidants
de personnes ayant une démence) vivent souvent des facteurs de stress
imprévisibles comme les changements de personnalité. Cela peut être plus
difficile de voir des changements lors des interventions avec cette clientèle.
Les proches aidants de personnes âgées ont plus de chance d’avoir davantage
d’éléments stressants et de limitations dans leurs activités, selon une étude
de Cohen, Swanwick, O’Boyle, et Coakley (1997). Ainsi, ils ont plus de chance
de tirer profit d’un groupe de soutien qui ne leur prend pas trop de leur
temps et qui leur fournit du soutien émotionnel. Il est clair qu’en général les
interventions qui adaptent les sujets et les méthodes aux besoins spécifiques
des proches aidants sont plus efficaces. De plus, le groupe de soutien peut
être plus efficace comme intervention auprès des proches aidants qui sont
plus isolés en leur fournissant un réseau social et la possibilité d’échanger
des idées et leurs expériences (Toseland, Rossiter, & Labrecque, 1989).
Sörensen et al. (2006) donnent plusieurs conseils pour la pratique
clinique auprès de proches aidants. Entre autres, ils suggèrent d’intégrer des
éléments dans l’intervention qui permet de développer une estime de soi
positive, de trouver un sens et de reconnaître les aspects positifs d’être proche
aidant; d’utiliser une combinaison d’interventions, car les proches aidants
répondent différemment aux approches; d’augmenter les connaissances du
proche aidant dès le début en fournissant de l’information pertinente sur la
maladie et leur rôle. De plus, le soutien que les proches aidants reçoivent
possède un grand impact sur la façon dont ils perçoivent leur rôle de fournir
des soins à long terme (Gubrium, 1998).
Éléments théoriques : regard sur la musicothérapie
Musicothérapie et maladie d’Alzheimer
De nombreux écrits traitent de l’utilisation de la musicothérapie auprès
de patients ayant la maladie d’Alzheimer. Par exemple, la musicothérapie peut
diminuer l’agitation et la confusion chez les personnes qui sont atteintes de
cette maladie. Une étude de Clark, Lipe, et Bilbrey (1998) a démontré que
l’utilisation de musique personnalisée durant le bain de patients ayant la
maladie d’Alzheimer diminuait de 63,4 % les problèmes de comportement
et l’agitation durant les semaines où la musique a été utilisée. Une autre
étude (Ziv, Granot, Hai, Dassa, & Haimov, 2007) est parvenue à des résultats
similaires. En effet, un groupe de 28 participants ayant la maladie d’Alzheimer
a été observé d’une part, avec de la musique stimulante et familière en
arrière-plan, et d’autre part, sans musique. Les résultats de cette recherche
démontrent que la présence de musique entraînait une augmentation
significative des comportements sociaux positifs et une diminution
importante des comportements d’agitation. En outre, une étude suédoise
(Ragneskog, Kihlgren, Karlsson, & Norberg, 1996) a testé différents types de
musique avec des patients souffrant de démence pour observer l’effet sur
leurs comportements. Une musique que les chercheurs considèrent comme
douce, mélodieuse, relaxante et romantique, jouée par des instruments à
cordes et avec un tempo et un volume consistants, les aidait à rester assis
plus longtemps et à manger plus calmement. Quant à Bruer, Spitznagel, et
Cloninger (2007), ils ont découvert qu’une intervention en musicothérapie
augmente significativement les fonctions cognitives de patients qui ont
une démence le lendemain de la séance de thérapie. En effet, juste après
l’intervention, les résultats au MMSE (Mini Mental State Exam) (Folstein,
Folstein, & McHugh, 1975) du groupe de musicothérapie augmentent de
2 points, comparé au groupe sous contrôle. Le lendemain, les résultats au
même test montrent une augmentation de 3,69 points, si on compare avec
le même groupe. Une semaine après, il n’y a aucune différence entre les deux
groupes, mais cela démontre tout de même que la musicothérapie aide à
augmenter les fonctions cognitives à court terme chez les personnes ayant
une démence.
Musicothérapie et groupes de soutien
On retrouve quelques recherches sur la musicothérapie en dyade
avec la personne malade et le proche aidant. Clair (2002) a observé huit
couples participant à des séances individuelles de musicothérapie. Après
cinq séances, les résultats démontrent que la musicothérapie est efficace
pour augmenter l’engagement entre les proches aidants et les personnes
ayant une démence. Également, la recherche montre que les proches aidants
peuvent faciliter l’interaction avec leurs proches au moyen de la musique.
Brotons et Marti (2003) ont créé un projet pilote pour évaluer les bienfaits
de la musicothérapie sur les personnes ayant la maladie d’Alzheimer et
leurs proches aidants. La moitié des 11 proches aidants ont observé une
amélioration dans les comportements sociaux des patients ainsi que leur
état émotionnel. Tous les proches aidants étaient d’accord pour dire que la
musicothérapie leur apportait des bienfaits, car elle les aidait à relaxer. Une
portion de 66,7 % a ajouté que la musicothérapie leur offrait un endroit pour
exprimer ce qu’ils ne sont pas capables d’exprimer dans un autre contexte.
Hanser, Butterfield-Whitcomb, Kawata, et Collins (2011) ont découvert
pour leur part qu’un programme de musique avec 14 proches aidants et
14 membres de famille qui ont une démence augmente leur niveau de
relaxation, de confort et de bonheur. Ce sont les proches aidants qui ont le
plus bénéficié de l’intervention et qui ont exprimé du plaisir en se rappelant
des souvenirs et en participant également à des activités musicales avec leurs
proches aimés. De plus, une étude de faisabilité (Guétin et al., 2009) a aussi
été réalisée auprès de personnes ayant la maladie d’Alzheimer aux stades
légers à modérés et auprès de leurs proches aidants afin d’évaluer l’effet de
la musicothérapie sur l’anxiété et la dépression de la personne malade ainsi
que la charge ressentie par son accompagnant. Une séance de musicothérapie
réceptive hebdomadaire a été offerte pendant 10 semaines, en suivant la
méthode en U. Cette méthode se définit par l’utilisation de plusieurs œuvres
musicales qui sont structurées en plusieurs phases, avec une diminution ou
une augmentation progressive de trois éléments, soit le tempo, l’orchestre et
le volume. L’objectif peut être d’endormir ou de stimuler la personne selon
les besoins (Guétin & Giniès, 2004). Les participants étaient au nombre de
cinq et ont participé à un total de 44 séances. Les résultats ont montré une
diminution significative du niveau d’anxiété, de dépression et aussi de la
charge ressentie par l’aidant principal.
Stewart et al. (2005) ont constaté que les proches aidants, qu’ils
soient de la famille ou des professionnels, vivent des deuils, des pertes et
du stress quand ils travaillent avec des individus en fin de vie. Ils traitent
particulièrement d’une approche de groupe avec les proches aidants, ici la
famille, et soulignent l’importance du soutien pour ces derniers. D’autres
chercheurs (Magill, 2009; Murrant et al., 2000) ont aussi étudié les groupes
de soutien utilisant la musicothérapie avec des proches aidants en soins
palliatifs. Pour sa part, Krout (2003) rapporte les effets de la musicothérapie
sur les proches aidants de personnes en soins palliatifs : une diminution
de l’anxiété, un partage d’expériences positives, une augmentation de la
communication, plus d’ouverture dans l’expression des sentiments, plus de
partage sur les souvenirs de leur vie, une augmentation de la capacité à relaxer,
une augmentation du sentiment d’appui de la collectivité, le développement
d’une vision plus humaniste du personnel de la santé.
Il existe peu de littérature traitant de groupes de soutien en
musicothérapie pour les proches aidants (Hilliard, 2006; Magill, 2009;
Murrant et al., 2000; Rykov, 2007, 2008). D’ailleurs, Hanser et al. (2011)
ont effectué une recherche auprès de personnes souffrant de démence et
de leurs proches aidants. Ils suggèrent que les musicothérapeutes devraient
développer des stratégies qui soutiennent plus directement les proches
aidants. Vu les besoins importants de ceux-ci tels que maintenir leur santé
émotionnelle et physique (Wayne & Segal, n.d.), la musicothérapie leur serait
probablement bénéfique.
Interventions en musicothérapie
La musicothérapie est une thérapie dont l’outil principal d’intervention
est la musique pour améliorer, maintenir ou restaurer la santé de l’individu.
Plusieurs modes d’intervention existent : la composition de chansons, la
musique et l’imagerie guidée, l’improvisation musicale, la chanson, le jeu
instrumental, etc. Selon O’Kelly (2008), les musicothérapeutes ont développé
des techniques pour soutenir les patients, les proches aidants ainsi que les
personnes endeuillées. Par exemple, la composition de chansons (O’Callaghan,
1999) et l’improvisation musicale (Lee, 1996) figurent parmi ces techniques
qui peuvent soutenir les proches aidants. Également, Ferguson (2006)
suggère que l’imagerie guidée et la relaxation pourraient être bénéfiques.
Composition de chansons. La composition de chansons est de plus en
plus utilisée comme méthode d’intervention en musicothérapie, et ce, avec
plusieurs types de clientèle. Baker et Wigram (2005) l’ont définie comme
suit : « the process of creating, notating and/or recording lyrics and music
by the client or clients and therapist within a therapeutic relationship to
address psychosocial, emotional, cognitive and communication needs of the
client » (p. 16). Il existe plusieurs techniques de composition de chansons,
allant de la parodie de chansons existantes ou de la substitution de mots de
chansons (Baker, Kennelly, & Tamplin, 2005) jusqu’à l’improvisation vocale
(Robb, 1996).
Improvisation musicale. Selon O’Kelly (2002), l’improvisation
musicale peut faciliter l’expression des émotions puisqu’elle est non
verbale et permet ainsi d’exprimer ce qui est difficile à dire avec les mots.
Salmon (1995) soutient que l’improvisation musicale permet d’explorer le
thème des pertes. Or, on sait que les proches aidants vivent des deuils. Par
exemple, les enfants adultes aidants connaissent un renversement des rôles,
alors ils perdent en quelque sorte leur rôle d’enfant et doivent prendre des
décisions pour leurs parents (Silverman, 2008). Les proches aidants peuvent
ainsi expérimenter le rôle d’être un leader, lequel implique de prendre des
décisions et, à l’inverse, prendre le rôle de suiveur et ressentir ce que ça fait de
suivre les directives du leader. Les aidants font des liens avec ce qu’ils vivent
dans leur relation avec leur parent ou leur proche. Ainsi, l’improvisation
musicale pourrait aider à diminuer le niveau de détresse des proches aidants.
Écoute et analyse de chansons. Hogan (1999) et Bailey (1984)
rapportent que le choix de chansons est une intervention qui peut aider
à confirmer les pensées et les sentiments des clients. En effet, les paroles
des chansons viennent les stimuler de plusieurs façons, ce qui leur permet
d’exprimer leurs sentiments, qui sont difficiles à formuler de façon verbale.
L’écoute de chansons sur des thèmes que vivent les proches aidants (deuil,
perte, différents rôles, relation, isolement, etc.) pourrait donc aider à
développer une discussion de groupe et à augmenter l’expression de soi.
Écriture de journal. L’écriture de journal n’est pas une intervention
spécifique à la musicothérapie, mais elle peut aider à mettre en mots ce qui
a été ressenti dans la musique. De plus, elle peut être une ressource pour la
composition de chansons lorsqu’on cherche des paroles.
Pennebaker (1990) a étudié l’impact de l’utilisation d’un journal de
bord auprès de professionnels payés ou de bénévoles qui vivent beaucoup de
stress en soins palliatifs. Il a développé un atelier d’exploration de soi dans
lequel l’écriture du journal était une des interventions utilisées. Le journal
pouvait servir entre autres pour documenter les moments difficiles comme
les moments plaisants, et aussi pour faire des exercices d’expression. La
prochaine partie traitera de la méthodologie utilisée en vue de développer
un programme de musicothérapie.
Méthodologie
Cette recherche constructive (Creative Arts Therapies Department,
2009) vise à développer un programme d’intervention pour répondre aux
besoins de proches aidants dont les parents sont atteints du stade modéré de
la maladie d’Alzheimer.
La raison d’être du projet provient principalement du désir de la
chercheuse d’approfondir ses connaissances avant de travailler avec cette
clientèle. Il existe malheureusement peu de documentation sur ce type de
méthodologie. Cette méthodologie a été utilisée par Lindsay Petts (2009),
une étudiante en drama-thérapie à Concordia, pour sa recherche sur Making
connections: The construction of a drama therapy program fostering social
skills for adolescents living with Asperger’s syndrome. Junge et Linesch (1993)
ont apporté plus de précisions sur la recherche théorique en la décrivant
comme une méthode de recherche qui critique et incorpore des théories qui
sont déjà existantes dans le but de créer de nouvelles connaissances ou de
nouvelles théories. Cette méthodologie est appropriée, car elle permet de
construire un programme qui pourrait permettre d’offrir des services aux
proches aidants. Un autre bénéfice est que le programme puisse servir de
modèle pour d’autres domaines comme les thérapies par les arts.
De façon concrète, la chercheuse a commencé avec une revue de
littérature qui couvre tous les sujets qui sous-tendent son sujet de recherche
tels que la maladie d’Alzheimer, les proches aidants, les groupes de soutien, la
musicothérapie et les thérapies par les arts. Elle a analysé les résultats pour
comprendre quelles composantes pourraient faire partie d’un programme de
musicothérapie pour cette clientèle.
Étude de cas
La recherche est enrichie par l’expérience professionnelle d’une
musicothérapeute afin d’appuyer la construction du programme de soutien
en musicothérapie. La participante est une musicothérapeute travaillant
avec les proches aidants de personnes ayant la maladie d’Alzheimer. Étant
donné le peu de musicothérapeutes qui travaillent avec cette clientèle, la
musicothérapeute a été sélectionnée selon l’unique critère selon lequel elle a
déjà travaillé avec la clientèle visée par la recherche.
Modalités qui ont soutenu la réflexion de l’auteure : l’entrevue
L’entrevue a été utilisée pour appuyer la revue de littérature et a permis
de répondre à la question : « Comment la musicothérapie peut-elle répondre
aux besoins des proches aidants? ».
La collecte de données, en regard de l’entrevue, a été produite sur support
audiovisuel avec l’autorisation de la participante et a duré environ deux
heures. Elle s’est déroulée dans un endroit privé choisi par la participante.
Les données (enregistrements et transcriptions) ont été entreposées dans un
dossier de l’ordinateur auquel seule la chercheuse a accès. Le type d’entrevue
était une entrevue guidée (Patton, 2002), car cette méthode permet le
maintien de la conversation et l’élaboration sur le sujet. Des sous-sujets avec
des exemples de questions ont été posés pour diriger l’entrevue.
Analyse des données
La chercheuse a ensuite analysé l’entrevue avec les trois phases de la
méthode Coding qualitative data : le Open coding, Axial coding et Selective
coding (Creswell, 2003). Elle a fait ressortir les thèmes principaux qui l’ont
aidée à construire un programme pour les proches aidants de personnes
ayant la maladie d’Alzheimer, plus spécifiquement les enfants adultes
de parents atteints de la maladie. À la suite de ce processus, la technique
Member checking (Marshall & Rossman, 2011) a été utilisée pour confirmer
les thèmes qui ressortent de l’entrevue et pour valider la compréhension de
l’entrevue par la chercheuse.
La nature de ce projet comporte des limites, car il n’a été possible
d’interviewer qu’une seule musicothérapeute. Ainsi, l’entrevue ne reflète
qu’une pratique. L’inexpérience de la recherche avec la clientèle des proches
aidants place aussi des limitations. En travaillant avec la clientèle, cela permet
de connaître davantage leurs besoins et d’avoir une meilleure idée des
interventions en musicothérapie qui pourraient être utilisées. La chercheuse
avait également des idées préconçues par rapport à cette clientèle. En effet,
elle croyait que l’accent aurait été mis sur la discussion des problèmes que les
proches aidants vivent au quotidien avec la personne atteinte.
Exemple d’un programme de musicothérapie
Comme mentionné, les enfants adultes ont besoin de plus d’aide, car
c’est souvent la première fois qu’ils deviennent proches aidants, à l’opposé
des conjoints (Bruce & Paterson, 2000; Gitlin et al., 2003; Sörensen et al.,
2002). Les proches aidants vivent de l’isolement (Wayne & Segal, s.d.), des
deuils (Lindgren et al., 1999; Stewart et al., 2005), du stress (Stewart et al.,
2005) et ont souvent une perte de la vision d’avenir (Silverman, 2008). Ils ont
plusieurs besoins dont le maintien de leur santé émotionnelle et physique,
la préparation à la maladie et le besoin de prendre soin de soi (Wayne &
Segal, n.d.). Leurs besoins varient selon l’évolution de la maladie chez l’aidé.
Ils doivent développer des stratégies d’adaptation pour diminuer le stress
(Lévesque et al., 2002), conserver ou développer une estime de soi positive et
reconnaître les aspects positifs d’être proche aidant (Sörensen et al., 2006). Il
est important qu’ils développent un réseau social afin d’échanger leurs idées
et leurs expériences (Toseland et al., 1989).
Un seul modèle de soins ne peut satisfaire tous les besoins des
proches aidants (Harding & Higginson, 2003). On sait que les interventions
psychoéducationnelles et psychothérapeutiques montrent de meilleurs
résultats à court terme (Sörensen et al., 2002) et que les proches aidants
profitent davantage d’une intervention à long terme (Otswald et al., 1999).
Silverman (2008) décrit trois étapes qui sont traversées par les proches
aidants ainsi que des suggestions d’interventions en séance individuelle.
Dans la première étape du cheminement, les aidants sont à la recherche
d’informations et l’intervenant est là pour leur en fournir ou pour compléter
celles du médecin. Il dirige ensuite les proches aidants vers les ressources
adaptées à leur situation. Il est important aussi que l’intervenant explique que
les proches aidants jouent maintenant un nouveau rôle qui fait partie de leur
identité. Aussi, la perception de l’avenir change tout au long du parcours du
proche aidant. Des émotions peuvent surgir avec l’anticipation de la perte de
la personne dont ils prennent soin et il est bon d’avoir un lieu pour explorer
et exprimer ces émotions. Dans l’étape intermédiaire du cheminement de
l’aidant, les changements de comportements apparaissent chez la personne
atteinte et c’est là que l’utilisation de la technique des jeux de rôles peut être
utile. Les proches aidants réalisent qu’ils doivent établir leurs limites. Le rôle
de l’intervenant est d’encourager l’aidant à réfléchir sur ses propres limites.
C’est aussi durant cette étape que les proches aidants devront apprendre à
être à l’écoute de leurs besoins. Ici, le rôle de l’intervenant est de favoriser
l’exploration des besoins de l’aidant et de travailler sur les émotions
conflictuelles qui surgissent dont, notamment, la culpabilité. La dernière
étape vécue par le proche aidant se définit par la détérioration de l’aidé et
l’épuisement du proche aidant qui doit prendre plusieurs décisions. C’est là
que les thèmes de décès et de deuil apparaissent.
Le rôle de l’intervenant est d’encourager l’expression des proches aidants. La
question d’hébergement de l’aidé arrive souvent durant la dernière étape du
cheminement de l’aidant.
Des recherches en musicothérapie (Brotons & Marti, 2003; Guétin et al.,
2009; Hanser et al., 2011) ont montré que celle-ci aide les proches aidants à
relaxer, à exprimer ce qu’ils ne sont pas capables d’exprimer dans un autre
contexte, à augmenter le niveau de confort et de bonheur, à diminuer le
niveau d’anxiété et de dépression et à diminuer la charge ressentie. Plusieurs
interventions sont utilisées en musicothérapie, mais la composition de
chansons est celle qui est la plus employée auprès des proches aidants. Elle
aide à enseigner des stratégies d’adaptation en encourageant l’expression
de soi et en diminuant le sentiment d’impuissance (Edgerton, 1990; Freed,
1987; Goldstein, 1990; Robb, 1996). De son côté, l’improvisation musicale
peut faciliter l’expression des émotions (O’Kelly, 2002), aider à exprimer le
sujet des pertes (Salmon, 1995), diminuer le niveau de dépression (Albomoz,
2009), ainsi qu’augmenter la connaissance de soi et le développement des
interactions sociales (Wigram, 2004) chez les proches aidants. L’écriture
d’un journal de bord peut de plus favoriser l’expression de soi (Pennebaker,
1990) et servir d’outil de réflexion pour la composition de chansons (O’Kelly,
2008).
Présentation du programme
Le programme de groupe de soutien proposé permet d’offrir du soutien
au moyen de la musique. En découvrant plusieurs moyens d’expression,
le proche aidant acquiert des outils avec lesquels il peut développer ses
propres stratégies d’adaptation (Edgerton, 1990; Ferguson, 2006; Freed,
1987; Goldstein, 1990; Robb, 1996). L’entrevue avec une musicothérapeute
qui travaille dans ce type de groupe a dévoilé que les sujets difficiles à travers
lesquels passent les proches aidants font souvent surface à travers les
expériences vécues durant les séances.
Approche humaniste
L’approche humaniste, centrée sur les besoins de la personne, est
privilégiée avec ce type de groupe. Elle permet aux proches aidants qui
négligent leur vie personnelle de répondre au besoin d’actualisation qui
n’est plus au premier plan. En effet, les proches aidants ont peu l’habitude de
prendre soin d’eux-mêmes et de leurs besoins à cause de leur rôle qui leur
demande beaucoup de temps (Silverman, 2008). Selon l’approche humaniste
(Chalifour, 1999), leurs besoins viennent du fait qu’ils ignorent une partie
d’eux-mêmes :
Le besoin d’aide apparaît quand, consciemment ou non, elle
(la personne) renie ou ignore une partie d’elle et s’empêche de
l’exprimer. En agissant ainsi, elle devient de plus en plus étrangère
à elle-même. L’aide professionnelle de l’intervenant vise à aider le
client à apprendre ou à réapprendre à être à l’écoute des processus
internes de son organisme et à laisser libre cours à leur expression.
(p. 42)
Différentes approches permettent de répondre aux besoins des proches
aidants, que ce soit une approche éclectique ou des approches spécifiques
(approches féministe, cognitivo comportementale, psychodynamique,
thérapie de soutien, etc.). Elles pourraient également être utilisées selon
l’orientation musicothérapeutique du thérapeute et le contexte particulier
des séances de thérapie.
Cadre thérapeutique
Le cadre thérapeutique, constitué du lieu de la thérapie, de la structure
des séances et de la qualité de la relation thérapeutique, doit être soigné
quand on travaille avec des proches aidants (Silverman, 2008), car ceux-ci
vivent déjà beaucoup de changements dans leur quotidien étant donné leurs
nouvelles responsabilités. Ils ont besoin de stabilité et d’un sentiment de
sécurité. Les séances se tiennent dans un lieu qui n’est pas associé à l’aidé
et qui leur inspire confiance (lieu confidentiel, sans danger physique, sans
distraction, etc.). Le fait que la personne atteinte ne soit pas présente aide
le proche aidant à comprendre que l’espace qui lui est donné lui est dédié
et qu’il peut parler sans entrave de sa situation (Silverman, 2008). La taille
du groupe doit varier entre trois et huit personnes afin de répondre plus
facilement aux besoins des aidants.
Rôle du thérapeute. Le rôle du thérapeute consiste à offrir un soutien
aux participants et à faciliter le processus du groupe. Le thérapeute doit
également offrir un espace de création musicale où les membres du groupe
peuvent exprimer leur musique à leur façon sans se sentir jugés et en étant
bien soutenus dans leur démarche. L’accent est mis sur le processus créatif
plutôt que le résultat final. Il est possible que certains membres du groupe
expriment des difficultés vécues à travers leur rôle d’aidant. Le rôle du
thérapeute est de montrer de l’empathie et d’être à l’écoute. Il peut aussi
inviter les participants à se soutenir les uns et les autres. Le thérapeute
encouragera les membres du groupe à exprimer les éléments positifs comme
les plus difficiles.
Buts et bienfaits possibles du programme. Les principaux buts
du programme de musicothérapie sont (a) d’encourager l’acte de prendre
soin de soi, (b) de développer des stratégies d’adaptation grâce aux outils
d’expression, (c) d’augmenter les opportunités d’exprimer l’expérience
vécue à travers le rôle d’aidant, et (d) de fournir les possibilités pour trouver
un sens au rôle d’aidant. Ainsi, un des buts importants consiste à chercher
un sens et à trouver un sens au rôle de proche aidant. Noonan et Tennstedt
(1997) ont rencontré en entrevue 48 proches aidants de personnes âgées,
et la recherche a montré que le sens attribué au rôle d’aidant aide celui-ci
à persévérer malgré le stress. Plusieurs thèmes sont aussi ressortis de ces
entrevues : la gratification et la satisfaction venant avec le rôle d’aidant,
un sens de responsabilité et de réciprocité dans la famille, l’amitié, puis
l’engagement de faire ce qui doit être fait. Rubinstein (1989) appuie ces
résultats en maintenant que de trouver un sens fait partie du processus du
proche aidant. Avec les différentes techniques (composition de chansons,
improvisation instrumentale, poésie, etc.), des éléments tels que l’absence de
jugement, l’accent sur le succès et l’écoute empathique seront intégrés afin
de développer une estime de soi positive, trouver un sens au rôle d’aidant et
reconnaître les aspects positifs d’être proche aidant (Sörensen et al., 2006).
Pour les proches aidants qui sont plus isolés, le groupe permet de créer un
réseau social et d’augmenter les possibilités d’échanger avec autrui au sujet
de leurs expériences (Toseland et al., 1989).
Rencontre initiale prégroupe. Avant d’entreprendre le programme de
musicothérapie en groupe, des rencontres individuelles sont organisées pour
que le musicothérapeute discute avec chaque personne afin de déterminer
quelles sont leurs attentes pour le groupe. Selon la musicothérapeute
interviewée, la plupart des participants du groupe de musicothérapie
souhaitaient oublier la maladie et faire quelque chose pour eux-mêmes. Il est
donc important de vérifier de manière plus précise les besoins et les attentes
des participants dès le départ.
Une première évaluation individuelle permet de déterminer les besoins
principaux du participant et de voir s’il est dans une situation à risque (mauvais
traitements, pensées suicidaires). Si tel est le cas, le musicothérapeute
pourra le diriger vers les ressources adéquates. La deuxième partie de
l’évaluation est centrée sur la musique. Le musicothérapeute discute avec
le participant de l’intérêt musical, des goûts musicaux et de la présence de
la musique dans la vie du participant. Il est réitéré que ce dernier n’a pas
besoin d’avoir de connaissances musicales préalables pour faire partie du
groupe. Le musicothérapeute donne la possibilité au participant d’explorer
les instruments de musique, ce qui lui fournit d’autres informations sur
les habiletés physiques, sociales, cognitives, musicales, émotionnelles et
de communication du participant. L’évaluation préliminaire permet au
musicothérapeute de discuter avec le participant si la musicothérapie est
une intervention qui pourrait répondre à ses besoins et si le groupe était une
bonne formule pour lui.
Évaluation périodique. Un élément important à considérer lorsqu’on
établit un programme de musicothérapie est l’évaluation périodique du
groupe. Dans le cas des proches aidants, l’évaluation est essentielle puisque
leur situation et leurs besoins sont changeants selon la situation qui évolue.
Selon Silverman (2008), certains domaines doivent être couverts dans
l’évaluation :
La description du travail de l’aidant et du soutien reçu, les rapports
entre l’aidant et le personnel des services officiels, l’habitation et le
transport, la conciliation des responsabilités, le coût financier des
soins fournis, la santé de l’aidant, les relations entre l’aidant, l’aidé
et la famille ainsi que la prévention des crises et la planification de
l’avenir. (p. 51-52)
Toutefois, il est important de mentionner que le musicothérapeute travaille
en équipe pour répondre aux besoins multiples, soit la santé de l’aidant, la
relation entre l’aidant et ses proches ainsi que la prévention des crises et la
planification de l’avenir.
À la moitié des rencontres, le musicothérapeute fait une deuxième évaluation
au moyen d’un formulaire et rencontre le participant s’il y a lieu afin de
déterminer si les besoins sont toujours les mêmes et si la musicothérapie
répond à ses besoins. À la fin des rencontres, le musicothérapeute complète
une dernière évaluation à l’aide d’un formulaire qui lui permet d’évaluer les
progrès réalisés durant la thérapie.
Format proposé. Ce programme est conçu pour un groupe d’environ
6 à 10 proches aidants de parents étant aux stades modérés de la maladie
d’Alzheimer. Le choix de ce nombre de participants facilite les échanges et le
travail de groupe. Les séances ont lieu une fois par semaine pour une heure et
demie, pendant une période de 12 semaines. Cette période est assez longue
pour permettre de développer la confiance dans le groupe et développer des
stratégies d’adaptation. Puisque les proches aidants n’ont pas beaucoup de
temps libre (Silverman, 2008), il est préférable d’opter pour une séance de
courte à moyenne durée (p. ex. : 45 à 90 minutes). Une intervention à long
terme (plus de 10 séances) permet aux proches aidants d’avoir plus de temps
pour apprendre et développer un sentiment de confiance, et pour permettre
l’exploration de plusieurs approches durant l’intervention (Ostwald et al., 1999).
Le processus thérapeutique est divisé en trois phases : l’étape initiale,
la seconde étape et la troisième étape (Yalom, 2005).
Dans l’étape initiale, les membres du groupe sont à la recherche de sens
pour comprendre comment ils vont réaliser le but pour lequel ils joignent
le groupe. Les membres du groupe se posent beaucoup de questions au
début des séances et recherchent des similitudes avec d’autres participants.
Le rôle du thérapeute est de promouvoir une direction et une structure
pour développer la confiance ainsi que diminuer le niveau d’anxiété et
d’anticipation présent dans le groupe. Dans la seconde étape, chaque membre
du groupe tente d’atteindre un niveau de confort qui leur permet de prendre
des initiatives. Les membres du groupe se permettent de se critiquer les uns
les autres et de se donner des conseils. C’est une période qui les amène à
mieux se connaître dans leurs différences. La troisième étape consiste au
développement de la cohésion du groupe. Dans cette étape, le groupe est en
résonance, en sécurité, en confiance et est assez ouvert pour le dévoilement
de soi. Les membres du groupe sont plus conscients des participants absents
et bénéficient d’une plus grande liberté d’expression.
La dernière étape est la terminaison. Les sentiments à propos de
la terminaison doivent être abordés selon différentes perspectives : le
participant comme individu, le thérapeute et le groupe comme un tout. La
terminaison consiste en une fin planifiée de la thérapie qui se définit par le
retour et le sommaire des séances, le sentiment de deuil et la célébration du
commencement d’une prochaine étape de vie.
Séance type. La séance est divisée en deux sections; la première
est axée sur le plan personnel afin d’augmenter l’expression de soi, et la
deuxième est axée sur le groupe lui-même pour développer les liens et la
collaboration. Une structure qui permet aux participants de s’exprimer
d’abord puis d’aller davantage vers le groupe permet de boucler la boucle.
Une pause entre les deux sections se veut une occasion pour les participants
de relaxer et, pour ceux qui le désirent, d’écrire dans leur journal au sujet
de leurs expériences de la première section. Il est important de noter que
les plans de séances sont seulement des lignes directrices pour la thérapie.
Étant donné les besoins des proches aidants et l’évolution de la maladie
de la personne qu’ils accompagnent, le musicothérapeute sera à l’écoute
des besoins du groupe dans le moment présent et décidera donc des
interventions les plus appropriées. De plus, chaque groupe est différent et
évolue à son propre rythme dans le processus thérapeutique. La séance type
respecte une structure de base qui permet d’établir une structure sécurisante.
On y retrouve les différentes propositions, telles que : 1) ouverture de séance;
2) rituel d’ouverture musical; 3) expression musicale sur le plan personnel;
4) pause et écriture du journal de bord; 5) expression musicale en groupe; 6)
relaxation (optionnel); 7) clôture de la séance (rituel de fermeture).
Discussion et Conclusion
Ce projet de recherche a exploré la question des proches aidants
de personnes ayant la maladie d’Alzheimer, les groupes de soutien et la
musicothérapie en vue de créer un programme en musicothérapie. La
recherche montre que les groupes de soutien sont en croissance pour la
clientèle des proches aidants, mais il y a un manque de ressources dans les
thérapies par les arts. Une entrevue auprès d’un musicothérapeute a permis
de comprendre que l’importance est d’être à l’écoute des proches aidants et
qu’ils doivent sentir que les rencontres sont là pour qu’ils puissent s’exprimer
et développer des moyens pour vivre leur situation souvent précaire.
La question principale, « Comment un programme de soutien en
musicothérapie peut-il répondre aux besoins de proches aidants dont les
parents sont atteints du stade modéré de la maladie? », m’a emmenée à me
poser plusieurs questions et à réfléchir sur la création du programme. J’ai
choisi de baser le programme dans une perspective humaniste, car celle-ci
met l’accent sur la personne et ses besoins. Les buts thérapeutiques pour ce
programme sont d’encourager l’acte de prendre soin de soi, de développer
des stratégies d’adaptation à travers les outils d’expression, d’augmenter
les occasions d’exprimer l’expérience vécue à travers le rôle d’aidant et de
fournir les possibilités pour trouver un sens au rôle d’aidant. Ce programme
thérapeutique encourage les proches aidants à utiliser leurs propres
ressources pour trouver un sens à leur situation de vie.
La musicothérapie offre des modes d’expression qui ne sont pas offerts
dans d’autres formes d’intervention, parce que la musique constitue un
moyen d’expression non verbal qui permet d’aller au-delà des mots. Grâce à
des techniques telles que la composition de chansons, l’analyse de chansons,
la poésie, l’improvisation instrumentale/vocale et les jeux instrumentaux,
les proches aidants ont l’opportunité d’exprimer leurs émotions et leurs
expériences. Le programme s’attarde particulièrement au côté émotionnel
en mettant l’accent sur l’expression et la solidarité entre aidants.
Ce programme pourrait être implanté dans des centres d’hébergement
pour les proches aidants qui visitent leur proche ou dans des centres qui
offrent des services pour les proches aidants. Le programme est conçu pour
être dirigé par un musicothérapeute accrédité qui est formé et qui a des
connaissances sur la question des proches aidants. Les besoins varient pour
les aidants et il est essentiel que le musicothérapeute développe des outils
d’intervention, notamment par des formations sur le sujet. En ayant une
meilleure compréhension des différents stades de la maladie d’Alzheimer
ainsi que les comportements associés, cela nous permet de mieux
comprendre ce que les proches aidants traversent au cours de la maladie
d’un proche. Le plan du programme est un guide qui peut être modifié et
ajusté à la clientèle choisie. Il serait souhaitable qu’il y ait davantage de
recherche en thérapies par les arts auprès de cette clientèle et surtout plus
de développements de programmes.
Bien que ce programme ne soit que théorique pour l’instant, on peut
répondre davantage aux questions posées initialement : (a) Quelles seraient
les approches en musicothérapie qui pourraient répondre aux besoins
des proches aidants?, (b) Qu’est-ce que la musicothérapie peut apporter
dans le soutien des proches aidants?, (c) Comment intégrer une approche
multimodale (utilisant plusieurs modalités) dans un programme de
musicothérapie pour les proches aidants?
Les techniques en musicothérapie qui sont les plus utilisées avec les
proches aidants ont été confirmées par la musicothérapeute qui a rapporté
que la poésie et la composition de chansons sont deux approches qui donnent
des résultats intéressants en conjonction avec une approche humaniste qui
met l’accent sur le respect et l’écoute. De plus, les groupes de soutien qui
intègrent une approche multimodale arrivent à répondre à des besoins
différents chez les proches aidants. Dans le cadre de la musicothérapie,
l’approche multimodale consiste en l’utilisation de différentes techniques
provenant des autres thérapies par les arts comme l’art, le mouvement et
l’art dramatique. La musicothérapie combinée avec ces autres techniques
(ex. : collage, mouvement et musique, boîte magique, etc.) peut seulement
augmenter les possibilités d’expression pour les proches aidants.
Certaines limitations sont présentes puisque la recherche n’est que
théorique. En effet, il est impossible d’affirmer que le programme fonctionne
puisqu’il n’a pas été appliqué. De plus, il n’y a eu qu’une seule entrevue
avec une musicothérapeute; en conséquence, les résultats de l’entrevue ne
montrent qu’une seule pratique. Il est aussi important de mentionner que le
nombre restreint de recherches sur les proches aidants dans les thérapies
par les arts diminue les ressources pour la création du programme.
Également, le fait que la chercheuse n’ait jamais travaillé avec les proches
aidants apporte une autre limitation à la recherche.
Pour conclure, j’ai choisi de centrer ma recherche sur les proches
aidants, car je travaille en musicothérapie dans des centres d’hébergement
et je vois comment le rôle de proche aidant peut être difficile sans le soutien
nécessaire. Cette recherche m’a donné le goût de pousser mes connaissances
et de travailler avec la clientèle des proches aidants de personnes ayant la
maladie d’Alzheimer. Je pense qu’en travaillant avec la clientèle je pourrai
mieux comprendre leurs besoins et la façon dont la musicothérapie peut les
aider. Mon souhait pour le futur est que la musicothérapie et les thérapies
par les arts prennent une plus grande place dans les ressources disponibles
pour les proches aidants.
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Annexe
La séance type respecte une structure de base qui permet d’établir une
structure sécurisante.
1re partie
1. Ouverture de séance: Rituel d’ouverture musical
But : Créer une structure dans le temps pour clarifier le début de la séance
et apporter une familiarité qui fournit un sentiment de sécurité. Permettre
également à chacun des membres de se sentir accueilli dans le groupe. Dans
le rituel d’ouverture musical, les participants choisissent un instrument et en
jouent chacun leur tour. Puis, ils partagent un aspect positif de leur semaine
avec les autres membres du groupe.
2. Expression musicale sur le plan personnel
But : Explorer différents moyens d’expression pour développer des
stratégies d’adaptation et travailler les difficultés. Les participants
s’expriment notamment au moyen de jeux instrumentaux, d’improvisations
instrumentales et vocales, de chansons et de compositions de chansons.
3. Pause et écriture du journal de bord
But : Renforcer l’importance de prendre soin de soi et permettre un moment
de réflexion et d’expression au moyen du journal de bord.
2e partie
4. Expression musicale en groupe
But : Développer la cohésion du groupe et le sentiment d’appartenance,
créer des liens entre les membres du groupe, développer la collaboration et
souligner l’importance d’avoir un réseau social. Tout comme la première partie
de la séance, les participants s’expriment au moyen de jeux instrumentaux,
d’improvisations instrumentales et vocales, de chansons et de compositions
de chansons, mais tout cela en mettant l’accent sur le groupe plutôt que la
personne dans le groupe.
5. Relaxation (optionnel)
But : Développer d’autres stratégies d’adaptation par l’exploration de
méthodes de relaxation afin de diminuer le stress.
Exemples :
-
-
-
Mindful Music Listening : L’écoute de musique de façon consciente
consiste à faire écouter de la musique aux participants et de leur
demander de se concentrer sur certains éléments dans la musique
(sons, rythme, instrument, etc.) (Magill, 2009);
L’induction par la couleur : L’induction par la couleur consiste à ce
que les participants choisissent une couleur qu’ils respirent et expirent
ensuite dans une relaxation. Cette relaxation aide à se concentrer
sur différentes parties du corps (Grocke & Wigram, 2007);
La relaxation progressive des muscles (Jacobson) : La relaxation
progressive des muscles met l’accent sur la tension et le relâchement
des groupes de muscles de tout le corps (Grocke & Wigram, 2007).
Cette intervention est utilisée seulement si le groupe le désire.
6. Clôture de la séance : Rituel de fermeture
But : Créer une structure dans le temps pour apporter une familiarité qui
fournit un sentiment de sécurité. Dans le rituel de fermeture, les participants
jouent chacun leur tour un bol tibétain et nomment un adjectif pour décrire
ce qu’ils ont apprécié du groupe.
Le milieu scolaire québécois et les élèves ayant des besoins
particuliers; enseignant de musique ou musicothérapeute?
Quebec’s Education System and Students with Special
Needs: Music Teacher or Music Therapist?
Sylvain Larouche, B. Mus – MTA
Lachine, Québec, Canada
Résumé
Cet article tente de répondre à la question que l’auteur se pose, soit de
savoir s’il est plus approprié, en milieu scolaire québécois avec des élèves
ayant des besoins particuliers, d’avoir un enseignant de musique ou un
musicothérapeute. Cette question est soulevée puisqu’il dénombre trois
facteurs à l’origine du problème tout en démontrant qu’il existe une
mince ligne à définir entre les deux professions. Finalement, l’auteur
exprime l’idée qu’un travail collaboratif devrait naître de cette réflexion.
Mots-clés : musicothérapie, éducation musicale, collaboration
spécialiste en musique et musicothérapeute, milieu scolaire
This paper seeks to answer the author’s question whether it is more
appropriate to have a music teacher or a music therapist with students with
special needs within the Quebec education system. This issue has been raised
after the author identified three factors at the source of the problem while
at the same time asserting that a thin line, still to be defined, exists between
both professions. Finally, the author shows that a collaborative work should
result from this reflection.
Keywords: Music therapy, music education, collaboration, music
specialist, music therapist, school system
Il existe, à la grandeur du Québec, de nombreuses classes spécialisées
en déficience intellectuelle et troubles du comportement où les élèves
ayant des besoins de services spécifiques et adaptés sont dirigés et pris en
charge. Chaque commission scolaire possède au moins une école ou des
classes adaptées pour une clientèle en déficience intellectuelle ou en trouble
envahissant du développement. Plus rares sont les commissions scolaires qui
intègrent dans les classes régulières et de façon systématique, tous les élèves
ayant un handicap, une difficulté d’adaptation ou d’apprentissage (EHDAA) sur
leur territoire. Dans ce cas plus spécifique, ces élèves exigeant un cheminement
particulier se retrouvent soit dans les classes de musique du régulier entre
les mains d’un enseignant en musique, ou soit dispensés tout simplement du
cours de musique sans bénéficier de service de musicothérapie. Il ne faudrait
pas non plus passer sous silence les nombreuses écoles privées spécialisées
qui offrent le service de musicothérapie à leurs élèves, par exemple l’école À
Pas de Géant, à Montréal.
Bien qu’ayant des besoins particuliers, il n’en demeure pas moins que
ces élèves ont le droit à la musique. Sandi Curtis et Guylaine Vaillancourt, de
l’Université Concordia, l’ont très bien démontré en expliquant le droit des
enfants à la musique à la lumière des conventions des Nations Unies, tout
comme l’indique si bien l’article 31 des conventions relatives aux droits des
enfants, et transcrites dans le document publié sur le site Children’s right
to music1. Ces auteurs reconnaissent l’importance de promouvoir le droit
des enfants à « participer pleinement à la vie culturelle et artistique »
tel que mentionné à l’article 29 qui reconnaît que l’éducation des enfants
« doit viser à favoriser l’épanouissement de la personnalité de l’enfant et
le développement de ses dons et de ses aptitudes mentales et physiques, et
cela, dans toute la mesure de leurs potentialités ». De plus, il est reconnu que
ces élèves sont souvent attirés, stimulés et motivés par la musique (Bruscia,
1987). En effet, cette dernière semble un bon moyen d’entrer en relation avec
eux et leur monde tout en facilitant un mode de communication non verbal,
non menaçant, intrinsèque et inné, par exemple chez les élèves autistes.
Aujourd’hui, la plupart des milieux scolaires qui sont à l’affût des
besoins de cette clientèle et à l’avant-garde des différents types d’approches
s’accordent pour dire que les arts, et en particulier la musique, se doivent
d’être offerts dans les écoles fréquentées par des élèves ayant des besoins
spécifiques (ministère de l’Éducation du Québec, 2001). Ainsi, cette
intervention basée sur la musique répond à leurs besoins d’être stimulé
sensoriellement, et ce, de façon adéquate. Toutefois, un dilemme réside
depuis l’implantation de la musicothérapie en milieu scolaire, quant à savoir
s’il est préférable d’avoir un enseignant en musique ou un musicothérapeute
accrédité.
1
http://musictherapy.concordia.ca/CurtisVaillantcourtDocsFR.pdf
Plusieurs facteurs démontrent que cette question vaut la peine que
l’on s`y attarde et qu’il est primordial autant pour l’élève que pour le milieu
scolaire, de trouver incessamment une solution qui soit profitable à tous et
qui distingue les deux professions l’une de l’autre.
À titre de musicothérapeute accrédité oeuvrant dans une école
spécialisée en autisme de la commission scolaire Marguerite-Bourgeoys
depuis 25 ans, il me paraît important de faire ressortir différents éléments qui
sont venus à mon attention, soit par le biais de mon expérience personnelle,
soit lors de discussions que j’ai eues avec des musicothérapeutes en milieu
scolaire ou encore avec des enseignants de musique travaillant dans une
école spéciale et des écoles pour élèves neurotypiques et qui ont bien voulu
que je livre ici leur témoignage.
L’origine du problème selon trois facteurs
Tout d’abord, le problème semble provenir en partie de trois facteurs
distincts. Le premier est que la profession n’est pas encore reconnue en
tant que tel par le gouvernement. En effet, celui-ci tarde à reconnaître cette
profession, bien qu’une formation universitaire soit donnée dans différentes
universités à travers le Canada, telle la formation de deuxième cycle à l’Université
Concordia de Montréal. D’un côté, il existe un palier gouvernemental, soit
le gouvernement du Canada, qui reconnaît cette approche en donnant
son accord pour que les musicothérapeutes canadiens bénéficient d’une
formation universitaire dans le domaine, mais qui ne reconnaît pas sur un
autre palier, voire celui du Québec, le titre de musicothérapeute. L’éducation
et la santé n’étant pas de même juridiction et puisque le domaine de la santé
relève du gouvernement provincial, il est impossible pour le gouvernement
canadien d’officialiser un ordre professionnel, qui relève strictement du
gouvernement québécois. Il semblerait que le même problème persiste dans
les autres provinces où pour l’instant, seulement l’Ontario possède un ordre
des psychothérapeutes qui inclut la musicothérapie. Nous vivons donc une
situation paradoxale et une contradiction de la part des gouvernements
attestant, en somme, que la musicothérapie a le droit de prendre naissance
au Canada. Toutefois, elle n’a pas le droit d’exister!
Un deuxième facteur à l’origine du problème résulte du fait que les
premiers musicothérapeutes à avoir obtenu un emploi en milieu scolaire
« depuis 1977 dans les écoles de la Commission scolaire de Montréal (CSDM),
anciennement la Commission des Écoles Catholiques de Montréal (CECM) »
(Boisvert & Labbé, 1998) l’ait été à titre d’enseignants de musique. De
plus, avant 1985, une formation de premier cycle était offerte à l’UQAM,
soit le baccalauréat d’enseignement en musique avec le cheminement
musicothérapie en milieu scolaire. Plusieurs commissions scolaires
ont par la suite emboîté le pas en ce sens et demandent dorénavant
à un musicothérapeute d’avoir une double formation, soit un brevet
d’enseignement (donc une formation en enseignement de la musique) et
une formation en musicothérapie. Ces musicothérapeutes sont alors perçus
d’abord et avant tout au plan administratif comme des enseignants. La
tâche qui leur est alors conférée n’est pas celle d’un thérapeute ni d’un
professionnel non enseignant, mais bien une tâche d’enseignant. Celle-ci
contient des périodes classes qui n’encouragent pas la thérapie individuelle
et pénalisent les élèves parce qu’elles sont trop longues, limitant ainsi
l’encadrement et la liberté de décloisonnement.
Le troisième facteur est la perception qu’ont les gens de l’enseignement
de la musique et de la musicothérapie en milieu scolaire, et c’est sur cette
perception que peut résider la réponse au problème. Pour le commun des
mortels, il serait difficile de percevoir toutes les subtilités qui se cachent
derrière ces deux professions. Notamment, il existe une similitude dans la
pédagogie musicale et la musicothérapie. Toutefois, le but inscrit dans le nom
même des deux professions devrait mettre la puce à l’oreille. L’enseignant de
musique offre une période d’apprentissage musical suivant le syllabus et le
programme de musique du Ministère de l’Éducation, du Loisir et du Sport
(MELS). Pour sa part, le musicothérapeute offre une séance de thérapie par
le biais de la musique avec des objectifs et un programme thérapeutique en
fonction des besoins spécifiques des élèves.
Le programme du MELS dans le domaine des arts suppose que chacune
des disciplines artistiques est aussi une manière particulière pour l’élève de
se connaître soi-même, d’entrer en relation avec les autres et d’interagir avec
l’environnement. Ces disciplines permettent à l’élève d’exprimer sa réalité et
sa vision du monde et elles lui servent à communiquer ses images intérieures
par la création et l’interprétation de productions artistiques. Ce programme
vise donc par le biais des compétences à apprendre à créer, à interpréter
et à apprécier des productions artistiques de façon à intégrer la dimension
artistique dans sa vie quotidienne. Finalement, à travers une démarche
de création, l’élève est amené à utiliser diverses stratégies telles que la
recherche, l’expérimentation, l’adaptation et l’ajustement qui l’aideront dans
ses étapes au niveau du processus créatif (MEQ, 2001).
La démarche en musicothérapie, et plus particulièrement dans le modèle
de Nordoff & Robbins (2007), consiste à utiliser la création et l’improvisation
musicale du thérapeute dans la thérapie. L’improvisation musicale est utilisée
dans chaque séance afin de rechercher, acquérir ou maintenir le contact avec
l’élève et finalement créer une progression dans l’expérience thérapeutique
de séance en séance. Les premières séances visent à présenter à l’élève son
nouvel environnement sonore et lui laisser la chance de l’explorer. Il s’agit
d’une évaluation spécifique. Par la suite, selon ses forces, ses besoins et les
aptitudes observées, le musicothérapeute établira une procédure ainsi qu’un
plan d’intervention.
La tâche des deux professionnels est donc bien différente. L’un préconise
l’enseignement de connaissances musicales par le biais de création, de
techniques et méthodes, alors que l’autre privilégie l’utilisation judicieuse de
la musique à des fins thérapeutiques. À ce titre, il suffit de comprendre que
deux tâches différentes illustrent bien la diversité des deux professions.
Bien que la tâche entre ces deux professions soit distincte, elle peut
parfois paraître bien mince. Bruscia (1998) formule d’ailleurs assez bien
cette pensée lorsqu’il explique que l’éducation musicale se concentre sur
l’acquisition de connaissances et d’habiletés. Il explique par ailleurs que la
démarcation entre l’éducation, la croissance personnelle et les changements
thérapeutiques est parfois mince. Il cite fréquemment quatre distinctions à
faire entre l’éducation et la thérapie : les objectifs, l’attention, le lien et la
formation.
1) Les objectifs sont différents. Ockelford (2000) abonde dans le
même sens en faisant la distinction entre la musicothérapie et
l’éducation musicale par la priorité des objectifs thérapeutiques
par rapport aux objectifs éducatifs. Les objectifs en musicothérapie
permettent à l’élève d’utiliser la musique afin de maîtriser davantage
l’aspect affectif, cognitif, social ou de communication. Les objectifs
en éducation musicale permettent à l’élève d’exploiter des éléments
du langage musical dans le but de l’aider à maîtriser son côté créatif.
2) L’attention est différente. En musicothérapie, la démarche
thérapeutique est personnalisée et centrée sur l’élève de façon
individualisée. En éducation musicale, la démarche est générale et
non dirigée sur l’individu. Un enseignant porte donc son attention
sur la matière à enseigner à son groupe classe, alors qu’un
musicothérapeute porte son attention aux besoins particuliers de
l’élève, pas nécessairement sur ses besoins musicaux.
3) Le lien est différent. En musicothérapie, il est habituellement
question d’un rapport client/thérapeute. En éducation, il est
question d’un rapport enseignant/étudiant. Le lien relationnel
d’un enseignant et d’un élève doit être de l’ordre d’un conseiller, un
guide qui motive l’élève. La motivation est l’un des facteurs les plus
importants de la réussite scolaire. C’est ce qui pousse les enfants
à faire les efforts requis pour réussir. Bien que je parle aussi en
tant que musicothérapeute de mes élèves et non de clients, et ce,
par choix personnel; j’ai toutefois un rapport différent puisque
ma mission n’est pas de motiver les élèves à réussir sur le plan
académique, mais plutôt d’instaurer un espace symbolique fondé à la
fois sur une intimité et sur une distance respectueuse par le biais de
la musique. En tant que lien symbolique, cette relation est l’élément
moteur du processus thérapeutique. Une des approches utilisées
avec les enfants est l’approche créative où le musicothérapeute place
son potentiel créatif, ses ressources musicales et sa personnalité au
service des besoins d’un individu. Ce modèle, selon Nordoff & Robbins
(2007), incite et encourage, grâce à la musique, cette relation à
se dévoiler en tant que réalisation de guérison créatrice à travers
l’improvisation. Aigen (2005), dans son livre Music-Centered Music
Therapy, explique que l’expérience du client à travers la musique
est la base de la thérapie, que l’on doit se concentrer en premier à
accroître l’implication du client dans la musique, que l’expérience du
processus musical est la thérapie, que les interventions sont guidées
par des propriétés musicales et que la relation thérapeutique est
une relation musicale.
4) La formation est différente. Alors que le musicothérapeute
reçoit plutôt une formation sur la compréhension des réponses
physiologiques, émotionnelles et mentales relativement à la
musique, la formation d’un enseignant est principalement basée
sur la didactique d’une matière. Il est vrai que la formation d’un
enseignant en musique contient des cours de formation au niveau
psychopédagogique tels que les enfants en difficulté d’adaptation, la
psychologie du développement; mais la base de leur formation réside
principalement sur la didactique de la musique, l’enseignement
collectif, la pédagogie musicale, des ateliers de création et des stages
d’enseignement.
En contrepartie, le musicothérapeute, en plus de détenir un
baccalauréat, doit au préalable avoir complété un certificat ou une maîtrise
en musicothérapie et être accrédité par l’Association de musicothérapie du
Canada (AMC). Pour être accrédité, le candidat musicothérapeute doit donc,
après l’obtention de son diplôme universitaire, compléter un internat de
1000 heures de pratique supervisée par un musicothérapeute accrédité, au
terme desquelles il présente à l’AMC une demande d’accréditation formelle.
Celle-ci est constituée d’un dossier incluant une description de ses milieux
de stage et de son milieu d’internat, une étude de cas clinique, une lettre
de recommandation et des résolutions de dilemmes éthiques. Par la suite,
afin de maintenir son statut de musicothérapeute accrédité (MTA), le
musicothérapeute doit cumuler périodiquement un minimum de 60 crédits
de formation continue à l’intérieur de chaque cycle de cinq ans.
Une mince ligne à définir…
Je reconnais, comme le démontre Élizabeth Mitchell (2007), qu’il
peut y avoir une valeur thérapeutique dans l’enseignement de la musique,
tout comme il peut y avoir une valeur pédagogique dans une séance de
musicothérapie en milieu scolaire. Ce lien est toutefois exceptionnel et non
une norme en soi.
Il m’est arrivé à maintes reprises de franchir le pont qui existe entre
la thérapie et l’enseignement musical et comment n’aurais-je pu le faire,
en présence d’élèves autistes par exemple, qui ont l’oreille absolue, un don
inné pour la musique et une facilité à jouer du piano, et cela, sans notion
musicale spécifique. Afin de leur donner un sens d’autonomie dans leur vie
musicale présente et à venir, j’ai dû, en tant que musicothérapeute, jouer le
rôle d’un enseignant de musique et leur apprendre à lire la musique, mon
objectif ici en tant que musicothérapeute n’étant toutefois pas en premier
lieu l’apprentissage de notions musicales, mais plutôt de les rendre le plus
autonome possible dans les forces auxquelles ils excellent.
Dans un autre ordre d’idée, les qualités à acquérir par ces deux
professions ne sont pas les mêmes. Plusieurs qualités sont inhérentes et font
partie de ce qu’est un thérapeute en général, comme l’empathie envers son
client. La connaissance de soi et l’introspection sont censées faire partie de
la formation d’un thérapeute et dans plusieurs pays, elles sont obligatoires et
incluses à même la formation d’un musicothérapeute.
L’enseignant de musique peut tout aussi bien avoir ou acquérir ces
préalables en tant que qualité humaine et avoir à cœur le bien-être de ses
élèves. Toutefois, le fait d’avoir un enseignant attentif au bien-être de ses
élèves n’en fait pas un thérapeute pour autant, ni comme le fait d’apprendre
à jouer d’un instrument par soi-même pour son développement personnel ne
fait en sorte qu’il y ait « thérapie » dans ces actions.
Un enseignant reçoit une formation à communiquer des habiletés
musicales, mais ne reçoit pas une formation sur la dynamique thérapeutique,
le processus thérapeutique et relationnel ni sur la psychothérapie ou la
psychologie clinique. Ce qui ne l’empêche toutefois pas de savoir comment
motiver ses élèves et de bien encadrer leur apprentissage au point de vue
créatif. Il existe donc à mon avis une preuve irréfutable de cette différence
entre les deux profils et elle se trouve dans la formation ainsi que dans le
développement de compétences pour exercer sa profession. Les compétences
et la formation pour devenir un enseignant en musique ne sont pas les
mêmes que celles du musicothérapeute … ce constat amorce la réponse à
notre dilemme.
Bien qu’un enseignant en musique possède des compétences
musicales équivalant à celles d’un musicothérapeute, à moins d’avoir
fait son baccalauréat au préalable en enseignement de la musique,
le musicothérapeute n’a pas de formation en pédagogie ni de brevet
d’enseignement. Il n’a donc pas le même suivi ni le même bagage de
connaissances qu’un enseignant. Il en va de même pour un enseignant en
musique, qui a peu de connaissances de la clientèle en déficience intellectuelle,
des troubles du comportement, de l’interaction avec cette clientèle, ni du
type d’aide qu’il peut apporter et encore moins de l’utilisation judicieuse de
la musique en fonction des besoins de l’élève.
Le statut de musicothérapeute au Québec
Plusieurs facteurs viennent compliquer la situation. En effet, ceci est
illustré par le fait qu’il se trouve au Québec certaines écoles à vocation spéciale,
avec des musicothérapeutes accrédités, alors que d’autres écoles optent pour
un enseignant en musique. Enfin, certaines écoles engagent un enseignant en
musique, mais lui confèrent la tâche de musicothérapeute, alors que d’autres
vont engager un musicothérapeute accrédité, mais vont lui donner plutôt une
tâche d’enseignant en musique. Cette multitude de façons d’attribution d’un
poste n’est pas sans embrouiller la perspective de cette spécialité.
Travail collaboratif entre le musicothérapeute et l’enseignant en musique
Un des premiers sentiments que certains enseignants en musique m’ont
confié ressentir face à leur tâche devant un élève ayant un besoin spécifique,
qui aurait dû au préalable se retrouver devant un musicothérapeute, est
qu’ils se sentent démunis. Un enseignant en musique n’est pas outillé et n’a
pas les compétences pour intervenir musicalement auprès de cette clientèle.
À maintes reprises, j’ai assisté (en donnant conseil par téléphone ou par
coaching) de nombreux enseignants en musique de différentes commissions
scolaires ayant fait appel à mon expertise. C’est une situation qui est parfois
difficile à vivre pour un enseignant du secteur régulier ayant à cœur l’intérêt
de développer le plus possible les talents et les aptitudes de ses élèves.
Cependant, les besoins des élèves ne se situent pas toujours aux mêmes
points d’intérêts et d’aptitudes qu’un jeune du secteur régulier, et c’est là, à
mon avis, qu’un musicothérapeute a son rôle à jouer.
Je crois sincèrement, tout comme l’indique Élizabeth Mitchell (2007),
qu’il serait important qu’une plus grande collaboration et qu’un travail
d’entraide soient établis dans les commissions scolaires. Un temps de
rencontre pourrait être alloué aux deux corps d’emplois dans l’éventualité où
la clientèle habituellement associée à un programme spécialisé se retrouve
intégrée en milieu régulier. Une plus grande possibilité de coopération devrait
être instaurée dans les commissions scolaires afin que les musicothérapeutes
puissent offrir une aide aux enseignants en musique intervenant auprès des
élèves ayant un handicap ou des difficultés d’adaptation ou d’apprentissage
fréquentant des classes d’adaptation scolaire.
Conclusion
Le plus important, et j’espère l’avoir bien identifié et résumé pour vous,
est la distinction entre un musicothérapeute et un enseignant en musique.
Il est important que cette distinction soit claire afin que les administrateurs
des commissions scolaires, les directions scolaires et les fonctionnaires du
gouvernement puissent faire un choix éclairé lorsque viendra le temps de
prendre une décision d’embauche. Nous devons tous déployer des efforts
pour que les élèves et les membres du personnel soient reconnus et évoluent
de la façon la plus saine possible, de façon à faire avancer notre système
scolaire québécois ainsi que la profession de musicothérapeute.
Bien entendu, dans les conjonctures économiques actuelles, le domaine
des arts est souvent une des matières à souffrir de coupes. Toutefois, il n’y
a en réalité aucune économie ou aucun bénéfice à faire en ne reconnaissant
pas une profession pour ce qu’elle est. Le milieu scolaire québécois et la
musicothérapie ont tout à gagner en faisant reconnaître et en donnant le
titre de professionnel non enseignant (PNE) aux musicothérapeutes qui
enrichissent tous les jours la vie de nos élèves spéciaux.
À l’aube du quarantième anniversaire de l’AMC, je suis fier de participer
à ma façon au développement de la musicothérapie. Aussi, je suis heureux
de constater le travail accompli au Québec depuis plus de 25 ans. J’espère
toutefois pouvoir vivre avant ma retraite le juste équilibre et la distinction
entre l’enseignant en musique et le musicothérapeute en milieu scolaire.
Références
Aigen, K. (2005). Music-Centered Music Therapy. Gilsum, NH: Barcelona.
Boisvert, S. & Labbé, L. (1998). La musicothérapie en milieu scolaire québécois.
Rapport présenté à l’Association québécoise de musicothérapie.
Bruscia, K. E. (1987). Improvisational models of music therapy. Springfield, IL:
Charles C. Thomas.
Ministère de l’Éducation du Québec (2001). Programme de formation de
l’école québécoise (volet primaire/arts-musique). Québec, Québec :
Gouvernement du Québec.
Mitchell, E. (2007). Therapeutic Music Education: An Emerging Model Linking
Philosophies and Experiences of Music Education with Music Therapy.
Nordoff, P. & Robbins, C. (2007). Creative music therapy: a guide to fostering
clinical musicianship (2nd ed., Revised with 4 cd’s). Gilsum, NH:
Barcelona Publishers.
Ockelford, A. (2000). Music in the education of children with severe or
profound learning difficulties: Issues in current U.K. provision, a new
conceptual framework, and proposals for research. Psychology of
Music, 28(2), 197- 217.
Guidelines for contributors / Directives pour
les collaborateurs
Information for Authors
The Canadian Journal of Music Therapy is a bilingual, peer-reviewed
publication that aims to raise standards of music therapy knowledge and
practice. The journal provides a written medium for the dissemination of
music therapy scholarship, especially that of Canadian music therapists
followed by non-Canadian music therapists and members of allied disciplines.
The principal criteria for acceptance of material are originality and quality.
Material submitted for publication is assumed to be submitted exclusively
to the CJMT and not previously published in any form unless the contrary
is stated. Before acceptance, articles will be peer reviewed. All authors will
be sent a transfer of copyright, which must be signed before the paper is
published. The editors retain the customary right to edit material accepted
for publication. For more information see the Call for Papers and/or the
Submission Guidelines link on the CAMT Web site (www.musictherapy.ca).
The annual deadline for regular publications of the journal is July 1, though
submissions are welcome any time of the year.
Copyright
Copyright of the CJMT is held by the CAMT. Permission must be obtained
in writing from the CAMT to photocopy, reproduce, or reprint any material
published in the Journal. There is a per page, per table, or per figure charge
for commercial use. Individual members of the CAMT have permission to
photocopy up to 100 copies of an article if such copies are distributed without
charge for education purposes.
Subscriptions
The Canadian Journal of Music Therapy is published once a year. Members
of the Canadian Association for Music Therapy (CAMT) receive the Journal
as a membership benefit. Libraries and similar institutions anywhere in the
world can subscribe to the journal—please download our Subscription Form
found under the Publications link at www.musictherapy.ca. Replacement
issues for damaged or undelivered copies must be requested within 2
months (4 months for overseas subscribers). Change of address notification
should be sent to the CAMT 6 weeks in advance. Copies not delivered because
of change of address will not be replaced. Back issues are available in PDF
or, when available, in hard copy. See www.musictherapy.ca/journal for a
complete list of titles and costs.
Advertising
The Canadian Journal of Music Therapy is accepting advertising for
upcoming issues. Rates and deadlines are available online at http://www.
musictherapy.ca/advertising.htm.
Information pour les auteurs
La Revue canadienne de musicothérapie est un périodique bilingue,
révisé par des pairs, qui vise à contribuer à l’avancement des connaissances
et aux normes d’excellence dans la pratique de la musicothérapie. La Revue
se veut d’abord une voie écrite pour la propagation de la mission professorale
des musicothérapeutes canadiens puis des musicothérapeutes d’une autre
provenance ainsi que des membres de disciplines connexes. Les critères
principaux pour qu’un article soit considéré sont l’originalité et la qualité.
Les textes présentés pour publication doivent être soumis exclusivement à
la RCM/CJMT sans aucune parution antérieure sous quelque forme que ce
soit, à moins d’indication contraire. Avant d’être retenus, les articles seront
révisés par des pairs. Tous les auteurs recevront un formulaire de transfert
de droits d’auteur à être signé avant la publication de l’article. Les éditeurs
conservent le droit d’éditer les textes retenus. Pour plus d’informations, voir
les liens Appel d’articles ou Directives pour la soumission d’articles sur le site
Web de l’AMC (www.musictherapy.ca).
Droits d’auteur
L’association de musicothérapie du Canada détient les droits d’auteur de
la RCM. Toute personne desirant photocopier ou reproduire tout document
publié dans la RCM doit obtenir une autorisation écrite de l’AMC au préalable.
Des frais devront être déboursés pour toute utilisation commerciale (tarif
par page, par tableau ou par figure). Les membres individuels de l’AMC
sont autorisés à photocopier jusqu’à 100 copies d’un article, pourvu que ces
copies soient distribuées sans frais et servent à des fins pédagogiques.
Publicité
On peut obtenir les tarifs pour publicité ainsi que les dates limites à
http://www.musictherapy.ca/fr/advertising.htm.
Canadian Journal of Music Therapy Revue canadienne de musicothérapie Vol 20(2), 2014
Canadian Journal of
Music Therapy
Revue canadienne de
musicothérapie
Numéro spécial du 40e anniversaire
1974 – 2014
40th Anniversary Special Issue
1974 – 2014
Volume 20(2), 2014

CMTJ-Vol 20-2-Web - Canadian Association for Music Therapy

Transcription

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